Table of Contents
Abstract
The Coordinated Care Attitudes Interview Measure (Hugunin et al., 2023) was developed to assess healthcare and mental healthcare providers’ perspectives of coordinated care for emerging adults. This instrument was designed for a study conducted with a sample of Massachusetts pediatricians and child/adolescent psychiatrists. The current construct was measured in this sample using six main interview questions, with multiple probing items. No reliability or validity results were reported for these items.
Keywords
Coordinated Care; Emerging Adults; Health Care Provider Attitudes; Mental Health Care Provider Attitudes; Serious Mental Health Conditions; Health Personnel Attitudes; Integrated Services; Therapeutic Processes; Emerging Adulthood; Treatment Process and Outcome Measures; Health Care Personnel Measures; Serious Mental Illness.
Authors
Hugunin, Julie; Khan, Sara; McPhillips, Emily; Davis, Maryann; Larkin, Celine; Skehan, Brian; Lapane, Kate L.
Purpose
The purpose of this interview guide is to explore perspectives of the role of coordinated care for emerging adults with serious mental health conditions, particularly as they transition to adult care.
Validity
No data is Available
Reliability
No data is Available
Factor Analysis
No data is Available
Instrument
Test Type: Original
Format: This interview guide consists of six main topics with multiple probing questions. Responses are open-ended.
Language Available: English
Population Group: Human; Male; Female
Age Group: Adulthood (18 yrs & older)
Population Details: Location: United States. Respondents: Pediatricians; Child/Adolescent Psychiatrists
Test Methodology: Interview Schedule/Guide
Keywords
Coordinated Care; Emerging Adults; Health Care Provider Attitudes; Mental Health Care Provider Attitudes; Serious Mental Health Conditions.
Authors
Author ORCID Identifier:
Hugunin, Julie: http://orcid.org/0000-0002-5906-8910
Larkin, Celine: http://orcid.org/0000-0003-2961-0585
Affiliation:
Hugunin, Julie: University of Massachusetts Chan Medical School Department of Population and Quantitative Health Sciences
Khan, Sara: University of Massachusetts Chan Medical School Department of Population and Quantitative Health Sciences
McPhillips, Emily: University of Massachusetts Chan Medical School Department of Population and Quantitative Health Sciences
Davis, Maryann: University of Massachusetts Chan Medical School Department of Psychiatry
Larkin, Celine: University of Massachusetts Chan Medical School Department of Psychiatry
Skehan, Brian: University of Massachusetts Chan Medical School Department of Psychiatry
Lapane, Kate L.: University of Massachusetts Chan Medical School Department of Population and Quantitative Health Sciences
Email addresses:
Hugunin, Julie: [email protected]
Correspondence Address:
Hugunin, Julie: [email protected]
Permissions & Fee and Test Year
Permissions: May use for Research/Teaching
Commercial: No
Fee: No
Test Year: 2023
References
Hugunin, J., Khan, S., McPhillips, E., Davis, M., Larkin, C., Skehan, B., & Lapane, K. L. (2023). Pediatrician and child adolescent psychiatrist perspectives of coordinated care for emerging adults. Journal of Adolescent Health, 72(5), 770–778. https://doi.org/10.1016/j.jadohealth.2022.12.002
Items of the Coordinated Care Attitudes Interview Measure
This instrument consists of six main items with multiple probing questions. Test items are available in Supplemental Material 3, Pages 6-7, and Supplemental Material 4, Pages 8-13 of the source reference.
Items
Interview script
In your practice, do you see many youths with serious mental health conditions?
a. What age range do you see?
b. What types of conditions do you see?
c. What do you see as your role in caring for youth with SMHCs?Can you think of a particular case example of caring for a youth with a serious mental health condition and could you briefly tell me a little bit about it?
a. Did you manage this patient on your own?
b. Who did you work with to manage their care?
c. What informed your decision making?
d. What role did age of the patient play?How do you coordinate with other providers on the youth’s care? [integrate with case example]
a. Does this differ with age?
b. To PCPs:
i. Who are the providers you coordinate with?
ii. Tell me more about how you communicate with these providers?
iii. What role do they typically play?
iv. What role do you think they should play?
v. We see in private insurance data that about 72% of youth with serious mental health conditions in MA don’t have a mental health outpatient visit with a psychiatrist, do you know/ask if your patients have a regular psychiatrist?
