1. CARE COORDINATION MEASURES ATLAS PROJECT Kathryn McDonald Stanford Health Policy AHRQ Quality Indicators Project

2. Project Team STANFORD/BATTELLE:  Ellen Schultz  Lauren Albin  Noelle Pineda  Julia Lonhart  Crystal Smith-Spangler  Jennifer Brustrom  Vandana Sundaram  Elizabeth Malcolm (Sutter)  Kathryn McDonald AHRQ:  David Meyers  Jan Genevro  Mamatha Pancholi

3. Project Context: Measurement Motivation  Patient-Centered Medical Home  Evidence-based Practice Center (EPC) report on care coordination  HIT advances and opportunities  Transparency objectives: evidence & evaluations

4. Project Objective: Develop Measures Atlas  Target scope  Ambulatory care  Patients who have access to healthcare  The Atlas aims to support the field of care coordination measurement by:  Finding, selecting and cataloging existing measures of care coordination  Present best measures in accessible format  Expected Atlas Users:  Evaluators of interventions or demonstration projects that aim to improve care coordination  Quality improvement practitioners  Researchers studying care coordination

5. Methods  Literature search  Environmental scan  2 workgroups and other informants  Framework development  Expert review  “Mapping” measures for two purposes:  Visualize landscape of measures available (and missing)  Help users target care coordination domains for intervention and measurement  Detailed measure profiles

6. AreaLessons Learned Results  Many available  Depends on perspective  Notion of “failures”  White space  Two dimensions  Care coordination domains  Perspectives  Links to outcomes of interest (clinical, resource, IOM 6 dimensions of quality)  Definitions  Measurement Framework

7. COORDINATION EFFECTS MECHANISMS Means of achieving goal Coordination Activities Actions hypothesized to support coordination. Not necessarily executed in structured way. COORDINATION MEASURES Experienced in different ways depending upon the perspective Patient/Family Perspective Healthcare Professional Perspective System Representative Perspective Broad Approaches Commonly used groups of activities and/or tools hypothesized to support coordination. GOAL: COORDINATED CARE Context: Settings; Patient Populations; Timeframe; Facilitators; Barriers

8. Measure Mapping Table M EASUREMENT PERSPECTIVE Patient/FamilyHealthcare Professional(s) System Representative(s) C ARE C OORDINATION ACTIVITIES Establish accountability or negotiate responsibility Communicate Interpersonal Communication Information Transfer Facilitate transitions Across settings As coordination needs change Assess needs and goals Create a proactive plan of care Monitor, follow-up, and respond to change Support self-management goals Link to community resources Align resources with patient and population needs B ROAD A PPROACHES P OTENTIALLY R ELATED TO C ARE C OORDINATION Teamwork focused on coordination Healthcare Home Care Management Medication Management Health IT-enabled coordination

9. Results: Measures  Identified 150 measures  Mostly survey-based  Included better measures based on  Previous testing, use and/or underlying logic model  Applicability  Final measure count: 52

10. Measure Mapping and Profile  See handout  CTM-15  12: When I left the hospital, I had a readable and easily understood written list of the appointments or tests I needed to complete within the next several weeks.  CAHPS  CC1!: Doctor talked with patient about all of the prescription medicines he/she was taking  SP5: Patient phoned doctor’s office for help or advice after surgery or procedure

11. Next Steps  Text version available  Development of web-based version Searchable Explicit links to care coordination-related measures included in Electronic Health Record Incentive Program (Medicare and Medicaid) Additional user testing and input Section on applicability to practice’s ongoing QI efforts  Systematic research on evidence base on measurable mechanisms hypothesized to produce better care coordination (process-outcome links)