Care Coordination Activities | Measurement Perspective | ||
---|---|---|---|
Patient/Family | Health Care Professional(s) | System Representative(s) | |
Establish accountability or negotiate responsibility | 11a, 17a, 45, 64 | 5, 7a, 7b, 11b, 18, 20, 46 | 16a, 16b |
Communicate | 11a, 17a, 45 | 5, 7a, 7b, 11b, 17d, 46 | 16a, 16b, 17c, 34 |
Interpersonal communication | 11a, 17a, 45, 64 | 7a, 7b, 11b, 17d, 18 | 17c |
Information transfer | 11a, 17a, 45 | 5, 11b, 17d, 18, 20, 27 | 16a, 17c, 34, 44, 50 |
Facilitate transitions | |||
Across settings | 17a, 64 | 5, 17d, 27 | 16a, 17c, 50 |
As coordination needs change | 11a | 11b | 16a, 16b |
Assess needs and goals | 11a, 17a, 45, 64 | 5, 11b, 17d, 20, 27, 46 | 16a, 16b, 17c, 44 |
Create a proactive plan of care | 11a | 5, 7b, 11b, 27 | 16a, 16b |
Monitor, follow-up, and respond to change | 11a, 17a, 45, 64 | 5, 11b, 17d, 20 | 17c, 19, 44 |
Support self-management goals | 11a, 17a, 64 | 5, 11b, 17d, 20 | 16a, 17c, 19, 34 |
Link to community resources | 11a, 64 | 5, 11b, 17d, 27 | 16a, 17c, 44 |
Align resources with patient and population needs | 11a, 17a | 5, 11b, 17d, 20 | 16a, 16b, 17c, 19 |
Note: Measures in bold are highest priority (group 1). Measures in plain font are in priority group 2.