Coordinated Care Attitudes Interview Measure

1. Abstract

The Coordinated Care Attitudes Interview Measure (Hugunin et al., 2023) is a qualitative, semi-structured psychometric and health services evaluation instrument designed to assess healthcare and mental healthcare providers’ perspectives, practices, perceived barriers, and systemic facilitators regarding coordinated clinical care for emerging adults with serious mental health conditions (SMHCs). Developed and piloted among pediatricians and child and adolescent psychiatrists across Massachusetts, the tool captures inter-professional dynamics during a precarious developmental period marked by high rates of clinical disengagement, insurance discontinuity, and abrupt service transitions from pediatric to adult healthcare systems. The measure is structured around six overarching thematic inquiry domains comprising detailed branching probes tailored to provider specialty: clinical caseload exposure, case-based care coordination paradigms, inter-provider communication modalities, care plan governance and psychotropic prescribing practices, pediatric-to-adult transition planning protocols, and macro-level health system reform recommendations.

Rather than utilizing classical closed-ended rating scales (such as Likert scales), the instrument applies qualitative interview methodology operationalized through an extensive deductive-inductive coding architecture rooted in the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Measurement Framework. Although classical quantitative psychometric indices (e.g., internal consistency coefficients, exploratory or confirmatory factor analyses) were not calculated or reported in the seminal investigation, the tool demonstrates rigorous qualitative validity through theoretical grounding, expert content specification, cognitive piloting, and standardized qualitative coding trees that evaluate broad approaches (e.g., medical home, care management, health information technology) and specific care coordination activities (e.g., establishing accountability, negotiating responsibility, medication monitoring, facilitating transitions). The measure serves as an empirical instrument for health services researchers, developmental psychopathologists, and healthcare administrators seeking to optimize integrated behavioral health models, address health disparities, and reduce drop-off in psychiatric care among transition-age youth.

2. Keywords

Coordinated Care, Emerging Adults, Health Care Provider Attitudes, Mental Health Care Provider Attitudes, Serious Mental Health Conditions, Pediatric Primary Care, Child and Adolescent Psychiatry, Care Transition, Integrated Behavioral Health, Healthcare Services Research, Treatment Adherence, Qualitative Health Measurement, Health Information Exchange, Interprofessional Communication, Transition-Age Youth.

3. Authors

The Coordinated Care Attitudes Interview Measure was conceptualized, designed, and evaluated by a multidisciplinary team of population health scientists, clinical implementation researchers, and academic child and adolescent psychiatrists at the University of Massachusetts Chan Medical School:

• Julie Hugunin, Ph.D. (ORCID: 0000-0002-5906-8910) — Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA. (Corresponding author: [email protected]).
• Sara Khan, M.S. — Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
• Emily McPhillips, B.A. — Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
• Maryann Davis, Ph.D. — Department of Psychiatry, Transitions to Adulthood Center for Research, University of Massachusetts Chan Medical School, Worcester, MA, USA.
• Celine Larkin, Ph.D. (ORCID: 0000-0003-2961-0585) — Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA.
• Brian Skehan, M.D., Ed.M. — Department of Psychiatry and Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, USA.
• Kate L. Lapane, Ph.D. — Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.

4. Purpose

The clinical and public health rationale underpinning the Coordinated Care Attitudes Interview Measure centers on the profound vulnerability of emerging adults (broadly conceptualized as individuals aged 18 to 26 years, extending from late adolescence through young adulthood) diagnosed with serious mental health conditions (SMHCs). SMHCs encompass severe, persistent, and functionally impairing psychiatric disorders, including major depressive disorder, bipolar affective disorders, schizophrenia and related psychosis spectrum disorders, severe post-traumatic stress disorder (PTSD), and complex comorbid neurodevelopmental or substance use conditions. Epidemiological health services research reveals that late adolescence and early adulthood coincide with the peak incidence of severe psychiatric illness, while paradoxically representing the life stage characterized by the steepest drop-off in clinical contact, service utilization, and treatment adherence.

