Table 2 Care coordination activities from the AHRQ measurement framework collapsed into three levels
Care coordination activities | Level |
|---|---|
1) Establish Accountability or Negotiate Responsibility | Provider-level |
2) Communicate | |
a. Interpersonal communication | |
b. Information transfer | |
3) Facilitate transitions | |
4) Assess needs and goals | Patient-level |
5) Create a proactive plan of care | |
6) Monitor, follow up, and respond to change | |
7) Support self-management goals | |
8) Link to community resources | System-level |
9) Align resources with patient and population needs |