Measure 2 - Goal Follow-up: % of individuals 18 years of age or older with a complex care need who received follow-up on their PCO goal within two weeks to six months of when the PCO goal and GAS or PROM were identified.

Measure 1 - Goal Identification: % of individuals 18 years of age and older with a complex care need who had a PCO goal identified resulting in completion of goal attainment scaling (GAS) or a Patient-Reported Outcome Measure (PROM) and development of an action plan.

FHIR helper expressions

Shared logic for Goal Attainment Scaling.

CQL logic for the Goal Follow-up Measure

CQL logic for the Goal Identification Measure

Shared CQL expressions for all Person-Centered Outcome libraries.

CQL logic for What Matters concepts.

Generalized anxiety disorder 7-item assessment

Depression assessment 9-item panel

A Questionnaire for a person's assessment of what matters most in their health and well-being.

A GAS score indicates how a patient, caregiver, or practitioner rated goal progress using goal attainment scaling.

Assessment observation about a barrier, bothersome symptom or health concern that interferes with goal achievement.

This observation records how a patient's progress is rated using a PROM assessment score.

A person-centered care plan SHALL reference a person-centered goal and SHALL include action steps that support progress toward achievement of the plan's goals and desired outcomes. A plan SHOULD address the person's stated priorities for what matters most to them. Action steps may include both treatment procedures and self-care steps identified by the person.

A person-centered goal using Goal Attainment Scaling (GAS) to measure its progress and achievement.

A person-centered goal is based on a values conversation with a patient to address what matters most to them.

Person-centered goal using a Patient-Reported Outcome Measure (PROM) score to measure its progress and achievement.

Personal Priorities Organizer is used to represent a set of person-centered goals, what matters assessment, or barriers in a preferred ranked order.

Assessment of a person's readiness for change including importance and confidence for making that change.

Assessment observation for What Matters to a person. May be a panel assessment with member observations.

Goal Attainment Scaling (GAS) is an extension used to specify five levels of attainment for a person-centered goal.

The score indicates how a patient, caregiver, or practitioner rated progress on goal attainment scaling.

Terminology codes for goal barrier assessment

Example value set containing types of goal barriers.

Value set to identify the goal domain category for PCO resources.

Target measure score codes used to track progress on patient-reported outcome measures (PROMs).

Categories for person-centered assessment or goals.

Terminology codes for readiness assessment types.

Example value set containing well-being domains from a Personal Health Inventory.

Example value set containing codes for What Matters observations.

Goal domain codes used to identify the category for PCO resources.

Code system to identify resource codes and category codes for Person-Centered Outcomes.

Code system to identify Personal Health Inventory concepts.

Code system to types of readiness for change.

Code system to identify observation codes for What Matters assessment.

Care Plan for a person-centered goal with action steps for achieving what matters most to that person.

Care Plan activity: Mindfulness coaching to support anxiety management

Baseline GAD-7 PROM score observation recorded by a Patient showing goal progress.

Follow-up GAD-7 PROM score observation recorded by a Patient showing goal progress.

Baseline GAS score observation at start of goal.

Follow-up GAS score observation recorded by a Patient showing goal progress.

Follow-up GAS score observation recorded by a Practitioner showing goal progress.

Barrier for goal achievement

Barrier with a free-text description

Person-centered goal with a PROM outcome target for GAD-7 score.

Person-centered goal with GAS extensions

Person-centered goal with GAS target measure and without GAS extensions

Dorothy Jones

Patient selecton of the most important items for well-being, goal barrier, and the most bothersome care trade-off

Maria Gonzalez, NBC-HWC

John Anderson, MD

Readiness assessment with two members

Readiness assessment of confidence to achieve a goal

Readiness assessment of importance for a goal

What Matters observation recorded by a Patient to indicate their focus area for well-being.

What Matters observation added by a Patient to record a free-text statement about a well-being focus area.

What Matters assessment observation panel.

What Matters assessment observation for future changes description.

What Matters assessment observation for future rating.

What Matters assessment observation for now rating.

What Matters assessment observation panel.

What Matters assessment observation for future rating.

What Matters assessment observation for now rating.

What Matters assessment observation for now reasons description.