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 |