1. About 6% don’t have any kind of outpatient mental health visit, do you know/ask if your patients receive additional outpatient mental health care?
c. To psychiatrists:
i. What providers do you coordinate with?
ii. Tell me more about how you communicate with these providers?
iii. What role do primary care providers typically play?
iv. What role do you think they should play?
v. We see in private insurance data that about 32% of youth with serious mental health conditions in MA don’t have a primary care visit, do you know or ask if your patients have a regular PCP?
d. In your experience, what makes care coordination easier?
i. What are barriers to coordination?
e. Have any issues come up that have affected the patient’s experience?Who typically creates and manages the care plan?
a. What role does the youth have in the care they are getting?
i. At what age does the youth’s voice start to matter more?
b. Who typically does the prescribing?
i. For PCPs:
1. How comfortable do you feel with prescribing?
2. Does prescribing differ for class of medication?
3. Which ones (anti-depressants, mood stabilizers, anti-psychotics, stimulants) do you feel comfortable prescribing?
ii. Does this differ with age?
c. Who monitors for side effects?
i. How often do you screen for metabolic markers?
ii. Do you share this information with other members of the youth’s care team?
iii. Does this differ with age?
d. What about talk therapy?
i. How do you engage with these mental health providers?
ii. Does this differ with age?
iii. If no, what are the barriers to talking to mental health providers?
iv. If yes, what facilitates this discussion?
v. Do you feel engaging with these mental health providers benefits the patient?I want to switch gears and think about patients in your practice as they age out of pediatric care and into adult care. Tell me about your experiences, if any, providing transitional planning to youth (PCPs: in general).
a. PCPs: Is this any different in those with serious mental health conditions?
b. PCPs: In our data, we’ve seen the transition to pediatric to adult care occurring at around 16-17 years. At what age do they typically leave your practice?
c. Do you have any kind of organized process for this handoff?
d. Are you notified that they’ve left?
e. What guidelines or tools do you use for transitional planning?
f. Do you have a network of adult primary care and mental health providers that you are able to refer your transition age youth to?
g. Do providers reach out for transfer records?
h. Are there particular populations within this group for whom you have difficulty finding either adult primary care or mental health for mental health care for?
i. Do you feel you’ve had training in transitional planning for youth with serious mental health conditions?
j. If you could re-design healthcare, what do you think would be the ideal transition?
k. How do you think transitional planning could be improved?
l. Why do you think transitional planning is important for this population?How can the healthcare system be improved to help providers care for youth and young adults with serious mental health conditions?
