Care Coordination Measures Atlas

The health care community is struggling to determine how to measure the extent to which care coordination activities are being implemented. AHRQ's new Care Coordination Measures Atlas lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination.

Prepared by: Kathryn M. McDonald, M.M.1; Ellen Schultz, M.S.1; Lauren Albin, B.A.1; Noelle Pineda, B.A.1; Julia Lonhart, B.S., B.A.1; Vandana Sundaram, M.P.H.1, 3; Crystal Smith-Spangler, M.D., M.S.1, 3; Jennifer Brustrom, Ph.D.2, Elizabeth Malcolm, M.D., M.S.H.S.4 


Jumpstart Guide
Chapter 1: Background
  Intended Audiences
  An Emerging Field
Chapter 2. What is Care Coordination?
  Perspectives on Care Coordination
  Title Screening, Article Review, and Selection of Individual Studies
  Example Scenarios
Chapter 3. Care Coordination Measurement Framework
  Elements of the Framework
  Care Coordination Measurement Framework
  Definitions of Care Coordination Domains
Chapter 4. Measure Mapping
  Measure Mapping Table
  Measure Selection Guide
Chapter 5. Measure Maps and Profiles
  Master Measure Mapping Tables
  Measure Profiles

  Appendix I. Measure Mapping Strategy
  Appendix II. Identifying Measures
  Appendix III. Identifying Measures
  Appendix IV, Care Coordination Measure Instruments—Updated December 2011 (PDF file PDF version - 7.827 MB; Plugin Software Help)


The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with the material presented in this report.


We thank Jan Genevro, David Meyers and Mamatha Pancholi of the Agency for Healthcare Research and Quality for their support, insightful comments, and enthusiasm. We thank Chris Stave for his expert guidance on literature and measures searches. We also thank Kathan Volrath for her thoughtful feedback on the framework development and Tammy Chapman for her assistance in preparing the Atlas. We thank members of our advisory panels for sharing their time and expertise to improve this work: Karen Adams, Melissa Affronti, Richard Antonelli, Anne-Marie Audet, Helen Burstin, Carol Cain, Eric Coleman, Susan Edgman-Levitan, Jinnet Fowles, Mark Friedberg, Adele Gorges, Tom Jewell, Sally Kraft, Gerri Lamb, Denise Love, Dana Safran, Sarah Scholle, Sara Singer, Vincenza Snow, Shoshana Sofaer, Scott Stumbo, Bert Vrijhoef, Eric Weil, Jonathan Weiner, and Daniel Wolfson. We also thank users who reviewed the Atlas and provided feedback: Steve Clauser, Bruce Finke, David Haggstrom, Paul Han, Diana Ordin, Sharon Pilus, and Kim Thompson. While their input guided and improved the Atlas, they are not responsible for the contents of the final product. We thank Joanne Abed and Marcía Treece, both of Battelle, for their editorial, design, and production assistance.

 Copyright Information

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders.


Author Affiliation

1Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, CA
2Battelle, Atlanta, GA
3Palo Alto Veterans Affairs Healthcare System, Palo Alto, CA
4Sutter Health, Emeryville, CA

Page last reviewed January 2011
Internet Citation: Care Coordination Measures Atlas. January 2011. Agency for Healthcare Research and Quality, Rockville, MD.