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.

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

This observation records how a patient rated their own progress score 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 what matters most to an individual. A Person-centered goal SHALL include either a Person-Centered Outcome category, or address a What Matters assessment.

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

A progress score observation for a person-centered goal.

Assessment observation for one aspect of What Matters Most to a person, with component values rating where a person is now and where they would like to be in the future.

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

The progress rating on goal attainment scaling.

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

Example value set to identify the category for PCO resources.

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

Example value set to identify focus areas from the VA Circle of Health. Whole Health is VA’s approach to care that supports your health and well-being. Whole Health centers around What Matters to you, not what is the matter with you. This means your health team will get to know you as a person, before working with you to develop a personalized health plan based on your values, needs, and goals.

Codes to identify content associated with this IG

NCQA goal domain codes used to identify the category for PCO resources.

Code system to identify “What Matters” concepts from the VA Whole Health appraoch and Circle of Health.

Code system to identify “What Matters” rating concepts.

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

Camila Lopez

Dorothy Jones

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

Baseline GAS score observation at start of goal.

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

Person-centered goal with attainment scaling extensions

Person-centered goal without attainment scaling or PROM

Maria Gonzalez, NBC-HWC

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

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

John Anderson, MD

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.