Care Coordination Measures Atlas Update

Chapter 6. Measure Maps and Profile

In the first section of this chapter we present three Master Measure Mapping Tables, one for each perspective— Patient/Family, Health Care Professional(s), and System Representative(s). In the second section of this chapter, we present specific measure mapping tables for each individual measure and profiles detailing information about each measure.

Master Measure Mapping Tables

Tables 7, 8, and 9 are Master Measure Mapping Tables for the three care coordination perspectives— Patient/Family, Health Care Professional(s), and System Representative(s), respectively. The tables indicate which measures focus on each of the care coordination domains for each perspective. The measure numbers seen in the Master Measure Mapping Tables correspond to the numbers assigned to each measure in Table 10.

Table 7. Care Coordination Master Measure Mapping Table, Patient/Family Perspective

  Measurement Perspective:

Patient/Family
Care Coordination Activities
Establish accountability or negotiate responsibility 3, 4a, 4b, 4c, 6, 9b, 11a, 13, 14, 16c, 17a, 17b, 26, 32, 37, 40, 42, 45, 48, 64, 68, 69, 73
Communicate 3, 4a, 4b, 4c, 4d, 4e, 6, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 24, 25, 26, 29, 30, 31, 32, 33, 37, 38a, 45, 48, 51, 65, 66, 68, 70, 72, 73
   Interpersonal communication 3, 4a, 4b, 4c, 6, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 33, 35, 36, 37, 38b, 39, 40, 41a, 41b,42, 45, 48, 51, 64, 66, 67, 68, 69, 70, 72
   Information transfer 3, 4a, 4b, 4c, 6, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 24, 26, 29, 30, 31, 32, 33, 35, 36, 37, 38a, 38b, 39, 40, 41a, 41b, 42, 45, 48, 49, 51, 65, 67, 68, 69, 70
Facilitate transitions  
   Across settings 4d, 4e, 9a, 9b, 13, 14, 16c, 17a, 17b, 21, 26, 31, 32, 37, 38a, 38b, 40, 42, 51, 64, 65, 67, 68, 70, 72, 73
   As coordination needs change 11a, 14, 24, 68
Assess needs and goals 3, 4a, 4b, 4c, 4d, 4e, 6, 9a, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 24, 25, 26, 30, 31, 32, 33, 35, 37, 38a, 38b, 40, 41a, 41b, 42, 45, 65, 66, 68, 69, 70, 73
Create a proactive plan of care 6, 9b, 10, 11a, 16c, 21, 24, 37, 38a, 40, 65, 66, 67, 68, 69
Monitor, follow up, and respond to change 3, 4a, 4b, 4c, 4d, 4e, 6, 9b, 10, 11a, 13, 16c, 17a, 17b, 21, 24, 25, 26, 29, 31, 32, 33, 36, 37, 39, 40, 41a, 45, 64, 65, 67, 68, 69, 70, 72
Support self-management goals 4a, 4b, 4c, 6, 9a, 9b, 10, 11a, 13, 16c, 17a, 17b, 21, 24, 25, 26, 29, 31, 32, 33, 35, 36, 37, 38a, 38b, 40, 41a, 41b, 64, 65, 66, 67, 68, 70, 72
Link to community resources 10, 11a, 16c, 17b, 21, 24, 31, 33, 38a, 38b, 64, 65, 67, 70, 73
Align resources with patient and population needs  6, 11a, 14, 16c, 17a, 17b, 31, 38a, 38b, 51, 65, 73
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination 6, 11a, 16c, 24, 25, 29, 30, 35, 36, 39, 40, 65, 68, 69, 70, 73
Health care home 4a, 4b, 4c, 4d, 4e, 16c, 17a, 17b, 45, 51
Care management 11a, 14, 21, 51
Medication management 4a, 4b, 4c, 4d, 4e, 6, 9a, 9b, 10, 17a, 17b, 21, 32, 35, 36, 37, 38a, 38b, 42, 48, 65, 66, 70
Health IT-enabled coordination 4a

A key to measure numbers can be found in Table 10: Index of Measures.

All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).

Table 8. Care Coordination Master Measure Mapping Table, Healthcare Professional(s) Perspective

  Measurement Perspective:

