Table 3 Primary, secondary, and monitoring outcomes
| Â | Metrics | Measurement source | Alignment with health reform |
|---|---|---|---|
Primary outcome goals | Â | Â | Â |
Reduce utilization by 10% | Total cost of care | All Payer All Claims data source; patient level | Strong; primary goal |
Hospitalization rate per patient per month | |||
ED visit rate per patient per month | |||
Improve experience of care by 10% | CG-CAHPS: 4/11 composite scores | Survey to 1,600 random stratified patients | Strong |
Secondary outcome goals | Â | Â | Â |
Improve quality of care by 10% | Composite of nine composite measures | EHR-based electronic clinical quality measures; clinic level | Strong: same measures used |
Improve teamness, collaboration, and patient-centered care | Composites of various tools | CSQ, TDM, CPAT, and novel collaboration tool; clinic level | Indirect |
Monitoring goals | Â | Â | Â |
Clusters engage in quality improvement | Monthly ‘score’ based on QI progress and goal setting | Novel practice facilitation-based measure; clinic level | Moderate |
HVE passed monthly | Monthly count of HVEs passed | HVEs derived from PCMH; clinic level | Strong |