Person-Centered Outcomes (PCO) Implementation Guide
1.0.0-ballot - STU 1 Ballot
Person-Centered Outcomes (PCO) Implementation Guide
1.0.0-ballot - STU 1 Ballot
This page is part of the Person-Centered Outcomes (PCO) Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions
| Page standards status: Informative |
The following user stories align with steps in the Person-Centered Outcomes Process Flow as shown on the Home page.
Dorothy’s primary care physician refers her to a Board Certified Health & Wellness Coach to identify and document Dorothy’s values and priorities for improving her health and well-being. Her coach asks Dorothy to complete a Personal Health Inventory with nine lifestyle areas including Moving the Body, Food & Drink, Family & Friends, Power of the Mind, and more. For each area, Dorothy rates herself with a number between 1 (low) and 5 (high) that best represents where she is now, and where she wants to be.
Two areas of her personal assessment stand out: Dorothy rated Friends & Family at 1 now with a desire to reach 4. She also rates Food & Drink at 2 now with a desire to reach 5. At the conclusion of this first health coaching session, their objective is to identify what matters most to Dorothy based on her personal values and priorities. Dorothy selects Family & Friends as what matters most to her at this time. She feels that making progress in this area will enable her to focus next on improving her diet by reducing stress eating.
Dorothy’s health coach uses motivational interviewing techniques to ask open-ended questions that identify Dorothy’s initial person-centered outcome goal to be more present when interacting with family and friends. By asking refining questions to rephrase the person-centered outcome goal as a SMART goal (Specific, Measurable, Achievable, Relevant and Time-bound), Dorothy arrives at a goal that focuses on what matters most to her:
Person-Centered Outcome Goal: I want to practice being present when interacting with family and friends in an uplifting way at least 3x monthly.
Dorothy’s health coach uses an additional motivational interviewing technique by asking her two questions about her readiness to pursue this goal:
Dorothy responds with scores of 8 and 3; important but not confident. Her coach asks what barriers or difficulties might be causing her to have low confidence, and Dorothy responds that she has a lot of anxiety in social situations.
Dorothy explains that her anxiety is causing substantial distress and interference with daily life activities. Dorothy is beginning to develop a fear of gathering with friends and family. She has declined many invitations to gatherings and recently her friends have stopped inviting her. Her worrying is causing a deterioration in family and friend connections, and she wants to overcome the fear of gathering with family and friends.
Together, they document all of these responses in a care planning system so that Dorothy’s choice of what matters most, her personal goal, her readiness ratings, and barriers are available to other members of her extended care team so that they all can help Dorothy to be successful.
Dorothy and her Board Certified Health & Wellness Coach choose goal attainment scaling as the method to document and track her person-centered outcome goal progress over time. They first put her person-centered outcome goal that they identified in the Realistic Goal (0) box of the scale.
| Worse (-2) | Current Status (-1) | Realistic Goal (0) | Better Than Expected (+1) | Much Better Than Expected (+2) |
|---|---|---|---|---|
| I practice being present when interacting with family and friends in an uplifting way at least 3x monthly. |
They then discuss where Dorothy currently is in being able to achieve her goal. Dorothy lets her coach know that currently she only sees her family and friends one to two times per month due to her severe anxiety disorder. This is added in the Current Status (-1) box of the scale.
| Worse (-2) | Current Status (-1) | Realistic Goal (0) | Better Than Expected (+1) | Much Better Than Expected (+2) |
|---|---|---|---|---|
| I practice being present when interacting with family and friends in an uplifting way 1-2x per month. | I practice being present when interacting with family and friends in an uplifting way at least 3x monthly. |
The coach then asks what would it mean for Dorothy to do even better than her realistic goal and even better than that. Dorothy tells her coach that being able to be present with her family and friends four times per month would be great and even better than that would be five times per month. Dorothy’s coach puts her responses in the Better Than Expected (+1) and Much Better Than Expected (+2) boxes of the scale.
| Worse (-2) | Current Status (-1) | Realistic Goal (0) | Better Than Expected (+1) | Much Better Than Expected (+2) |
|---|---|---|---|---|
| I practice being present when interacting with family and friends in an uplifting way 1-2x per month. | I practice being present when interacting with family and friends in an uplifting way at least 3x monthly. | I practice being present when interacting with family and friends in an uplifting way at least 4x monthly. | I practice being present when interacting with family and friends in an uplifting way at least 5x monthly. |
Finally, Dorothy and her coach discuss what would it look like if she did not work towards her goal. Dorothy lets her coach know that she would most likely not see her friends and family at all during the month because her anxiety would cause her to not leave the house. Her coach writes this down in the Worse (-2) box of the scale.
| Worse (-2) | Current Status (-1) | Realistic Goal (0) | Better Than Expected (+1) | Much Better Than Expected (+2) |
|---|---|---|---|---|
| I will not interact with family and friends at all each month. | I practice being present when interacting with family and friends in an uplifting way 1-2x per month. | I practice being present when interacting with family and friends in an uplifting way at least 3x monthly. | I practice being present when interacting with family and friends in an uplifting way at least 4x monthly. | I practice being present when interacting with family and friends in an uplifting way at least 5x monthly. |
The coach shares the scale with Dorothy and confirms that she agrees with each box in the scale and the expected outcomes. Dorothy agrees with what is documented in the system. They then start developing a care plan to support Dorothy in achieving her goal. The care plan along with the goal and scaling will be shared with Dorothy’s care team so they can support her in achieving her person-centered outcome goal.
