Care Coordination is a critical component of high quality and safe health care delivery. It is especially important for Children and Youth with Special Health Care Needs (CYSHCN) and for people of any age with chronic health conditions. Many providers in primary and subspecialty care settings do not have specific training to perform care coordination tasks systematically. Further, the outcomes of care coordination are rarely measured. In general, care coordination activities, independent of clinical evaluation and management services, are not typically reimbursed.
The Care Coordination Measurement Tool (CCMT) was developed by Richard C. Antonelli, MD, MS, FAAP, Medical Director of Integrated Care at Boston Children’s Hospital, Assistant Professor of Pediatrics at Harvard Medical School, with funding support from the US Maternal and Child Health Bureau. Use of the CCMT enables measurement of the activities of care coordination, the necessary resources to implement those activities, and the resulting outcomes. By assessing both resource allocation and outcomes, the CCMT is an important tool enabling assessment of value in health delivery models.
Description of the Care Coordination Measurement Tool and Intended Use
The CCMT can be utilized by any personnel performing care coordination, including nurses, social workers, patient navigators, case managers, and primary and subspecialty care providers. In multiple sites across the United States, it has been adapted for use in pediatric and adult delivery systems, in both ambulatory and in-patient settings.
Data collected by implementation of the CCMT demonstrates that when care coordination is successfully implemented, it can prevent the use of high cost resources such as unnecessary Emergency Department use and hospitalizations. The CCMT enables care providers to record the types of encounters that necessitate care coordination activities, the complexity level of the patient requiring care coordination, the activities performed, and the outcomes that occurred. The individual also logs outcomes prevented as a result of successful care coordination. The data provides a framework by which optimal staffing can be allocated to performing care coordination tasks systematically.
The CCMT has been cited in the AHRQ Care Coordination Measures Atlas.
For further information, please contact Richard Antonelli, MD.
Richard C. Antonelli, MD, MS
Medical Director for Integrated Care
Medical Director Physician Relations and Outreach
Boston Children’s Hospital, Harvard Medical School
Antonelli R, Antonelli, D. “Providing a medical home: the cost of care coordination services in a community-based, general pediatric practice.” Pediatrics. 2004;113:1522-1528. PMID: 15121921.
Antonelli RC, Stille C, Antonelli DM. “Care coordination for children and youth with special health care needs: a descriptive, multisite study of activities, personnel costs, and outcomes.” Pediatrics. 2008;122:e209-216. PMID: 18595966.
Antonelli R, McAllister J, Popp J. “Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework.” The Commonwealth Fund. May, 2009.
McDonald, K, Schultz, E, Albin, L, Care Coordination Measures Atlas. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/index.html
Antonelli, R, and Rogers, G, Coordinating Care through Authentic Partnerships with Patients and Families; in Care Coordination: The Game Changer; How Nursing is Revolutionizing Quality Care, Lamb, G. (ed), American Nurses Association. 2013.