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Care Coordination Measures Database

Patient or family member completes survey (so far there are not examples of patient perspective that are not survey-based)

Health care professional completes survey or collects data. Health care professional includes physicians, nurses, nurse practitioners, physician assistants, or other clinic or hospital staff

System administrator or someone else acting as a representative of a system completes the survey, or data source is from a healthcare delivery system, such as an electronic medical record or claims data. Measures based on chart review or administrative data are categorized here. When an individual healthcare professional is providing information that reflects the system experience, rather than their individual experience, we also classify that as system perspective.

Make clear the responsibility of participants in a patient‘s care for a particular aspect of that care. The accountable entity will be expected to answer for failures in the aspect(s) of care for which it is accountable. Specify who is primarily responsible for key care and coordination activities, the extent of that responsibility, and when that responsibility will be transferred to other care participants.

Share knowledge among participants in a patient‘s care. Communication may occur through a wide variety of channels, but for the purposes of measurement, we distinguish two key modes of communication:

The give-and-take of ideas, preferences, goals, and experiences through personal interactions. Examples include face-to-face interactions, telephone conversations, email, and letters

The flow of information, such as medical history, medication lists, test results, and other clinical data, from one participant in a patient‘s care to another. For example, a written summary of laboratory results sent from a primary care practice to the patient, verbal confirmation of a laboratory value from the laboratory to a physician, or transfer of a disk containing CT images from a hospital to a primary care office.

Facilitate specific transitions, which occur when information about or accountability for some aspect of a patient‘s care is transferred between two or more health care entities or is maintained over time by one entity. Facilitation may be achieved through activities designed to ensure timely and complete transmission of information or accountability.

For example, transitions from the inpatient (hospital) setting to the outpatient setting (i.e., physician‘s offices); or transitions between ambulatory care settings (i.e., primary care to specialty clinics).

For example, the transition from pediatric to adult care; transitions over the course of a woman‘s changing reproductive cycle; and transitions between acute episodes of care and chronic disease management.

Determine the patient‘s needs for care and for coordination, including physical, emotional, and psychological health; functional status; current health and health history; self-management knowledge and behaviors; current treatment recommendations, including prescribed medications; and need for support services.

Establish and maintain a plan of care, jointly created and managed by the patient/family and health care team, which outlines the patient‘s current and longstanding needs and goals for care and/or identifies coordination gaps. The plan is designed to fill gaps in coordination, establish patient goals for care and, in some cases, set goals for the patient‘s providers. Ideally, the care plan anticipates routine needs and tracks current progress toward patient goals.

Jointly with the patient/family, assess progress toward care and coordination goals. Monitor for successes and failures in care and coordination. Refine the care plan as needed to accommodate new information or circumstances and to address any failures. Provide necessary followup care to patients.

Tailor education and support to align with patients‘ capacity for and preferences about involvement in their own care. Education and support include information, training, or coaching provided to patients or their informal caregivers to promote patient understanding of and ability to carry out self-care tasks, including support for navigating their care transitions, self-efficacy, and behavior change.

Provide information on the availability of and, if necessary, coordinate services with additional resources available in the community that may help support patients‘ health and wellness or meet their care goals. Community resources are any service or program outside the health care system that may support a patient‘s health and wellness. These might include financial resources (e.g., Medicaid, food stamps), social services, educational resources, schools for pediatric patients, support groups, or support programs (e.g., Meals on Wheels).

Within the health care setting, assess the needs of patients and populations and allocate health care resources according to those needs. At the population level, this includes developing system-level approaches to meet the needs of particular patient populations. At the patient level, it includes assessing the needs of individual patients to determine whether they might benefit from the system-level approach. For example, a system-level approach to meeting the needs of patients with cancer (the population) might be to establish a multidisciplinary tumor board meeting to help coordinate cancer care among the many relevant specialties. In this scenario, aligning a particular patient‘s needs with available resources would include assessing whether that individual would likely benefit by having his/her case presented at the multidisciplinary tumor board meeting either for coordinating a consensus recommendation or for simplifying the patient‘s care pathway or both.

Integration among separate health care entities participating in a particular patient‘s care (whether health care professionals, care teams, or health care organizations) into a cohesive and functioning whole capable of addressing patient needs.

A source of usual care selected by the patient that functions as the central point for coordinating care around the patient‘s needs and preferences. This includes coordination among all participants in a patient‘s care, such as the patient, family members, other caregivers, primary care providers, specialists, other health care services (public and private), and nonclinical services, as needed and desired by the patient. Other terms are frequently used to describe this model, such as medical home, patient-centered medical home, and advanced primary care. Building on the work of a large and growing community, the Agency for Health Care Research and Quality defines a medical home as not simply a place but a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses several functions and attributes: it is patient-centered and provides superb access to comprehensive and coordinated care and employs a system-based approach to quality and safety.

A process designed to assist patients and their support systems in managing their medical/ social/ mental health conditions more efficiently and effectively.

Reconciling discrepancies in medication use in order to avoid adverse drug events associated with transitions in care. This can involve review of the patient‘s complete medication regimen at the time of admission/ transfer/ discharge, including assessing use of over-the-counter medications and supplements; comparison across information sources and settings; or direct communication between patients and providers.

Using tools, such as electronic medical records, patient portals, or databases, to communicate information about patients and their care between health care entities (health care professionals, care teams, or health care organizations) or to maintain information over time.