Two months later, Dorothy meets with her coach to discuss her progress on her person-centered outcome goal. Her coach takes out the goal attainment scale that they completed at her initial (baseline) visit to see where she is on her progress.
For goal attainment scaling, to achieve a goal, the patient must have achieved their Realistic Goal (0) or better [Better Than Expected (+1) or Much Better Than Expected(+2)] by their follow-up visit.
| Worse (-2) | Current Status (-1) | Realistic Goal (0) | Better Than Expected (+1) | Much Better Than Expected (+2) |
|---|---|---|---|---|
| I will not interact with family and friends at all each month. | I practice being present when interacting with family and friends in an uplifting way 1-2x per month. | I practice being present when interacting with family and friends in an uplifting way at least 3x monthly. | I practice being present when interacting with family and friends in an uplifting way at least 4x monthly. | I practice being present when interacting with family and friends in an uplifting way at least 5x monthly. |
Achieved Goal Scenario
Dorothy tells her coach that she was able to be present when interacting with her family three times in the last month (Realistic Goal - 0 scale level) and achieved her goal! She explains that she followed the action steps they identified in her care plan and worked her way up to seeing them three times.
Did Not Achieve Goal by Follow-up Scenario
At her follow-up visit, Dorothy lets her coach know she is still really struggling to leave her house and has only been able to interact with her family once, putting her at Less Than Expected (-1) on the scale. Dorothy’s coach tells her there are a few options they can take as next steps.
Dorothy decides to keep the goal and scale as is and will follow-up with her coach in a month to discuss progress and achievement.
Dorothy returns to see her primary care doctor (PCP), Dr. Anderson, to review her person-centered outcome goal and create a care plan to achieve it. Dr. Anderson notes the identified barrier related to anxiety and chooses a patient-reported outcome measure (PROM) as the method to document and track her person-centered outcome goal progress over time. Due to Dorothy’s severe anxiety, her PCP chooses the GAD-7 as the PROM to use to track goal progress. The GAD-7 tool indicates whether Dorothy has generalized anxiety disorder (GAD) and will help Dorothy and her health coach understand and address her anxiety.
Dorothy’s first GAD-7 assessment yields a total score of 15 which will be her baseline score. For the GAD-7, a score from 0-4 means minimal anxiety, 5-9 indicates mild anxiety, 10-14 implies moderate anxiety, and a score from 15-21 carries a sign of severe anxiety.
They next agree on a target measure for her goal. Dr. Anderson explains that Dorothy’s baseline score of 15 indicates severe anxiety with physical and behavioral symptoms of anxiety and disrupts her ability to achieve her goal. For the GAD-7, a decrease of 4 points from the baseline score is considered meaningful change and will signify achievement. They then start developing a care plan to support Dorothy in achieving her goal. The care plan along with the goal, PROM used and PROM score will be shared with Dorothy’s care team so they can support her in achieving her person-centered outcome goal.
Dorothy completes several GAD-7 self-assessments every two weeks and shares the results with the rest of her care team, where they all can track progress on attainment of Dorothy's person-centered goal with a target to achieve a GAD-7 score equal to or less than 11. The GAD-7 scores taken every two weeks demonstrate Dorothy’s progress and can be recorded in the health system’s EHR record.
Achieved Goal and PROM Target Score
Dorothy retakes the GAD-7 at her two month visit and gets a score of 10. She also notified her health coach that she was able to be present when interacting with her family three times in the last month and achieved her goal! She explains that she followed the action steps they identified in her care plan and worked her way up to seeing them three times.The action steps helped her manage her anxiety symptoms and enabled her to interact with her family more.
Achieved Goal but Did Not Achieve PROM Target Score
Dorothy retakes the GAD-7 at her two month visit and gets a score of 13. However, she tells her health coach that she was able to be present when interacting with her family three times in the last month. Dorothy’s health coach first celebrates the success of meeting the goal with Dorothy. This is a huge accomplishment for Dorothy and shows that she is moving in the right direction. Although this is a win, Dorothy’s health coach still wants to understand why her anxiety symptoms are still impacting her so much. Dorothy lets her coach know that although she was able to interact with her family those 3 times, prior and after each visit her anxiety increases and she regrets going. Dorothy and her coach decide to review the action steps to see what worked and what could be improved. They also discuss and reevaluate the barriers causing her anxiety. Dorothy and her coach create new action steps and decide she will come back in a month to discuss her progress and retake the GAD-7 to see if her symptoms and anxiety are decreasing.
Did Not Achieve Goal and PROM Target Score
At her two month follow-up visit, Dorothy retakes the GAD-7 and gets a score of 15. Dorothy and her coach have a conversation about her progress and barriers and Dorothy shares that she is still really struggling to leave her house and has only been able to interact with her family once. Dorothy’s coach tells her there are a few options they can take as next steps.
☛ Many alternative tools have been developed and are in use that enable individuals to reflect on What Matters Most for their health & well-being. One example is the U.S. Department of Veterans Affairs Whole Health approach to care that includes a Circle of Health and Personal Health Inventory. The examples in this FHIR IG are based on VA's approach, but can be adapted to other assessments used by different organizations or for targeted patient populations.
☛ GAD-7: See Preferred vocabulary bound to value set represented by LOINC 69737-5 Generalized anxiety disorder 7 item (GAD-7)
IG © 2024+ HL7 International / Patient Care. Package hl7.fhir.us.pco#1.0.0-ballot based on FHIR 4.0.1. Generated 2025-03-28
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