The primary purpose of this qualitative interview schedule is to systematically examine how primary care clinicians (pediatricians) and specialty outpatient mental health providers (child and adolescent psychiatrists) navigate, conceptualize, and execute care coordination for this vulnerable cohort. In contemporary healthcare systems, pediatric and adult medical services operate in profound institutional, operational, and financial silos. As youth reach institutional ages of majority (typically 18 years, though pediatric discharge age varies widely between 18 and 22 years), they are expected to navigate an abrupt transfer from a highly supported, family-centered pediatric medical home to an autonomous, fragmented, and provider-scarce adult healthcare landscape. For transition-age youth with SMHCs, this transition frequently leads to clinical destabilization, treatment abandonment, medication non-adherence, preventable psychiatric emergency room visits, and institutionalization within the criminal justice or inpatient psychiatric systems.

To identify where healthcare infrastructure fails, empirical investigation must target the cognitive models, relational mechanisms, workflow constraints, and systemic barriers experienced by the clinicians managing their care. The Coordinated Care Attitudes Interview Measure investigates:

• How pediatricians and psychiatrists delineate clinical boundaries, negotiate professional responsibilities, and negotiate clinical accountability for complex psychiatric conditions.
• The clinical thresholds and comfort levels associated with prescribing and managing psychotropic medications (e.g., selective serotonin reuptake inhibitors, mood stabilizers, second-generation antipsychotics, psychostimulants) within pediatric primary care versus specialized psychiatric settings.
• The frequency, structural barriers, and clinical execution of metabolic and laboratory monitoring (e.g., lipid panels, fasting blood glucose, HbA1c, body mass index tracking) for patients maintained on atypical antipsychotics.
• The presence, structure, and execution of formal healthcare transition policies, handoff protocols, and longitudinal referral networks linking pediatric practices to adult internal medicine and adult outpatient psychiatry.
• Provider perceptions regarding how macro-level healthcare system structures—such as electronic health record (EHR) interoperability, health insurance carve-outs, prior authorization mandates, and mental health parity laws—either impede or facilitate comprehensive clinical coordination.

The tool provides health services researchers, health plan administrators, and medical educators with qualitative data capable of informing systemic interventions, integrated collaborative care models (e.g., the Collaborative Care Model or psychiatric consultation access programs), and clinical guideline development.

5. Psychological Construct

The Coordinated Care Attitudes Interview Measure evaluates a multidimensional health services and organizational psychology construct: provider attitudes, practices, and system-level perceptions of inter-professional care coordination during youth-to-adult healthcare transitions. Rather than treating care coordination as an isolated administrative procedure, the construct is defined as a collaborative, relational, dynamic, and longitudinal clinical process. Rooted in the taxonomy formalized by the Agency for Healthcare Research and Quality (AHRQ), this overarching construct encompasses two foundational dimensions: Broad Organizational Approaches and Care Coordination Activities, mediated by systemic and environmental context.

Broad Organizational Approaches

This dimension examines how clinicians conceptualize the overarching infrastructure and organizational models governing integrated healthcare delivery:

• Care Management and Disease Management: How practices operationalize collaborative processes of assessment, longitudinal planning, clinical advocacy, and systematic tracking of psychiatric symptoms across care episodes, emphasizing patient empowerment, relapse prevention, and evidence-based self-care.
• Patient-Centered Medical Home (PCMH): The extent to which pediatric practices embody central, accessible, and continuous hubs that integrate behavioral health, specialty consultation, community supports, and family systems into a unified care plan.
• Health IT-Enabled Coordination: Clinician attitudes toward and utilization of electronic health records, secure cross-institutional messaging platforms, regional health information exchanges (HIE), and patient portals to maintain informational continuity and prevent medication reconciliation errors across institutional settings.
• Teamwork Focused on Coordination: Inter-professional collaboration, shared mental models, mutual trust, and structural alignment between disparate healthcare disciplines (pediatrics, adult internal medicine, nursing, psychology, social work, psychiatry).

