Chapter 5. Measure Maps and Profiles (continued, 15)

Care Coordination Measures Atlas

Measure #38b. PREPARED Survey — Carer Version

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care
Professional(s)		System
Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility   
Communicate   
   Interpersonal communication□  
   Information transfer■  
Facilitate transitions   
   Across settings■  
   As coordination needs change   
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 needs□  
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management□  
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

PREPARED Survey — Carer Version

Purpose: To gather information on the quality of process and outcomes of discharge planning activities undertaken in the acute hospital setting from the carer perspective.

Format/Data Source: 43-item questionnaire covering 4 key domains: (1) information exchange (community services and equipment), (2) medication management, (3) preparation for coping after discharge, and (4) control of discharge circumstances.

Date: Measure published in 1998.1

Perspective: Patient/Family

Measure Item Mapping:

  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 3.3
  • Information transfer:
    • Between health care professional(s) and patient/family: 2.1-2.5, 3.4
  • Facilitate transitions:
    • Across settings: 3.1-3.3
  • Assess needs and goals: 5.5
  • Support self-management goals: 2.5, 3.2
  • Link to community resources: 2.4, 3.1
  • Align resources with patient and population needs: 2.4, 3.1
  • Medication management: 2.1, 2.2

Development and Testing: Initial instrument developed based on extensive interviews with hospital staff, patients, and patient carers. The draft instrument was then reviewed by an expert panel of health professionals, a questionnaire layout designer, discharge planning staff, a health economist, and a qualitative researcher to further test for face and content validity. The instrument was then pilot tested, and factor analysis was conducted on patient and carer responses to the process questions. The validity of the instrument was established by comparing responses with interview data and by correlating the process and outcome domains. Divergent validity of the instrument was established by comparing responses to MOS SF-36, a measure of physical and mental health scores.2

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: None described in the sources identified.

Past or Validated Applications:

  • Setting: Acute care hospitals in Australia
  • Population: Patients over the age of 65 who have recently been discharged from medical or surgical wards of acute care hospitals to an independent living arrangement.
  • Level of evaluation: Hospital

Notes:

  • The PREPARED instrument is available in 6 versions: (1) Australian Patient Version, (2) Australian Carer Version, (3) Australian Residential Care Staff Version, (4) Australian Community Service Provider Version, (5) Australian Medical Practitioner Version, and (6) American Medical Practitioner Version. All of the Australian instruments can be found online.1
  • This instrument contains 43 items; 10 were mapped.

Sources:

1. International Centre for Allied Health Evidence (iCAHE) Web site. Available at: http://www.unisa.edu.au/cahe/Resources/DCP/Information.asp. Accessed: 21 September 2010.
2. Grimmer K, Moss J. The development, validity and application of a new instrument to assess the quality of discharge planning activities from the community perspective. Int J Qual Health Care 2001;13(2):109-16.
3. Grimmer KA, Moss JR, Gill TK. Discharge planning quality from the carer perspective. Qual Life Res 2000;9:1005-13.

Return to Contents

Measure #38c. PREPARED Survey — Residential Care Staff Version

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care
Professional(s)		System
Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility □ 
Communicate   
   Interpersonal communication   
   Information transfer ■ 
Facilitate transitions   
   Across settings □ 
   As coordination needs change   
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 needs   
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management □ 
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

PREPARED Survey — Residential Care Staff Version

Purpose: To gather information on the quality of process and outcomes of discharge planning activities undertaken in the acute hospital setting from the residential care staff perspective.

Format/Data Source: 14-item questionnaire.

Date: Measure released in 1998.1

Perspective: Health Care Professional(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 2
  • Communicate:
    • Information transfer:
      • Across health care teams or settings: 1, 3, 4, 6
  • Facilitate transitions:
    • Across settings: 7, 8
  • Medication management: 4

Development and Testing: No testing described in sources identified. However, testing information is available for related measures.2

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: None described in the sources identified.

Past or Validated Applications:

  • Setting: Acute care hospitals in Australia
  • Population: Patients over the age of 65 who have recently been discharged from medical or surgical wards of acute care hospitals to an independent living arrangement.
  • Level of evaluation: Hospital

Notes:

  • The PREPARED instrument is available in 6 versions: (1) Australian Patient Version, (2) Australian Carer Version, (3) Australian Residential Care Staff Version, (4) Australian Community Service Provider Version, (5) Australian Medical Practitioner Version, and (6) American Medical Practitioner Version. All of the Australian instruments can be found online.1
  • This instrument contains 14 items; 7 were mapped.

Sources:

1. International Centre for Allied Health Evidence (iCAHE) Web site. Available at: http://www.unisa.edu.au/cahe/Resources/DCP/Information.asp. Accessed: 21 September 2010.
2. Grimmer K, Moss J. The development, validity and application of a new instrument to assess the quality of discharge planning activities from the community perspective. Int J Qual Health Care 2001;13(2):109-16.

