Chapter 1: Background
Care Coordination Measures Atlas
Investigation into care coordination definitions, practices, and interventions has recently been sponsored by several national organizations including the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine, and the American College of Physicians, among others. While evidence is starting to build about the mechanisms by which care coordination contributes to patient-centered high-value, high-quality care, the health care community is currently struggling to determine how to measure the extent to which this vital activity is or is not occurring.
An AHRQ Evidence Report 1 published in 2007 demonstrated that systematic reviews of interventions to improve care coordination used a broad range of measures, with almost none that focused specifically on the structures, processes, or intermediate outcomes related to coordination. Most reports synthesized clinical and utilization measures. While these are the ultimate critical endpoints, the paucity of care-coordination-specific measurement results in limited insight about the exact mechanisms that produce better outcomes.
In response, AHRQ launched a research project with the following aim:
- To develop an atlas to help evaluators identify appropriate measures for assessing care coordination interventions in research studies and demonstration projects, particularly those measures focusing on care coordination in ambulatory care.
In developing this Care Coordination Measures Atlas (henceforth, the Atlas), we investigated currently available care coordination measurement approaches based on multiple data sources (e.g., electronic health record systems, consumer surveys, and databases of administrative claims), review of AHRQ Health Information Technology portfolio projects, information from national organizations on their care coordination measurement activities, input from expert and stakeholder/informant panels, and a comprehensive literature search.
The Atlas includes measures of patient and caregiver experiences with care coordination, as well as experiences of health care professionals and health system managers. To provide context to Atlas users and facilitate presentation of care coordination measurement approaches, we developed a care coordination measurement framework.
1 McDonald KM, Sundaram V, Bravata DM, et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, and Owens DK, eds. Closing the quality gap: A critical analysis of quality improvement strategies. Technical Review 9 (Prepared by Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). Vol. 7. Rockville, MD: Agency for Healthcare Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
The Atlas aims to support the field of care coordination measurement by:
- Providing a list of existing measures of care coordination.
- Organizing those measures along two dimensions (domain and perspective) in order to facilitate selection of care coordination measures by Atlas users.
- Developing a framework for understanding care coordination measurement, incorporating elements from other proposed care coordination frameworks whenever possible. The framework is designed to support current and future development of this field, while remaining flexible so that it may be adapted as the field matures.
The Atlas is designed with several key audiences in mind:
- Evaluators of interventions or demonstration projects that aim to improve care coordination (either as a primary or secondary goal).
- Anyone wishing to evaluate the practice of care coordination or its effects outside the context of interventions or demonstration projects, including quality improvement practitioners, recognizing a likely need for this audience to have some technical support from measurement experts or researchers in using the material presented in the Atlas.
- Researchers studying care coordination.
Selection of care coordination measures focused on:
- Those that could reasonably apply to the ambulatory care setting (e.g., a measure of care coordination focused on the transition from inpatient to outpatient care would be eligible for the Atlas but not one focused on care processes only applicable to a single hospital stay). The Atlas focuses on environments where patients already have access to health care.
- Structural measures hypothesized to reflect better coordination (e.g., presence of a patient registry with an algorithm that identifies complex patients with significant coordination needs).
- Process measures hypothesized to reflect better coordination (e.g., percent of patients asked to review their medication list during a primary care office visit).
- Intermediate outcomes of coordination (e.g., percent of test results communicated to patients within a specific timeframe).
- Those that have been tested with evidence of some valid measurement properties using National Quality Forum (NQF) standards and AHRQ Quality Indicators (QI) program methods.
- Those that at a minimum were developed in association with a logic model that has evidence of causal linkages between the activities measured and outcomes desired.
- Those that have been field tested and have shown feasibility or have had structured expert panel face validity testing. Some measures may be more helpful for research or quality improvement purposes, even if not feasible for performance measurement.
- Measures within the public domain.
The Atlas does not include commonly known endpoints, which evaluators are likely to identify easily without the aid of the Atlas. These endpoints reflect the Institute of Medicine goals for quality of care--safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. Specific examples of endpoints used in care coordination studies to date include:
- Emergency room visits
- Hospital readmissions
- Disease-specific hospital admissions
- Disease-specific mortality
- Short-term clinical outcomes (e.g., glycated hemoglobin levels for diabetic patients)
- Functional status (e.g., for congestive heart failure patients)
- Quality of life
- Other patient outcomes (e.g., missed school days for children due to illness)
- Treatment adherence
- Service adherence (e.g., remain in contact with services for mentally ill patients)
Because of concurrent timing with the completion of the Atlas and regulatory changes under way related to meaningful use of electronic medical records, the Atlas does not include the measures contained in the final rule, "Medicare and Medicaid Programs: Electronic Health Record Incentive Program" [CMS-0033-F]. This final rule was first publicly available on July 13, 2010, and is effective September 27, 2010. The final rule includes Stage 1 criteria of meaningful use for eligible providers (EP) and the proposed measures associated with them. For example, one of the core objectives for EPs related to care coordination is the capability to electronically exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results) among providers of care and patient-authorized entities. This objective's associated measure is demonstration by EP of performing at least one test of certified electronic health record technology's capacity to electronically exchange key clinical information.
An Emerging Field
This Atlas, and the measures it contains, represents early efforts in an emerging field. Care coordination is a complex concept, intertwined with many other concepts relating to quality, delivery, and organization of care. In its broadest sense, almost all aspects of health care and its delivery can be understood as part of care coordination. A very narrow definition, on the other hand, might encompass only a few of the domains included in the measurement framework presented in this report. The scope of the Atlas is purposefully broad in an attempt not to limit, but instead to stimulate, further thinking about which measures are most salient and useful to those working to improve the coordination of care.