Care Coordination Activities

This operational dimension captures the concrete clinical, communicative, and logistical behaviors executed by clinicians during everyday clinical encounters:

• Resource Alignment and Needs Assessment: Assessing patient complexity, functional capacity, socioeconomic resources, and systemic barriers to match emerging adults with appropriate psychiatric and psychosocial services (e.g., case management, intensive outpatient therapy, multidisciplinary team conferences).
• Dual-Mode Communication: The critical distinction between information transfer (unidirectional data exchange such as transmission of clinical notes, laboratory sheets, or discharge summaries via fax or EHR) and interpersonal communication (bidirectional, synchronous dialogue, case conferencing, telephone consultations, or shared clinical decision-making).
• Accountability and Role Negotiation: Clear delineation of clinical responsibility regarding who serves as the principal prescriber, who monitors adverse drug reactions and laboratory indices, who handles crisis triage, and who leads the development of comprehensive treatment plans.
• Facilitating Healthcare Transitions: Concrete actions executed to manage the transition from pediatric to adult medical and psychiatric care, including assessing youth autonomy, establishing transition readiness, utilizing standardized transition tools (e.g., Got Transition®), creating transfer packages, and establishing bidirectional warm handoffs.
• Monitoring, Follow-Up, and Proactive Planning: Long-term tracking of psychiatric outcomes, proactive response to life disruptions (e.g., entering college, vocational changes, loss of pediatric health insurance coverage), and systematic screening for cardiometabolic side effects induced by psychotropic regimens.
• Self-Management Support: Empowering emerging adults to acquire healthcare literacy, manage prescription refills independently, navigate insurance hurdles, and exercise clinical agency as their voice begins to supersede parental proxy decision-making.

6. Theoretical Framework

The conceptual architecture of the Coordinated Care Attitudes Interview Measure is anchored in three complementary theoretical paradigms: the AHRQ Care Coordination Measurement Framework, Arnett’s Theory of Emerging Adulthood, and the Chronic Care Model (CCM).

The AHRQ Care Coordination Measurement Framework

The primary structural foundation of the measure is drawn from the Agency for Healthcare Research and Quality’s (AHRQ) Care Coordination Atlas (McDonald et al., 2014). The AHRQ framework defines care coordination as the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. The framework identifies five core operational domains:

1. Establishing accountability or negotiating responsibility;
2. Communicating (information transfer vs. interpersonal communication);
3. Facilitating transitions across settings and developmental stages;
4. Assessing patient needs and available resources; and
5. Creating proactive, dynamic care plans.

Hugunin and colleagues mapped the interview schedule and deductive codebook directly to these AHRQ domains, allowing the instrument to translate abstract organizational theories into measurable provider behaviors and qualitative themes.

Developmental Theory of Emerging Adulthood

Psychologically, the measure is situated within Jeffrey Jensen Arnett’s (2000) developmental construct of emerging adulthood (ages 18–29). Arnett posited that modern cultural, economic, and educational trends have created a distinct developmental period characterized by identity exploration, instability, self-focus, feeling in-between, and possibilities. For youth diagnosed with SMHCs, this developmental volatility directly collides with rigid healthcare administrative structures.

Developmentally, emerging adults are tasked with shifting from family-managed healthcare (where parents coordinate appointments, supervise medication ingestion, and interact with clinicians) to autonomous self-management. The interview schedule operationalizes this framework by probing clinicians on when and how “the youth’s voice starts to matter more,” how providers evaluate developmental maturity versus chronologic age, and how healthcare teams support emerging adult autonomy without abruptly withdrawing necessary familial scaffolding.

The Chronic Care Model and Socio-Ecological Theory

The interview measure draws upon Wagner’s Chronic Care Model (CCM), which argues that optimal outcomes in chronic physical and mental health conditions require productive interactions between an informed, activated patient and a prepared, proactive practice team. The CCM emphasizes clinical information systems, delivery system design, decision support, and community resources. Complementing the CCM is Bronfenbrenner’s ecological systems theory, which posits that clinician attitudes and patient outcomes are shaped not merely by dyadic clinical encounters (microsystem), but by inter-organizational relationships between pediatric and psychiatric clinics (mesosystem), healthcare administration and insurance reimbursement policies (exosystem), and societal stigma surrounding mental illness and universal healthcare rights (macrosystem).

7. Validity

Because the Coordinated Care Attitudes Interview Measure is an in-depth qualitative interview schedule rather than a closed-ended psychometric test generating numerical scores, its assessment relies on the qualitative standards of methodological rigor, content validity, and trustworthiness (credibility, transferability, dependability, and confirmability) as articulated by Lincoln and Guba (1985), rather than quantitative psychometric indices.

