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September 2009 - September 2015

Care Coordination Measures Project


Executive Director, CHP/PCOR, Senior Scholar, CHP/PCOR
Research Associate, CHP/PCOR

This project focuses on identifying, evaluating, and developing measures of care coordination activities. Care coordination is the process of connecting the many different participants in a patient’s care – including the patient and any informal caregivers – to ensure that the right people have the right information at the right time so that patients receive high-quality, high-value, patient-centered care.

Specifically, this project focuses on the measures that capture the role of primary care practices in coordinating care for their patients. Over several phases of the project, the team has identified and evaluated a wide range of measures of care coordination, assessed the potential to measure coordination activities using data from health information technology systems, and recommended measures suitable for a variety of purposes. In on-going work, the team is collaborating with the American Institutes for Research and the National Committee for Quality Assurance to develop a new patient-reported measure of care coordination for use by primary care practices. Details about each of these efforts are listed below.

Care Coordination Measures Atlas. The Care Coordination Measures Atlas is a compendium of care coordination measures that aims to help researchers and evaluators efficiently select instruments appropriate for their measurement needs. It includes detailed information about measure format, content, reliability, validity, links to outcomes, and availability. The Atlas maps measures onto a framework of perspective and coordination mechanisms. The Atlas is freely available to the public. An update to the Atlas including additional measures and a review of emerging trends in care coordination measurement is forthcoming from the Agency for Healthcare Research and Quality. Available at:

An interactive, searchable version of the Atlas is also available, which allows users to filter results by measure focus, patient groups, and health care settings. Available at:

Prospects for Care Coordination Measurement Using Electronic Data. This effort assessed the potential for measuring care coordination processes using data from health IT systems such as electronic health records or health information exchanges, in addition to all-payer claims databases. This assessment was based in part on interviews with key stakeholders and informants from across the health care, quality measurement, and health IT sectors. Available at:

Care Coordination Accountability Measures for Primary Care Practice. This effort assessed existing care coordination measures to identify those most suitable for evaluating primary care practices’ care coordination efforts in pay for performance or other accountability purposes. It also recommended measures suitable for quality improvement or research purposes. Available at:

On-going work: The Stanford care coordination team is collaborating with the American Institutes for Research and the National Committee for Quality Assurance to develop a new survey of patients’ experiences with care coordination. It focuses on primary care practices’ care coordination activities, and is based on the Care Coordination Measures Atlas framework. The measure will be completed in 2015.

Additional collaborators: Battelle Memorial Institute and American Institutes for Research

Support: Agency for Healthcare Research and Quality