Health Care Professional(s)
Care Coordination Activities
Establish accountability or negotiate responsibility 5, 7a, 7b, 11b, 18, 20, 22b, 38c, 38d, 38e, 43, 46, 62, 74, 77
Communicate 5, 7a, 7b, 11b, 12a, 12b, 17d, 22b, 23, 38e, 38f, 43, 46, 62, 74, 77
   Interpersonal communication 7a, 7b, 8, 11b, 12a, 12b, 17d, 18, 22b, 28, 43, 74, 75, 77
   Information transfer 5, 8, 11b, 12a, 12b, 17d, 18, 20, 22b, 23, 27, 38c, 38d, 38e, 38f, 62, 74, 75, 77
Facilitate transitions  
   Across settings 5, 17d, 22b, 27, 43, 38c, 38d, 38e, 38f, 74, 75, 77
   As coordination needs change 11b, 22b
Assess needs and goals 5, 11b, 12a, 12b, 17d, 20, 23, 27, 38d, 38e, 38f, 43, 46, 74
Create a proactive plan of care 5, 7b, 8, 11b, 12a, 22b, 23, 27, 38e, 38f, 62
Monitor, follow up, and respond to change 5, 11b, 12a, 12b, 17d, 20, 22b, 23, 74, 75, 77
Support self-management goals 5, 8, 11b, 17d, 20, 22b, 38d, 38e, 38f, 74
Link to community resources 5, 11b, 17d, 22b, 27, 38e, 74
Align resources with patient and population needs 5, 8, 11b, 17d, 20, 38d, 38e, 74
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination 7a, 7b, 11b, 12a, 12b, 18, 23, 27, 28, 43, 46, 62, 74
Health care home 17d, 74
Care management 5, 11b, 22b, 27
Medication management 17d, 18, 20, 38c, 38e, 38f, 63
Health IT-enabled coordination 12a, 17d, 75

A key to measure numbers can be found in Table 10: Index of Measures.

All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).

Table 9. Care Coordination Master Measure Mapping Table, System Representative(s) Perspective

  Measurement Perspective:

System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility 1, 2, 15, 16a, 16b, 57, 58, 59, 60, 63, 71, 73, 76, 78, 79, 80
Communicate 1, 16a, 16b, 17c, 22a, 34, 71, 73, 76, 80
   Interpersonal communication 17c, 22a, 52, 71, 76, 78, 79
   Information transfer 1, 2, 15, 16a, 17c, 22a, 34, 44, 49, 50, 52, 53, 54, 56, 57, 58, 59, 60, 63, 71, 73, 76, 79, 80
Facilitate transitions  
   Across settings 15, 16a, 17c, 22a, 49, 50, 55, 57, 58, 59, 60, 63, 71, 73, 76, 78, 80
   As coordination needs change 16a, 16b, 22a, 73, 76
Assess needs and goals 1, 16a, 16b, 17c, 44, 49, 73, 76, 79, 80
Create a proactive plan of care 1, 16a, 16b, 22a, 49, 52, 55, 58, 59, 60, 73, 76, 80
Monitor, follow up, and respond to change 1, 2, 3, 17c, 19, 22a, 44, 49, 54, 58, 59, 60, 61, 63, 71, 73, 76, 78, 79, 80
Support self-management goals 1, 16a, 17c, 19, 22a, 34, 49, 71, 73, 76, 79, 80
Link to community resources 1, 16a, 17c, 22a, 44, 52, 73, 80
Align resources with patient and population needs 1, 2, 16a, 16b, 17c, 19, 49, 52, 73, 76, 79, 80
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination 1, 44, 52, 76, 79, 80
Health care home 2, 3, 16a, 16b, 17c, 19, 47, 71, 76, 80
Care management 15, 16a, 16b, 22a, 49, 76, 79, 80
Medication management 2, 3, 17c, 57, 58, 60, 63, 71, 76, 78
Health IT-enabled coordination 1, 16a, 17c, 19, 34, 44, 50, 71, 73, 76, 79, 80

A key to measure numbers can be found in Table 10: Index of Measures.

All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).

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Measure Profiles

This section contains measure mapping tables specific to each individual measure. Each individual measure mapping table is followed by a measure profile designed to provide more detailed information on the measure's purpose, format and data source, perspective, validation and testing, links to outcomes, applications, and key sources. The measure profiles also identify the specific measure items (i.e., survey questions or measure components) that map to each domain. Table 10 below is an index to the measure numbers (far left column) cited in the Master Measure Mapping Tables and the order in which the individual measure mapping tables and profiles appear.

