Person-Centered Outcomes, published by Mountain Lotus WellBeing LLC. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/mtnlotus/pco-ig/ and changes regularly. See the Directory of published versions

Feedback

This is a draft FHIR IG based on investigation and testing at two HL7 FHIR Connectathons.

• Goal-Directed Care Planning, May 2024
• Goal-Directed Care Planning, September 2024

We plan to submit a proposal to HL7 workgroup(s) for migrating this work into an HL7 published FHIR IG. Until then, please add an Issue on the GitHub repository or send feedback to Dave Carlson at dave@mtnlotus.com.

User Stories

Any feedback on User Stories or suggestions for additional stories?

Profiles

Questions for FHIR Connectathon participants on distinctions needed to select data for the quality measures shown below.

1. How do we determine that a person has “a complex care need?”

2. How do we distiguish a “PCO Goal” from other kinds of FHIR Goals?
   • Require a category from PCO Category value set defined by this IG?
   • Or, check for Goal.addresses relationship with a What Matters Assessment observation?
   • Or, check that a Goal satisfies either the GAS Goal or PROM Goal criteria listed below?
3. How do we distinguish a Goal with GAS from a Goal with PROM as measurement?
   • GAS Goal
     • Require 5 GAS extensions on each Goal?
     • Or, require Goal.target.measure = “Goal attainment scale” LOINC code?
   • PROM Goal
     • Require Goal.target.measure from a value set of PROM score LOINC codes?
4. How do we associate a PCO Goal with its progress score observations?
   • Require an Observation.focus relationship to a PCO Goal?
   • Or, require that the Observation.code SHALL equal the Goal.target.measure? Which would require that both GAS and PROM goals include a target measure code.

NCQA Measures

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.

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 3: Goal Achievement

% of individuals 18 years of age or older with a complex care need who achieved their PCO goal within two weeks to six months of when the PCO goal and GAS or PROM were identified.