Return to Contents

Measure #38d. PREPARED Survey — Community Service Provider Version

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care
Professional(s)		System
Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility   
Communicate □ 
   Interpersonal communication   
   Information transfer ■ 
Facilitate transitions   
   Across settings ■ 
   As coordination needs change   
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 needs □ 
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management   
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

PREPARED Survey — Community Service Provider Version

Purpose: To gather information on the quality of process and outcomes of discharge planning activities undertaken in the acute hospital setting from the community service provider perspective.

Format/Data Source: 30-item questionnaire.

Date: Measure published in 1998.1

Perspective: Health Care Professional(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 4a
  • Communicate:
    • Information transfer:
      • Between health care professional(s) and patient/family: 4b
      • Across health care teams or settings: 1, 6, 7a, 8c, 10, 12a
  • Facilitate transitions:
    • Across settings: 2, 5a, 5b, 9, 15
  • Assess needs and goals: 2, 9
  • Create a proactive plan of care: 2.3
  • Support self-management goals: 16a
  • Align resources with patient and population needs: 7c, 8b

Development and Testing: No testing described in sources identified. However, testing information is available for related measures.2

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: None described in the sources identified.

Past or Validated Applications:

  • Setting: Acute care hospitals in Australia
  • Population: Patients over the age of 65 who have recently been discharged from medical or surgical wards of acute care hospitals to an independent living arrangement.
  • Level of evaluation: Hospital

Notes:

  • The PREPARED instrument is available in 6 versions: (1) Australian Patient Version, (2) Australian Carer Version, (3) Australian Residential Care Staff Version, (4) Australian Community Service Provider Version, (5) Australian Medical Practitioner Version, and (6) American Medical Practitioner Version. All of the Australian instruments can be found online.1
  • This instrument contains 30 items; 16 were mapped.

Sources:

1. International Centre for Allied Health Evidence (iCAHE) Web site. Available at: http://www.unisa.edu.au/cahe/Resources/DCP/Information.asp. Accessed: 21 September 2010.
2. Grimmer K, Moss J. The development, validity and application of a new instrument to assess the quality of discharge planning activities from the community perspective. Int J Qual Health Care 2001;13(2):109-16.

Return to Contents

Measure #38e. PREPARED Survey — Medical Practitioner Version

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care
Professional(s)		System
Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility □ 
Communicate □ 
   Interpersonal communication   
   Information transfer ■ 
Facilitate transitions   
   Across settings □ 
   As coordination needs change   
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 needs □ 
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management □ 
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

PREPARED Survey — Medical Practitioner Version

Purpose: To gather information on the quality of process and outcomes of discharge planning activities undertaken in the acute hospital setting from the medical practitioner perspective.

Format/Data Source: 19-item questionnaire.

Date: Measure published in 1998.1

Perspective: Health Care Professional(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 5
  • Communicate:
    • Across health care teams or settings: 11
  • Information transfer:
    • Across health care teams or settings: 1-4, 6-9
  • Facilitate transitions:
    • Across settings: 7, 15
  • Assess needs and goals: 7, 10
  • Create a proactive plan of care: 15
  • Support self-management goals: 15
  • Link to community resources: 12
  • Align resources with patient and population needs: 12
  • Medication management: 11

Development and Testing: The measure was developed through a process that included a literature review, focus groups, and pilot surveys. A small group of general medical practitioners in Adelaide and Sydney were given the draft measure and asked to comment on layout, item wording, and question intent. Minor revisions were made based on the feedback received.2

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: None described in the sources identified.

Past or Validated Applications:

  • Setting: Acute care hospitals in Australia
  • Population: Patients over the age of 65 who have recently been discharged from medical or surgical wards of acute care hospitals to an independent living arrangement.
  • Level of evaluation: Hospital

Notes:

  • The PREPARED instrument is available in 6 versions: (1) Australian Patient Version, (2) Australian Carer Version, (3) Australian Residential Care Staff Version, (4) Australian Community Service Provider Version, (5) Australian Medical Practitioner Version, and (6) American Medical Practitioner Version. All of the Australian instruments can be found online.1
  • This instrument contains 19 items; 13 were mapped.

Sources:

1. International Centre for Allied Health Evidence (iCAHE) Web site. Available at: http://www.unisa.edu.au/cahe/Resources/DCP/Information.asp. Accessed: 21 September 2010.
2. Graumlich JF, Grimmer-Somers K, Aldag JC. Discharge planning scale: Community physicians' perspective. J Hosp Med 2008;3(6):455-64.
3. Grimmer K, Moss J. The development, validity and application of a new instrument to assess the quality of discharge planning activities from the community perspective. Int J Qual Health Care 2001;13(2):109-16.

Page last reviewed January 2011
Internet Citation: Chapter 5. Measure Maps and Profiles (continued, 15): Care Coordination Measures Atlas. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/chapter5n.html