Measure is targeted towards or has been used in a patient population described as pediatric, children, or parents/care takers of children receiving health care.

Measure is targeted towards or has been used in older adults, including measures designated for a geriatric patient population, the elderly, or aged individuals. All Older Adult measures are also included in the Adult category.

Measure is targeted towards or has been used in an adult population. This includes measures applicable to older adults.

Purpose states measure is intended for application to patients of all ages, or no information is available on the ages of patients to whom the measure has been applied.

Measure does not focus on patients.

Patients with any chronic condition, including patients with conditions captured by one of the other patient conditions categories. This category includes all measures coded to General Chronic Conditions, Multiple Chronic Conditions, Cancer, Mental Illness & Substance Use Disorders, and Children with Special Health Care Needs.

We include in this category patients who are described as having chronic conditions, chronic diseases, or chronic illnesses without specifying particular conditions. We also include in this category any specific chronic disease that is not captured by one of the other patient condition categories (cancer, mental illness, CSHCN). We define chronic condition as a disease or condition of long duration and typically slow progression. We do not restrict the definition of chronic condition to specific diseases, but the following are examples of conditions that would be included: HIV/AIDS, asthma, COPD, diabetes and cardiac conditions, including CHF and coronary artery disease. Measures included in the Multiple Chronic Conditions category are also included here.

Patients with at least two simultaneous chronic conditions. These may be two or more specific chronic diseases (e.g., CHF and diabetes), or a description of patients as having multiple chronic conditions, diseases or illnesses without specifying particular conditions. All measures included in this category are also included in the Combined Chronic Conditions category. If applicable, measures included here may also be included in one of the other Patient Condition categories (e.g., a measure designed for patients with diabetes and mental illness would also be included in the Mental Illness & Substance Use Disorders category).

Patients with any form of cancer, including leukemia, or patients of any oncology service or provider. This category also includes patients who are undergoing diagnosis for cancer because coordination issues during the period of diagnosis are likely similar to those during the treatment phase. All measures included in this category are also included in the Combined Chronic Conditions category.

Patients with any mental illness, such as depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, anxiety disorders, and post-traumatic stress disorder. This category also includes alcohol or substance abuse and unspecified mental illness or mental disorders. All measures included in this category are also included in the Combined Chronic Conditions category.

Children who have or are at an increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. All measures included in this category are also included in the Combined Chronic Conditions category.

Measure is targeted towards patients with a specific condition not captured by one of the above categories.

Measure is targeted towards or has been applied to the general population or to a patient group not limited by condition. Validation or application of the measure is not limited to particular patient disease or condition groups, or the disease/condition of interest was not specified.

Measure does not focus on patients.

Any care received by a patient admitted to any department of an acute care hospital. This includes patients admitted to the psychiatric department of acute care hospitals. This category does not include services provided by hospitals without an admission (e.g., emergency department, outpatient clinic or same-day surgery).

Care provided in an emergency department, ER, urgent care clinic, or other emergency setting, with or without an admission.

A primary care practice serves as the patient's first point of entry into the health care system and as the continuing focal point for all needed health care services. 1. We define ambulatory primary care facility as any setting described as primary care, or settings providing care by generalists or practitioners in internal medicine, family practitioners, general pediatricians or general practice providers. 2. This includes settings described as a medical or healthcare home or PCMH.

Any outpatient care facility that does not meet the definition of any other setting category. This includes outpatient specialty clinics such as cardiology, orthopedics, and also outpatient or same-day surgery centers. It does not include outpatient mental or behavioral health centers (classify these as behavioral health care facilities) or urgent care clinics (classify these as emergency facilities).

Care provided in any facility or setting that specializes in mental or behavioral health. This includes psychiatric hospitals, substance use treatment centers and behavioral health clinics. It does not include the psychiatric department of an acute care hospital (classify these as inpatient).

Any long-term care facility or institutional care setting, including nursing homes, skilled nursing facilities, incremental care facilities for the mentally retarded (ICF-MR), residential care settings, or step-down facilities.

Health or supportive care provided in the patient’s home by healthcare professionals.

Any other setting not included in one of the above categories, but that is specifically noted as the target location for use of the measure, or where the measure has been used in the past (in published work). This might include coordination around physical or occupational therapy, rehabilitation, etc.

The measure application is not limited to a particular type of setting, or the setting was not specified in measure development or application publications.

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What is the Care Coordination Measures Database and what does it do?

It can be difficult to measure the extent to which care coordination has been implemented in health care settings. This Database, based on AHRQ's Care Coordination Measures Atlas, is intended to assist evaluators and researchers interested in care coordination measurement. Users of the database can compare more than 60 validated care coordination measurements tools found in the Database, many of which are intended for ambulatory care settings to identify those that are most appropriate for their needs.

For more information about how the Care Coordination Measures Database was developed, please refer to the Background page. To learn more about implementing care coordination, please consult the related resources below.

Related Resources and Content

How to use the Database

Users can conduct a search of measurement tools by either:

  • Selecting care coordination activities or approaches they would like to evaluate
  • Identifying which audiences' perceptions of care coordination they would like to measure

Users receive a list of measurement tools that fit the selected criteria. Summary pages are available that can help users learn more about the background, validation, and content of each measurement tool.

Begin using the Database now by proceeding to the Search page and making selections in the left sidebar.