The Agency for Healthcare Research and Quality has issued an “atlas” of care coordination measures.  As care coordination becomes more important as part of the implementation of electronic health records and health information exchanges, and as required elements of medical homes and accountable care organizations, having valid and useable measures for care coordination becomes vital.

The atlas defines care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in the patient’s care to facilitate the appropriate delivery of health care services.  Organizing care involved the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.”

The atlas notes that there are patient and family, health care professionals, and system perspectives to care coordination.  Some of  domains of care coordination that should be measured are:

  • Establish Accountability or Negotiate Responsibility
  • Communicate
  • Facilitate Transitions
  • Assess Needs and Goals
  • Create a Proactive Plan of Care
  • Monitor, Follow Up, and Respond to Change
  • Support Self-Management Goals
  • Link to Community Resources
  • Align Resources with Patient and Population Need

The atlas provides useful, evidence-based measures to improve care coordination.

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