SDOH Clinical Care
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SDOH Clinical Care, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 2.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-sdoh-clinicalcare/ and changes regularly. See the Directory of published versions

Resource Profile: SDOHCCGoal - Detailed Descriptions

Page standards status: Trial-use

Definitions for the SDOHCC-Goal resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Goal
Definition

For representation of SDOH goals.

ShortDescribes the intended SDOH-related objective(s) for a patient.
Comments

Many of the SDOHCC profiles reference one another. One flow supported by this IG is that QuestionnaireResponses result in Observations that can be used as evidence for Conditions that can lead to Goals, ServiceRequests and Procedures. However, alternatives paths are also possible.

2. Goal.achievementStatus
Must Supporttrue
4. Goal.category
SlicingThis element introduces a set of slices on Goal.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ $this
  • 6. Goal.category:SDOH
    Slice NameSDOH
    Definition

    An SDOH category assigned to the goal.

    Shorte.g., food-insecurity | transportation-insecurity
    Control0..*
    BindingThe codes SHALL be taken from SDOHCC ValueSet SDOH Category
    (required to http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory)

    Codes for high-level SDOH categories.

    Must Supporttrue
    Requirements

    Codes from this value set can be used to assign one or more SDOH categories (e.g., food-insecurity, transportation-insecurity, etc.) to a goal. It is recommended that SDOH category codes be used to facilitate searching for SDOH-related goals.

    8. Goal.description
    Comments

    If no code is available, use CodeableConcept.text.

    BindingThe codes SHOULD be taken from SDOHCC ValueSet LOINC SNOMEDCT
    (preferred to http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetLOINCSNOMEDCT)

    Codes providing the details of a particular goal. In many systems, only the text element will be used.

    Additional BindingsPurposeUsage
    SDOHCC ValueSet LOINC SNOMEDCTPreferredGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): digital-access
    SDOHCC ValueSet LOINC SNOMEDCTPreferredGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): digital-literacy
    Less Than High School Education Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): educational-attainment
    Elder Abuse Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): elder-abuse
    Unemployment Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): employment-status
    Financial Insecurity Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): financial-insecurity
    Food Insecurity Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): food-insecurity
    Health Insurance Coverage Status Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): health-insurance-coverage-status
    Homelessness Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): homelessness
    Housing Instability Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): housing-instability
    Inadequate Housing Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): inadequate-housing
    Intimate Partner Violence Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): intimate-partner-violence
    Material Hardship Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): material-hardship
    Medical Cost Burden Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): medical-cost-burden
    Health Literacy Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): personal-health-literacy
    Social Connection Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): social-connection
    Stress Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): stress
    Transportation Insecurity Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): transportation-insecurity
    Utility Insecurity Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): utility-insecurity
    Veteran Status Goals .ExtensibleGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): veteran-status
    SDOHCC ValueSet LOINC SNOMEDCTPreferredGoal.category (Details: SDOHCC-Goal code Goal.category = ' Goal.category ', stated as ' null '): sdoh-category-unspecified
    10. Goal.subject
    Definition

    Identifies the patient for whom the goal is being established.

    12. Goal.target
    14. Goal.target.measure
    BindingThe codes SHOULD be taken from LOINCCodes
    (preferred to http://hl7.org/fhir/ValueSet/observation-codes)

    Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.

    16. Goal.statusDate
    Comments

    To see the date for past statuses, query history.

    The Goal Resource does not clearly specify whether Goal.statusDate applies to Goal.achievementStatus or to Goal.lifecycleStatus. For consistent use in the SDOH context, it is recommended that Goal.statusDate be synchronized with Goal.achievementStatus.

    18. Goal.addresses
    TypeReference(Condition, Observation, RiskAssessment)
    SlicingThis element introduces a set of slices on Goal.addresses. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ resolve()
    • 20. Goal.addresses:SupportedAddresses
      Slice NameSupportedAddresses
      Control0..*
      TypeReference(SDOHCC Condition, SDOHCC Observation Screening Response, SDOHCC Observation Assessment)
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Requirements

      When a goal addresses SDOH screening response observations generated from a survey/questionnaire, SDOH assessment observations, or SDOH conditions, Goal.addresses should reference instances that comply with the SDOHCC Observation Screening Response, SDOHCC Condition, or SDOHCC Observation Assessment profiles. However, references to other instance types are also possible.

      22. Goal.outcomeCode
      Comments

      Note that this should not duplicate the goal status.

      Information represented by Goal.outcomeCode may overlap significantly with information represented by Goal.outcomeReference. Multiple approaches to representing the same information may negatively impact interoperability. Therefore, where there is significant overlap in information provided by Goal.outcomeCode and Goal.outcomeReference, it is recommended that Goal.outcomeReference should be used to provide details of goal outcomes.

      BindingThe codes SHOULD be taken from SDOHCC ValueSet LOINC SNOMEDCT
      (preferred to http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetLOINCSNOMEDCT)

      The result of the goal; e.g., "Food security", "Has access to a car ".

      24. Goal.outcomeReference
      Comments

      The goal outcome is independent of the outcome of the related activities. For example, if the Goal is to achieve a target body weight of 150 lb and a care plan activity is defined to diet, then the care plan’s activity outcome could be calories consumed whereas goal outcome is an observation for the actual body weight measured.

      Additionally, see comments for Goal.outcomeCode.

      SlicingThis element introduces a set of slices on Goal.outcomeReference. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ resolve()
      • 26. Goal.outcomeReference:SupportedOutcomeReference
        Slice NameSupportedOutcomeReference
        Control0..*
        TypeReference(SDOHCC Observation Screening Response, SDOHCC Observation Assessment)
        Must Supporttrue
        Must Support TypesNo must-support rules about the choice of types/profiles
        Requirements

        When a goal outcome can be represented by SDOH screening response observations or SDOH assessment observations, Goal.outcome should reference instances that comply with the SDOHCC Observation Screening Response or SDOHCC Observation Assessment profiles. However, references to other instance types are also possible.