Table 10. Index of Measures

Measure Number Measure Title
1. Assessment of Chronic Illness Care (ACIC)
2. ACOVE-2 Quality Indicators: Continuity and Coordination of Care Coordination
3. Coleman Measures of Care Coordination
4. Consumer Assessment of Healthcare Providers and Systems (CAHPS)
     a. Adult Primary Care 1.0
     b. Adult Specialty Care 1.0
     c. Child Primary Care 1.0
     d. Patient-Centered Medical Home (PCMH) Supplementary Survey Adult Version 2.0*
     e. Patient-Centered Medical Home (PCMH) Supplementary Survey Child Version 1.1*
5. Care Coordination Measurement Tool (CCMT)
6. Client Perception of Coordination Questionnaire (CPCQ)
7. Collaborative Practice Scale (CPS)
     a. Nurse Scale
     b. Physician Scale
8. Breast Cancer Patient and Practice Management Process Measures
9. Care Transitions Measure (CTM)
     a. CTM-3
     b. CTM-15
10. Patient Assessment of Care for Chronic Conditions (PACIC)
11. Family-Centered Care Self-Assessment Tool
     a. Family Version
     b. Provider Version
12. ICU Nurse-Physician Questionnaire
     a. Long Version
    b. Short Version
13. Primary Care Assessment Survey (PCAS)
14. National Survey of Children With Special Health Care Needs (CSHCN)
15. Head And Neck Cancer Integrated Care Indicators
16. Medical Home Index (MHI)
     a. Long Version (MHI-LV)
     b. Short Version (MHI-SV)
     c. Medical Home Family Index and Survey (MHFIS)
17. Primary Care Assessment Tool (PCAT)
     a. Child Expanded Edition (PCAT-CE)
     b. Adult Expanded Edition (PCAT-AE)
     c. Facility Expanded Edition (PCAT-FE)
     d. Provider Expanded Edition (PCAT-PE)
18. Physician-Pharmacist Collaboration Instrument (PPCI)
19. Patient-Centered Medical Home Survey of Structural Capabilities of Primary Care Practice Sites
20. Family Medicine Medication Use Processes Matrix (MUPM)
21. Resources and Support for Self-Management (RSSM)
22. Continuity of Care Practices Survey
     a. Program Level (CCPS-P)
     b. Individual Level (CCPS-I)
23. Nursing Home Work Environment and Performance Team Survey
24. Measure of Processes of Care (MPOC-28)
25. Care Evaluation Scale for End-of-Life Care (CES)
26. Oncology Patients' Perceptions of the Quality of Nursing Care Scale (OPPQNCS)
27. Care Coordination Services In Pediatric Practices
28. Collaboration and Satisfaction About Care Decisions (CSACD)
29. Follow Up Care Delivery
30. Family Satisfaction in the Intensive Care Unit (FS-ICU 24)
31. Korean Primary Care Assessment Tool (KPCAT)
32. Primary Care Multimorbidity Hassles for Veterans With Chronic Illnesses
33. Primary Care Satisfaction Survey for Women (PCSSW)
34. Personal Health Records (PHR)
35. Picker Patient Experience (PPE-15)
36. Physician Office Quality of Care Monitor (QCM)
37. Patient Perceptions of Care (PPOC)
38. Prepared Survey
     a. Patient Version
     b. Carer Version
     c. Residential Care Staff Version
     d. Community Service Provider Version
     e. Medical Practitioner Version
     f. Modified Medical Practitioner Version
39. Health Tracking Household Survey
40. Adapted Picker Institute Cancer Survey
41. Ambulatory Care Experiences Survey (ACES)
  a. ACES
  b. Primary Care Provider Ambulatory Care Experiences Survey (PCP ACES)*
42. Patient Perception of Continuity Instrument (PC)
43. Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration
44. Clinical Microsystem Assessment Tool (CMAT)
45. Components of Primary Care Index (CPCI)
46. Relational Coordination Survey
47. Fragmentation of Care Index (FCI)
48. After-Death Bereaved Family Member Interview
49. Schizophrenia Quality Indicators for Integrated Care
50. Degree of Clinical Integration Measures
51. National Survey for Children's Health (NSCH)
52. Mental Health Professional HIV/AIDS Point Prevalence and Treatment Experiences Survey Part II
53. Cardiac Rehabilitation Patient Referral from an Inpatient Setting
54. Cardiac Rehabilitation Patient Referral from an Outpatient Setting
55. Patients with a Transient Ischemic Event ER Visit That Had a Follow Up Office Visit
56. Biopsy Follow Up
57. Reconciled Medication List Received by Discharged Patients
58. Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges)
59. Timely Transmission of Transition Record
60. Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges)
61. Melanoma Continuity of Care—Recall System
Measure Titles New with this Update
62. Team Survey for Program of All-Inclusive Care for the Elderly (PACE)
63. Medication Reconciliation for Ambulatory Care
64. Promoting Healthy Development Survey PLUS – (PHDS-PLUS)
65. Canadian Survey of Experiences with Primary Health Care Questionnaire
66. Interpersonal Processes of Care Survey
67. Brief 5 A’s Patient Survey
68. Patient Perceived Continuity of Care from Multiple Providers
69. Relational and Management Continuity Survey in Patients with Multiple Long-Term Conditions
70. Patient Perception of Integrated Care Survey (PPIC)
71. Safety Net Medical Home Scale (SNMHS)
72. Parents' Perceptions of Primary Care – (P3C)
73. Primary Care Questionnaire for Complex Pediatric Patients
74. Safety Net Medical Home Provider Experience Survey
75. Rhode Island Physician Health Information Technology Survey
76. The Joint Commission Patient-Centered Medical Home Self-Assessment Survey
77. Communication with Referring Physicians Practice Improvement Module (CRP-PIM)
78. Safe Transitions Community Physician Office Best Practice Measures
79. National Survey of Physicians Organizations and the Management of Chronic Illness II (NSPO-2)
80. Patient-Centered Medical Home Assessment (PCMH-A) Tool

* An additional version of this measure was added to this update.

At the request of the measure developer, the title of this measure was changed from that which appeared in the original Atlas.

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Page last reviewed June 2014
Page originally created June 2014
Internet Citation: Chapter 6. Measure Maps and Profile. Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter6.html