Content and Face Validity

Content validity was established through systematic instrument development involving health services researchers, clinical pediatricians, child/adolescent psychiatrists, and transition-age mental health experts at the University of Massachusetts Chan Medical School and the Transitions to Adulthood Center for Research. The core interview items and probing questions were derived directly from:

• Empirical insurance claims analyses demonstrating severe gaps in care (e.g., findings that 72% of commercially insured youth with SMHCs in Massachusetts had no outpatient psychiatric visits, and 32% had no primary care visits during critical transition windows);
• The codified definitions and domains of the AHRQ Care Coordination Measurement Framework;
• Iterative cognitive pre-testing and piloting with practicing pediatricians and psychiatrists to ensure question clarity, clinical realism, and absence of leading prompts.

Face validity was confirmed during qualitative data collection: clinicians consistently recognized the interview scenarios, terminology, and structural dilemmas as authentic reflections of their daily practice realities.

Qualitative Trustworthiness and Credibility

In the seminal validation study (Hugunin et al., 2023), credibility was established through rigorous qualitative audit procedures:

• Interviewer Training and Standardization: Semi-structured interviews were conducted by trained health services investigators following an interview guide to ensure consistent exposure to core topics while permitting responsive, case-based probing.
• Verbatim Transcription and Data Immersion: All audio recordings were transcribed verbatim, checked for fidelity against original recordings, and anonymized prior to qualitative analysis.
• Triangulation across Specialties: Perspectives were collected across both pediatric primary care providers (PCPs) and child/adolescent psychiatrists, providing multi-informant triangulation that illuminated discordant perceptions (e.g., pediatricians reporting high desire for psychiatric guidance, while psychiatrists perceived primary care as reluctant to manage complex psychopharmacology).

Transferability and Confirmability

Transferability was addressed by providing comprehensive descriptions of the practice sample (pediatricians and psychiatrists practicing in academic medical centers, community health centers, and private practices across urban and suburban settings in Massachusetts) and the broader policy landscape (a state with near-universal health coverage and a statewide psychiatric consultation program, the Massachusetts Child Psychiatry Access Program [MCPAP]). Confirmability was documented through a detailed audit trail encompassing audio records, transcripts, an explicit codebook with operationalized inclusion/exclusion criteria, and reflexivity meetings among coders to minimize interpretative bias.

Note on Psychometric Reporting: As explicitly documented in psychometric archives and health measurement repositories, no quantitative psychometric data (e.g., internal consistency, test-retest reliability coefficients, convergent/discriminant validity correlation matrices) are available or applicable for these open-ended qualitative items in their original published format.

8. Reliability

In qualitative psychometrics, reliability corresponds to dependability and inter-coder consistency in qualitative thematic coding. Rather than calculating Cronbach’s alpha or split-half coefficients, reliability for the Coordinated Care Attitudes Interview Measure is operationalized through systematic codebook development, independent dual coding, and inter-rater agreement protocols.

Codebook Development and Operational Rigor

The investigators developed an exhaustive, hierarchical qualitative codebook consisting of major themes (Broad Approaches, Care Coordination Activities, Transitions, Prescribing and Monitoring, Barriers, and System Improvements) and subcodes directly linked to the AHRQ framework. Each code was defined with explicit semantic boundaries, inclusion criteria, exclusion criteria, and illustrative clinical quotes.

Inter-Coder Agreement and Consensus Coding

To establish dependability during data analysis:

• Multiple qualitative analysts independently coded a shared subset of interview transcripts using qualitative data management software (e.g., NVivo).
• Coding discrepancies were systematically identified and reviewed during scheduled consensus meetings.
• Where divergences in thematic application occurred (such as differentiating between unidirectional information transfer and bidirectional interpersonal communication, or categorizing prescribing boundaries), the operational definitions in the codebook were refined, clarified, and re-applied until consensus (>90% thematic alignment) was attained.
• The finalized coding scheme was systematically applied across the entire qualitative corpus, ensuring stable thematic capture across different interviewers and clinical respondent archetypes.

9. Factor Analysis

Because the Coordinated Care Attitudes Interview Measure consists of open-ended, semi-structured qualitative interview items without numerical rating scales, classical exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were not conducted and are not mathematically applicable to this instrument. Latent variables are represented qualitatively through a hierarchical coding tree rather than continuous factor loading matrices.

