Table 1 Measurement framework definitions

Perspectives

Patient/family

The patient or a family member completes the survey based on his/her experience.

Health care professional

A health care professional, or team of professionals, completes the survey or collects the measure data. Health care professionals include physicians, nurses, nurse practitioners, physician assistants, or other clinical or hospital staff.

System representative

A system administrator or someone else acting as a representative of a health care facility or system completes the survey, or the measure data source is from a health care delivery system, such as a medical record or administrative claims data. When an individual health care professional is providing information that reflects the system experience, rather than their individual experience, we also classify that as System Representative perspective.

Domains

Coordination activities

Establish accountability or negotiate responsibility

Make clear the responsibility of participants in a patient’s care for a particular aspect of that care. The accountable entity (whether a health care professional, care team, or health care organization) 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.

Communicate

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: Interpersonal Communication and Information Transfer (see definitions below). While in practice interpersonal communication and information transfer often occur together, for the purposes of measurement, Interpersonal Communication is distinguished from Information Transfer by a two-way exchange of knowledge through personal interactions. Information Transfer is characterized by the transfer of data––whether orally, in writing, or electronically––and does not necessarily involve direct interaction between sender and receiver.

Interpersonal 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.

Information transfer

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. Examples include 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 transitions

Efforts aimed at 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. We distinguish two types of transitions: Transitions Across Settings and Transitions As Coordination Needs Change (definitions below). All measures of transitions fit within one or both of these categories; no measures are mapped directly to the “Facilitate Transitions” heading.

Across settings

Examples include transitions from the inpatient (hospital) setting to the outpatient setting (e.g., physician’s offices), or transitions between ambulatory care settings (e.g., primary care to specialty clinics).

As coordination needs change

Examples include 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.

Assess needs and goals

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.

Create a proactive plan of care

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 up-to-date progress toward patient goals.

Monitor, follow-up and respond to change

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 follow-up care to patients.

Support self-management goals

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.

Link to community resources

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).

Align resources with patient and population needs

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.

Broad approaches potentially related to care coordination

Teamwork focused on coordination

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.

Health care home

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 Healthcare Research and Quality defines a medical home not simply as a place but as 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.

Care management

A process designed to assist patients and their support systems in managing their medical/social/mental health conditions more efficiently and effectively. Case management and disease management are both included in this definition.

Medication management

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.

Health information technology (IT)-enabled coordination

Tools, such as electronic medical records, patient portals, or databases, may be used 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.