Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. 3.5.1. Care Coordination Measures

10/29/2013

This section describes several frameworks that are useful in identifying potential measures of HIE on care transitions and care coordination.

AHRQ Care Coordination Measures

The AHRQ Care Coordination Measures Atlas provides a framework for care coordination measures, and consists of domains that are important to care coordination, informed by a number of care coordination sources.h AHRQ's framework starts with the goal of achieving coordinated care, defined as the means to help achieve care goals by meeting patient needs and preferences, and facilitating delivery of high-quality, high-value care.8 The framework identifies various actions that have been hypothesized or demonstrated to facilitate care coordination and improve the delivery of health care. These actions can guide the selection of relevant measures for HIE interventions that support care transitions and coordination, and can be employed in an improvised or systematic way.

The measures do not gauge the endpoints of care coordination; rather they capture the care coordination processes and activities that may impact those endpoints. Many, but not all of the measures are applicable to HIE in LTPAC/LTSS settings. An example of a care coordination measure relevant to HIE is the percent of patients discharged from an inpatient facility who receive a transition record at discharge, and documentation that all of the specified elements were reviewed with the patient. (See http://www.qualitymeasures.ahrq.gov/content.aspx?id=28140 for information on the care coordination measures rationale and definitions.)

National Quality Forum's Measure Application Partnership

The NQF convened the Measure Application Partnership (MAP), which developed "Measures under Consideration by HHS for 2012 Rulemaking''. These measures include "PostAcute Care/Long-Term Care Performance Measurement Programs".115 The MAP analyzed the quality measurements and the gaps in measurements for LTPAC including shared accountability for care coordination through transitions, functional status, advanced care planning, and mental/behavioral health as they apply to providers and health plans integrating with community organizations. The MAP identified performance measurement for areas with the most opportunity to improve the quality of health care, and examples of core measure concepts are provided in Table 3-3.

TABLE 3-3. LTPAC Highest-Leverage Areas for Performance Improvement and Core Measure Concepts from MAP

  Highest-Leverage Areas for  
Performance Measurement
Core Measure Concepts
Function
  • Functional and cognitive status assessment
  • Mental health
Goal Attainment
  • Establishment of patient/family/caregiver goals
  • Advanced care planning and treatment
Patient Engagement  
  • Experience of care
  • SDM
Care Coordination
  • Transition planning (discharge planning and timely and bi-directional communication during transitions, requiring educating and preparing patients and families/caregivers, and timely communication between sending and receiving clinicians/institutions)
Safety
  • Falls
  • Pressure ulcers
  • ADEs
Cost/Access
  • Inappropriate medicine use
  • Infection rates
  • Avoidable admissions

CMS ACO Measures

The ACO measures may serve as another potential source of potential measures related to care coordination, particularly if the HIE intervention is part of the health care delivery under an ACO. The ACO care coordination and patient safety areas being measured are as follows:

  • Risk standardized all condition readmissions;
  • Ambulatory-sensitive conditions admissions: chronic obstructive pulmonary disease (COPD) or asthma in older adults, heart failure;
  • EHR Incentive Programs reporting;
  • Medication reconciliation; and
  • Falls: screening for future fall risk.

In addition, see the Pioneer ACO measures in Appendix K.

Endpoints of Care Coordination

"Endpoints of care" is another approach to measuring care and reflect the Institute of Medicine goals for quality of care -- safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.8 Endpoints of care coordination relevant to HIE include rates of ED visits and transfers; hospital admissions/readmissions; disease-specific hospital admissions; mortality and disease; short-term clinical outcomes (e.g., glycated hemoglobin levels for patients with diabetes); functional status (e.g., for telehealth patients); quality of life; and treatment/service adherence.8 The case study sites use endpoints as measures of care coordination supported by HIE.


8. McDonald K, Schultz E, Albin L, et al. Care coordination measures atlas version 3. Rockville, MD: Prepared by Stanford University under Subcontract to Battelle on Contract No. 290-04-0020 for the AHRQ; 2010. AHRQ Publication No. 11-0023-EF.

115. National Quality Forum. MAP pre-rulemaking report: 2013 recommendations on measures under consideration by HHS, final report. ISBN 978-1-933875-47-7. Washington, DC: National Quality Forum; 2013.

h. These include: (1) Antonelli RC, McAllister JW, Popp J. Making care coordination a critical component of the pediatric health system: A multidisciplinary framework. New York, NY: The Commonwealth Fund. May 2009. Publication No. 1277. (2) The CMS Definition of Case Management; (3) Coeira E. Guide to health informatics. 2nd ed. London, England: Hodder Arnold, a member of the Hodder Headline Group; 2003; (4) Mathematica Policy Research Report -- Coordinating care for Medicare beneficiaries: Early experiences of 15 demonstration programs, their patients, and providers: Report to Congress. Princeton, NJ: Mathematica Policy Research, Inc.; May 2004; and (5) NQF -- Endorsed definition and framework for measuring care coordination. Washington, DC: National Quality Forum; 2006.

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