Coding tree
| Name | Description |
| Broad Approaches | Aimed at improving the delivery of health care, including improving or facilitating coordination, often incorporate a number of coordination activities. |
| Care management | A process designed to assist patients and their support systems in managing their medical/social/mental health conditions more efficiently and effectively. Case management and disease management are included in this definition and further defined below. |
| Case management | The Case Management Society of America defines case management as: “A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.” |
| Disease management | The Disease Management Association of America defines this term as: “A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.” |
| Health care home | A source of usual care selected by the patient that functions as the central point for coordinating care around the patient’s needs and preferences. This includes coordination among all participants in a patient’s care, such as the patient, family members, other caregivers, primary care providers, specialists, other health care services (public and private), and nonclinical services, as needed and desired by the patient. Other terms are frequently used to describe this model, such as medical home, patient-centered medical home, and advanced primary care. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality defines a medical home as not simply a place but a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses several functions and attributes: it is patient-centered and provides superb access to comprehensive and coordinated care and employs a system-based approach to quality and safety. |
| Health IT-enabled coordination | Using tools, such as electronic medical records, patient portals, or databases, to communicate information about patients and their care between health care entities (health care professionals, care teams, or health care organizations) or to maintain information over time. |
| Medication management | Reconciling discrepancies in medication use in order to avoid adverse drug events associated with transitions in care. This can involve review of the patient’s complete medication regimen at the time of admission/transfer/discharge, including assessment of over-the-counter medications and supplements; comparison across information sources and settings; or direct communication between patients and providers. |
| Teamwork focused on coordination | Integration among separate health care entities participating in a particular patient’s care (whether health care professionals, care teams, or health care organizations) into a cohesive and functioning whole capable of addressing patient needs. |
| Care Coordination Activities | Actions that help achieve coordination, whether employed in an improvised or systematic way. |
| Align resources with patient and population needs | Within the health care setting, assess the needs of patients and populations and allocate health care resources according to those needs. At the population level, this includes developing system-level approaches to meet the needs of particular patient populations. At the patient level, it includes assessing the needs of individual patients to determine whether they might benefit from the system-level approach. For example, a system-level approach to meeting the needs of patients with cancer (the population) might be to establish a multidisciplinary tumor board meeting to help coordinate cancer care among the many relevant specialties. In this scenario, aligning a particular patient’s needs with available resources would include assessing whether that individual would likely benefit by having his/her case presented at the multidisciplinary tumor board meeting either for coordinating a consensus recommendation or for simplifying the patient’s care pathway or both. |
| Communicate | Share knowledge among participants in a patient’s care. Communication may occur through a wide variety of channels, but for the purposes of measurement, we distinguish two key modes of communication: |
| Information transfer | The flow of information, such as medical history, medication lists, test results, and other clinical data, from one participant in a patient’s care to another. For example, a written summary of laboratory results sent from a primary care practice to the patient, verbal confirmation of a laboratory value from the laboratory to a physician, or transfer of a disk containing CT images from a hospital to a primary care office. Characterized by the transfer of data—whether orally, in writing, or electronically—and does not necessarily involve direct interaction between sender and receiver. |
| Interpersonal communication | The give-and-take of ideas, preferences, goals, and experiences through personal interactions. Examples include face-to-face interactions, telephone conversations, email, and letters. Distinguished from information transfer by a two-way exchange of knowledge through personal interactions. |
| Establish accountability or negotiate responsibility | Make clear the responsibility of participants in a patient’s care for a particular aspect of that care. The accountable entity (whether a health care professional, care team, or health care organization) will be expected to answer for failures in the aspect(s) of care for which it is accountable. Specify who is primarily responsible for key care and coordination activities, the extent of that responsibility, and when that responsibility will be transferred to other care participants. |
| Pediatrician role | Includes how pediatricians view their role, how psychiatrists view their role. |
| Psych role | Includes any description of psych role, when pediatricians reach out to psych, etc. |
