Purpose

SDOHCC Goal is generally intended to represent a goal established to address an identified social risk or need (i.e., SDOHCC Condition, SDOHCC Observation Screening Response, SDOHCC Observation Assessment). An SDOHCC ServiceRequest and SDOHCC Procedure can pertain to an SDOHCC Goal. See the Data Modeling Framework for more detail on the relationships between SDOHCC Goal and the other profiles in this IG.

Usage

Rather than offer a separate Goal profile for each SDOH category (also called domain – e.g., food insecurity, transportation insecurity), this profile can support any SDOH category. For Goal.description, the minimum value set bindings are specified in the profile. Additionally, based on the code selected for the optional Goal.category slice, the Table below provides the Gravity-vetted, preferred value sets for Goal.description. Where a preferred value set contains a code to describe a needed concept, servers SHOULD use that code.

The preferred value sets in the Table are hosted in the NIH Value Set Authority Center (VSAC). Social Determinants of Health Goals Value Set in VSAC is a grouper value set containing all members of the VSAC Value Sets below. The Gravity Project plans to continue to work with the HL7 Vocabulary WG to determine how best to represent and validate these preferred, category-specific value sets.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
Slices for category		0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:SDOH	S	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description		1..1	CodeableConcept	Code or text describing goal Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): Codes providing the details of a particular goal. In many systems, only the text element will be used.
subject		1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target
measure		0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
statusDate		0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory
Goal.description	preferred	SDOHCCValueSetLOINCSNOMEDCT
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC)
Goal.outcomeCode	preferred	SDOHCCValueSetLOINCSNOMEDCT

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
lifecycleStatus	?!SΣ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): Codes providing the details of a particular goal. In many systems, only the text element will be used.
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target	SC	0..*	BackboneElement	Target outcome for the goal
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
Slices for due[x]	Σ	0..1	date	Reach goal on or before Slice: Unordered, Closed by type:$this
due[x]:dueDate	SΣ	0..1	date	Reach goal on or before
statusDate	Σ	0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory
Goal.description	preferred	SDOHCCValueSetLOINCSNOMEDCT
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC)
Goal.outcomeCode	preferred	SDOHCCValueSetLOINCSNOMEDCT

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	External Ids for this goal
lifecycleStatus	?!SΣ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): Codes providing the details of a particular goal. In many systems, only the text element will be used.
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
start[x]	Σ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
startCodeableConcept			CodeableConcept
target	SC	0..*	BackboneElement	Target outcome for the goal
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
detail[x]	ΣC	0..1		The target value to be achieved Binding: (unbound) (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
detailQuantity			Quantity
detailRange			Range
detailCodeableConcept			CodeableConcept
detailString			string
detailBoolean			boolean
detailInteger			integer
detailRatio			Ratio
Slices for due[x]	Σ	0..1	date	Reach goal on or before Slice: Unordered, Closed by type:$this
due[x]:dueDate	SΣ	0..1	date	Reach goal on or before
statusDate	Σ	0..1	date	When goal status took effect
statusReason		0..1	string	Reason for current status
expressedBy	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
note		0..*	Annotation	Comments about the goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory
Goal.priority	preferred	GoalPriority
Goal.description	preferred	SDOHCCValueSetLOINCSNOMEDCT
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC)
Goal.target.detail[x]	example
Goal.outcomeCode	preferred	SDOHCCValueSetLOINCSNOMEDCT

Differential View

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
Slices for category		0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:SDOH	S	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description		1..1	CodeableConcept	Code or text describing goal Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): Codes providing the details of a particular goal. In many systems, only the text element will be used.
subject		1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target
measure		0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
statusDate		0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory
Goal.description	preferred	SDOHCCValueSetLOINCSNOMEDCT
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC)
Goal.outcomeCode	preferred	SDOHCCValueSetLOINCSNOMEDCT

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
lifecycleStatus	?!SΣ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): Codes providing the details of a particular goal. In many systems, only the text element will be used.
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target	SC	0..*	BackboneElement	Target outcome for the goal
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
Slices for due[x]	Σ	0..1	date	Reach goal on or before Slice: Unordered, Closed by type:$this
due[x]:dueDate	SΣ	0..1	date	Reach goal on or before
statusDate	Σ	0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory
Goal.description	preferred	SDOHCCValueSetLOINCSNOMEDCT
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC)
Goal.outcomeCode	preferred	SDOHCCValueSetLOINCSNOMEDCT

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	External Ids for this goal
lifecycleStatus	?!SΣ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): Codes providing the details of a particular goal. In many systems, only the text element will be used.
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
start[x]	Σ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
startCodeableConcept			CodeableConcept
target	SC	0..*	BackboneElement	Target outcome for the goal
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
detail[x]	ΣC	0..1		The target value to be achieved Binding: (unbound) (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
detailQuantity			Quantity
detailRange			Range
detailCodeableConcept			CodeableConcept
detailString			string
detailBoolean			boolean
detailInteger			integer
detailRatio			Ratio
Slices for due[x]	Σ	0..1	date	Reach goal on or before Slice: Unordered, Closed by type:$this
due[x]:dueDate	SΣ	0..1	date	Reach goal on or before
statusDate	Σ	0..1	date	When goal status took effect
statusReason		0..1	string	Reason for current status
expressedBy	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
note		0..*	Annotation	Comments about the goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: SDOHCC ValueSet LOINC SNOMEDCT (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory
Goal.priority	preferred	GoalPriority
Goal.description	preferred	SDOHCCValueSetLOINCSNOMEDCT
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC)
Goal.target.detail[x]	example
Goal.outcomeCode	preferred	SDOHCCValueSetLOINCSNOMEDCT

This structure is derived from USCoreGoalProfile

Summary

Must-Support: 4 elements

Structures

This structure refers to these other structures:

• SDOHCC Condition (http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-Condition)
• SDOHCC Observation Screening Response (http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-ObservationScreeningResponse)
• SDOHCC Observation Assessment (http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-ObservationAssessment)

Slices

This structure defines the following Slices:

• The element Goal.category is sliced based on the value of value:$this
• The element Goal.addresses is sliced based on the value of profile:resolve()
• The element Goal.outcomeReference is sliced based on the value of profile:resolve()