Table 5 Descriptive statistics of the German MHCCS-H

Our primary care team is made up of members with clearly defined roles in caring for patients.

Accountability

139

1.52

0.871

0.759

1.980

3.911

13.00

0.446

Our primary care team and the patients share responsibilities in managing patients’ health.

136

1.47

0.740

0.547

1.885

4.380

11.75

0.455

Our primary care team is characterised by trusting collaboration.

139

1.32

0.616

0.380

2.491

8.978

8.00

0.453

Our primary care team works with patients to help them understand their roles and responsibilities in their care.

139

1.37

0.617

0.381

1.807

3.758

9.25

0.630

Our primary care team uses electronic data (e.g. diagnostical findings, lab results), to identify patients with complex health needs (e.g. multimorbity).^N

IT capacity

130

1.53

0.728

0.530

1.605

3.636

13.25

0.515

Our primary care team uses electronic data (e.g. diagnostical findings, lab results), to monitor the outcomes of patient treatment.

137

1.36

0.541

0.292

1.125

0.264

9.00

0.621

Our primary care team uses electronic data (e.g. diagnostical findings, lab results), to track quality indicators of patient care, e.g. percentage of patients with type 2 diabetes mellitus whose HbA1C was checked last year.

121

1.77

1.101

1.213

1.501

1.498

19.25

0.544

Our primary care team uses an electronic patient chart or other electronic system, to support the documentation of patient needs.

136

1.24

0.683

0.467

3.614

14.701

6.00

0.305

Our primary care team uses an electronic health record system or other electronic systems to develop care plans.

125

2.55

1.405

1.975

0.485

−1.094

38.75

0.529

Our primary care team uses an electronic health record system or other electronic systems to determine clinical outcomes.

136

1.63

0.949

0.901

1.749

2.842

15.75

0.462

Our primary care team informs patients about any diagnosis in a way that they can understand.

Communication

136

1.60

0.837

0.700

1.708

3.477

15.00

0.475

Someone on our primary care team helps patients understand all of the choices for their care.

135

1.44

0.665

0.443

1.518

2.244

11.00

0.695

Our primary care team considers and respects patients’ individual values when recommending treatments.

135

1.65

0.716

0.512

1.000

0.991

16.25

0.553

Our primary care team’s care coordination activities are based upon ongoing assessment of patient needs.

128

1.75

0.896

0.803

1.317

1.813

18.75

0.408

Someone on our primary care team asks for patients‘ input when making a plan for their care.

Plan of Care

39

1.97

0.932

0.868

0.876

0.165

24.25

0.704

Someone on our primary care team helps make care plans that patients can follow in their daily life.

41

1.93

0.818

0.670

1.002

1.184

23.25

0.811

Someone on our primary care team develops care plans that incorporate plans recommended by other health care providers that patients see.

40

1.90

0.709

0.503

0.600

0.779

22.50

0.487

Our primary care team reviews and updates patients‘ care plans with them.

Follow-up Plan of Care

42

1.57

0.737

0.544

1.276

1.569

14.25

0.524

Our primary care team gives patients a copy of their care plan.^M

40

1.55

0.677

0.459

0.852

−0.368

13.75

0.308

Our primary care team follows through with the care plans.

42

1.71

0.774

0.599

0.885

0.385

17.75

0.598

Our primary care team uses patients‘ care plans to follow progress.

39

1.82

0.644

0.414

0.177

−0.534

20.50

0.596

Our primary care team helps patients plan so they can take care of their health even when things change or when unexpected things happen.

133

1.68

0.792

0.627

1.001

0.457

17.00

0.288

Someone on our primary care team helps patients set goals for managing their health.

Self-Management

132

1.93

0.764

0.583

0.429

−0.306

23.25

0.489

Someone on our primary care team checks to see if patients are reaching their goals.

128

2.00

0.851

0.724

0.701

0.451

25.00

0.618

Our practice has behaviour change interventions readily available for patients as part of routine care.

132

2.01

1.149

1.321

1.119

0.387

25.25

0.548

Our practice has peer support readily available for patients as part of routine care.

119

3.71

1.311

1.718

−0.586

−0.833

67.75

0.492

Someone on our primary care team asks patients about what they need for support, e.g. with home care, equipment or transportation.

Link to Community Resources

137

1.74

0.885

0.783

1.189

0.781

18.50

0.582

Someone on our primary care team offers patients the opportunity to learn more about managing their health, e.g. with group appointments, support groups, or patient education.

134

2.16

1.343

1.802

0.977

−0.334

29.00

0.412

Someone on our primary care team gives patients information about additional supportive services offered at the practice or in their community, e.g. counselling programmes, support groups or rehabilitation programmes.

136

1.76

0.960

0.922

1.457

1.959

19.00

0.650

Someone on our primary care team encourages patients to attend programmes in their community, e.g. support or sports groups.

134

1.65

0.895

0.801

1.585

2.514

16.25

0.720

Someone on our primary care team connects patients to needed services, e.g. transportation or home care.

135

1.36

0.592

0.350

1.676

2.849

9.00

0.554

When patients are discharged from the hospital, our primary care team is informed about the care patients received from the hospital.

Care Transitions

134

1.71

0.812

0.659

1.267

1.946

17.75

0.604

When patients are discharged from the hospital, our primary care team knows about new prescriptions or if there was a change in medication.

136

1.57

0.737

0.543

1.660

4.088

14.25

0.727

When patients are discharged from hospital, our primary care team receives the discharge summaries in a timely manner.

136

1.90

0.702

0.493

0.797

1.356

22.50

0.592

When patients are discharged from the hospital and there are test results pending, they will be integrated into the patient records within two weeks.

137

2.15

0.817

0.758

0.796

0.513

28.75

0.425