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.

Generalized anxiety disorder 7-item assessment

Depression assessment 9-item panel

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

The progress rating on goal attainment scaling.

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.

Example value set to identify the goal domains 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 the VA Circle of Health.

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 types of readiness for change.

Code system to identify concepts from the VA Whole Health approach and Circle of Health.

Code system to identify observation codes for What Matters.

Care Plan for a person-centered goal using a PROM score measure.

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

Care Plan activity: Anti-inflammatory gel for knee pain to enable walking

Care Plan activity: Physical therapy to relieve pain related to walking

Care Plan activity: Initial personal action step toward goal of walking dog outside

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

Baseline GAS score observation at start of goal.

Barrier with a free-text description

Barrier for goal achievement

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

Person-centered goal with attainment scaling extensions

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

Person-centered goal without attainment scaling or PROM

Maria Gonzalez, NBC-HWC

Camila Lopez

Dorothy Jones

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

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

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

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 recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

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

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

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

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.

Person-centered goal with goal attainment scaling.

Person-centered goal focused on an individual's well-being. A Person-centered goal SHALL include either a PCO category, or address a What Matters assessment.

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

Person-centered goal with a Patient-Reported Outcome Measure (PROM) score target.

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.