| Facilitate transitions | Facilitate specific transitions, which occur when information about or accountability for some aspect of a patient’s care is transferred between two or more health care entities or is maintained over time by one entity. Facilitation may be achieved through activities designed to ensure timely and complete transmission of information or accountability. |
| Across settings | For example, transitions from the inpatient (hospital) setting to the outpatient setting (i.e., physician’s offices); or transitions between ambulatory care settings (i.e., primary care to specialty clinics). |
| As coordination needs change | Focus on the transition from pediatric to adult care. |
| Barriers | |
| age cut offs | |
| college | |
| drop off in care | |
| insurance changes | |
| lack of family involvement | |
| low availability of adult providers | |
| state to state issues | |
| Organized process | Does the provider’s system have an organized process for the transition from pediatric to adult care? If not, what personal process do they use? |
| Create a proactive plan of care | Establish and maintain a plan of care, jointly created and managed by the patient/family and health care team, which outlines the patient’s current and longstanding needs and goals for care and/or identifies coordination gaps. The plan is designed to fill gaps in coordination, establish patient goals for care and, in some cases, set goals for the patient’s providers. Ideally, the care plan anticipates routine needs and tracks current progress toward patient goals. |
| Link to community resources | Provide information on the availability of and, if necessary, coordinate services with additional resources available in the community that may help support patients’ health and wellness or meet their care goals. Community resources are any service or program outside the health care system that may support a patient’s health and wellness. These might include financial resources (e.g., Medicaid, food stamps), social services, educational resources, schools for pediatric patients, support groups, or support programs (e.g., Meals on Wheels). |
| Monitor, follow up, and respond to change | Jointly with the patient/family, assess progress toward care and coordination goals. Monitor for successes and failures in care and coordination. Refine the care plan as needed to accommodate new information or circumstances and to address any failures. Provide necessary follow-up care to patients. |
| Assess needs and goals | Determine the patient’s needs for care and for coordination, including physical, emotional, and psychological health; functional status; current health and health history; self-management knowledge and behaviors; current treatment recommendations, including prescribed medications; and need for support services. |
| Support self-management goals | Tailor education and support to align with patients’ capacity for and preferences about involvement in their own care. Education and support include information, training, or coaching provided to patients or their informal caregivers to promote patient understanding of and ability to carry out self-care tasks, including support for navigating their care transitions, self-efficacy, and behavior change. |
| Case example | Used when provider is describing a particular patient scenario. |
| Context | Care coordination measurement must also consider the context: which patient population(s), which setting(s), what timeframe. In addition, care coordination effects may be magnified or muted by facilitators and barriers of care coordination (e.g., effect modifiers). Examples of factors that may facilitate or impede care coordination, depending upon the specific circumstances, include the availability of resources, payment structure, patient complexity and capacity. |
| Ages | Ages seen by providers interviewed. |
| Barriers | Overall barriers to care coordination. |
| Covid | |
| Guilt and burn-out | |
| Insurance | |
| Lack of providers | |
| Patient burden | |
| Prior authorizations | |
| Privacy | |
| Provider turn-over | |
| Reimbursement and money | |
| SES | |
| Silos | |
| Stigma | |
| Time | |
| Proposed facilitators | |
| Leadership | |
| Parity | |
| Pediatric training | |
| Single payer health system | |
| Team meetings | |
| Telehealth | |
| Universal EMR | |
| Serious mental health conditions | SMHCs seen by providers, including trauma. |
| Powerful quote |
*Codebook guided by The Care Coordination Measurement Framework, which includes activities that have been hypothesized as important for carrying out care coordination and broad approaches that have been proposed as means of achieving coordinated care: https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapters3.html
Cite this article
Mohammed looti (2026). Coordinated Care Attitudes Interview Measure. PSYCHOLOGICAL SCALES. Retrieved from https://scales.arabpsychology.com/s/coordinated-care-attitudes-interview-measure/
Mohammed looti. "Coordinated Care Attitudes Interview Measure." PSYCHOLOGICAL SCALES, 5 Apr. 2026, https://scales.arabpsychology.com/s/coordinated-care-attitudes-interview-measure/.
Mohammed looti. "Coordinated Care Attitudes Interview Measure." PSYCHOLOGICAL SCALES, 2026. https://scales.arabpsychology.com/s/coordinated-care-attitudes-interview-measure/.
Mohammed looti (2026) 'Coordinated Care Attitudes Interview Measure', PSYCHOLOGICAL SCALES. Available at: https://scales.arabpsychology.com/s/coordinated-care-attitudes-interview-measure/.
[1] Mohammed looti, "Coordinated Care Attitudes Interview Measure," PSYCHOLOGICAL SCALES, vol. X, no. Y, ص Z-Z, April, 2026.
Mohammed looti. Coordinated Care Attitudes Interview Measure. PSYCHOLOGICAL SCALES. 2026;vol(issue):pages.