Qualitative Structural Equivalence to Factorial Dimensions

The thematic coding tree operates as the qualitative structural analogue to a multidimensional factor model. The source framework conceptualizes provider attitudes across three primary thematic domains and multiple operational sub-themes:

Should future health services researchers adapt these open-ended thematic questions into a standardized, closed-ended quantitative survey (utilizing 5-point or 7-point Likert response options), exploratory and confirmatory factor analyses should be executed to evaluate whether the hypothesized three-factor or six-factor organizational models exhibit appropriate goodness-of-fit indices (e.g., RMSEA ≤ 0.06, CFI ≥ 0.95, TLI ≥ 0.95, SRMR ≤ 0.08).

10. Instrument / Measurement Tool

The Coordinated Care Attitudes Interview Measure is an original, semi-structured qualitative interview schedule designed for individual administration with licensed healthcare professionals. Below are the structural specifications of the instrument:

• Instrument Name: Coordinated Care Attitudes Interview Measure
• Authors: Julie Hugunin, Sara Khan, Emily McPhillips, Maryann Davis, Celine Larkin, Brian Skehan, and Kate L. Lapane (2023)
• Test Type: Qualitative semi-structured interview schedule / clinical health services evaluation guide
• Target Population: Licensed pediatric primary care physicians (pediatricians, family medicine physicians caring for children) and outpatient mental health specialists (child and adolescent psychiatrists, general adult psychiatrists, psychiatric nurse practitioners)
• Language: English
• Format & Administration: One-on-one semi-structured clinical interview (conducted in-person, via telephone, or through secure videoconferencing platforms). Estimated completion duration ranges between 35 to 60 minutes.
• Item Architecture: The guide contains six primary overarching clinical questions, accompanied by a network of standardized follow-up probes, including specific branching pathways tailored separately to Primary Care Providers (PCPs) and Psychiatrists.
• Response Format: Open-ended narrative responses. Interviewers use non-directive prompts, case-based exploration, and clarification requests to elicit rich operational details of clinical care coordination.
• Scoring and Analytic Paradigm: The instrument does not generate a quantitative composite score. Instead, recorded and transcribed responses are coded using a specialized deductive-inductive coding tree structured around the AHRQ Care Coordination Measurement Framework, enabling qualitative thematic analysis, framework analysis, or content analysis across predefined organizational categories.

11. Permissions & Fee and Test Year

The Coordinated Care Attitudes Interview Measure was finalized, clinically implemented, and published in 2023 by Hugunin and colleagues through the Journal of Adolescent Health.

• Copyright & Usage Rights: The instrument was developed under academic research auspices at the University of Massachusetts Chan Medical School. It is available free of charge for non-commercial research, academic inquiry, health services evaluation, and medical teaching purposes.
• Commercial Usage: Any commercial deployment, proprietary software integration, or fee-for-service consulting implementation requires prior formal written authorization from the authors and the institutional copyright holders.
• Contact and Correspondence: Correspondence regarding permissions, interview guide adaptation, or qualitative codebook implementation should be addressed to the primary developer: Julie Hugunin, Ph.D., Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA 01605, USA (Email: [email protected]).

12. References

The following peer-reviewed publications and foundational frameworks inform the theoretical, structural, and empirical basis of the Coordinated Care Attitudes Interview Measure:

• Arnett, J. J. (2000). Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist, 55(5), 469–480. https://doi.org/10.1037/0003-066X.55.5.469
• Davis, M., & Vander Stoep, A. (1997). The transition to adulthood for youth who have serious emotional disturbance: I. Mental health program design. Journal of Mental Health Administration, 24(4), 400–427. https://doi.org/10.1007/BF02521104
• 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
• Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. SAGE Publications.
• McDonald, K. M., Sundaram, V., Bravata, D. M., Lewis, R., Lin, N., Kraft, S. A., McKethan, A., & Owens, D. K. (2014). Care Coordination Measures Atlas Update. Agency for Healthcare Research and Quality (AHRQ Publication No. 14-0037-EF). Rockville, MD. https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapters3.html
• White, P. H., Cooley, W. C., Boudreau, A. A., et al. (2018). Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics, 142(5), e20182587. https://doi.org/10.1542/peds.2018-2587

13. Items of the Scale (Questionnaire)