Patient-centered medical homes offer accessible, coordinated, comprehensive care focused on patients’ needs. One of the primary activities of the medical home is care coordination, which involves sharing test results with patients and all of their providers, ensuring patients have follow-up appointments, and much more. Effective care coordination results in better outcomes, reduced waste and duplication, and higher patient satisfaction. Through a care team, which includes not only the primary care provider, but also nurses, medical assistants, and other office staff, medical homes are responsible for coordinating care with patients, among providers within a practice, and with providers in other settings. To understand if patients’ needs are being met, routine performance measurement and reporting about the effectiveness and quality of care coordination are critical.
In a guide released today by the Patient-Centered Primary Care Collaborative, a chapter by Commonwealth Fund staff outlines seven key strategies to help health systems effectively measure care coordination as a routine part of medical home activities.
The seven strategies are:
Improving care coordination within and among health care settings is a critical step to achieving high performance in the U.S. health care system. And obtaining information about care coordination performance can help identify weaknesses, stimulate improvement, and track progress. Practice systems that enable routine data collection, standardization of measures, involvement of patients and staff, and systematic processes to respond to poor performance will bring us one step closer to achieving better-coordinated, higher-value care for all patients.
Table 1. Resources to Help Organizations Select Care Coordination Measures
|AHRQ’s Care Coordination Measures Atlas||A framework for care coordination measurement, documenting and mapping more than 60 existing measures to key care coordination activities and different perspectives of key stakeholders.|
|National Quality Forum’s National Priorities Partnership||Measures aimed to 1) improve care and achieve quality by facilitating and carefully considering feedback from all patients regarding coordination of their care, 2) improve communication around medication information, 3) work to reduce 30-day hospital readmission rates, and 4) work to reduce preventable hospital emergency department visits by 50 percent. Highlighted measures focus on coordination in specific areas of clinical care, such as cardiac rehabilitation, stroke, and cancer, as well as transitions from inpatient to other settings.|
|NCQA Care Coordination Measures||In its 2011 patient-centered medical home (PCMH) standards, NCQA incorporated a number of process measures that indicate care coordination. This table provides summarizes the process measures, or elements, from the NCQA PCMH standards.|
|The MacColl Institute for Healthcare Innovation, Group Health Research Institute’s Care Coordination Questions from Validated Instruments||In this table, MacColl Institute for Healthcare Innovation compares care coordination questions from validated patient experience surveys. The table is an appendix to a larger implementation guide to improve care coordination in medical homes.|
|Centers for Medicare and Medicaid Services’ (CMS) The Physician Quality Reporting System||The goal of this CMS initiative is to provide an incentive payment for eligible professionals who satisfactorily report data on quality measures for professional services furnished to Medicare beneficiaries. One hundred thirty-one searchable quality measures are available from the American Medical Association.|
|The Care Transitions Program® Care Transitions Measure (CTM®)||This 15-item uni-dimensional measure, developed by Eric Coleman, M.D., assesses the quality of care transitions. The measure is applicable to a variety of settings, including skilled nursing facilities, rehabilitation, and other locations patients are likely to utilize during transition.|