Community Care Coordination Score Card: Raising the Bar Across Communities (Text Version)
On September 27, 2010, Mary E. Overall made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (2.5 MB).
Community Care Coordination Score Card: Raising the Bar Across Communities
Mary E. Overall BS, MSN
AHRQ Health Care Innovations Exchange
Community Care Coordination Learning Network
Co-Chair Scorecard Workgroup
September 27, 2010
- To measure outcomes for care coordination.
- To standardize a measurement strategy.
- To develop a method for tracking community coordination.
- To present results of the pilot study.
The field of community care coordination lacks a systematic approach for measuring performance that links at risk individuals to needed care services.
Community Care Coordination Learning Network Overview
The Pathways Model (PM) is a strategy to establish measurable positive outcomes for populations most at risk in the community, develop action steps to accomplish those outcomes, and track progress at the level of individuals. The purpose of this Learning Network is to brink together sites that have expressed interest in implementing this innovative model in their communities. Through this Learning Network, the sites have an opportunity to share information on their individual settings, learn the strategies and techniques needed to implement the Pathways Model, and benefit from each others' experiences.
Figure 1. 17 CCCLN Members Representing 16 Communities in 10 States
Image: A map of the United States is shown. The points on the map show the 16 communities.
7 sites have participated in the data collection
- Albuquerque, New Mexico
- Indianapolis, Indiana
- Central Oregon
- Mansfield, Ohio
- Cincinnati, Ohio
- Toledo, Ohio
- Dallas, Texas
The CCCLN envisioned that the scorecard pilot would facilitate care coordination through...
- Standard data collection and reporting.
- Identification of unmet needs among high-risk and vulnerable populations.
- Assessments of how well the program is addressing unmet needs among targeted high-risk and vulnerable populations.
- Measurement strategy for cross-cutting needs.
- Determine community care coordination outcomes/impacts.
Data Items and Definitions...
- Client demographic information.
- Barriers—Primary Care, Social Services.
- Confirmed connection—Primary Care, Social Services.
Measure: Connection to ongoing primary care
- Domain: Connection to care
- Description: This measure assesses a patient's connection to ongoing primary care.
- Eligible Population: All patients who are enrolled in the Pathways program and do not have an ongoing source of primary care.
- Denominator: The number of patients who indicate that they do not currently have a source of ongoing primary care and are referred for primary care.
- Numerator: The number of patients who indicate that they do not currently have a source of ongoing primary care (and are referred for primary care) and are connected to ongoing primary care.
Measure: Connection to social services
- Domain: Connection to care.
- Description: This measure assesses a patient's referral for social services.
- Eligible Population: All patients who are enrolled in the Pathways program and have social service referrals.
- Denominator: The number of patients who have referrals to social services.
- Numerator: The number of patients who have referrals to social services and are connected to those social services.
The Scorecard Data Collection Strategy
- Primary outcome measures adopted:
- Connection to ongoing primary care.
- Connection to at least one social service.
- Data collection started March 1, 2010.
- Data collected on a monthly basis.
- Information submitted on the scorecard template.