Person-Centered Outcomes (PCO) FHIR IG (Jira PSS-2480)

Everyone deserves fair and just access to high-quality health care that addresses their unique needs, reflects their diverse background and culture, and is designed to deliver the outcomes they want. This is particularly true for people with complex health care needs, many of whom are older adults who often receive care that may be misaligned with their needs and goals. Nearly 30% of Medicare beneficiaries have complex health care needs, and more than 14 million people in the U.S. need long-term services and supports. These numbers are growing every year. [1]

Goal-directed care in healthcare centers on setting and achieving specific, personalized goals that prioritize an individual's well-being and 'What Matters Most' to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify individual goals related to health outcomes, functional improvement, or symptom management. Once goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness.

The Person-Centered Outcomes (PCO) approach [2] focuses on setting and achieving specific, personalized, measurable goals that prioritize an individual's well-being and 'What Matters Most' to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify individual goals related to health outcomes, functional improvement, or symptom management. After goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness. Clinicians throughout the care continuum—from primary care to specialty care, to home and community-based services - can use this approach to identify what is important to a person (e.g., feeling well enough to visit grandchildren). This approach and its coordinating measures can help support and assess the quality of goal-directed care being implemented.

The need for the PCO IG was identified as a natural next step from the scope of the MCC eCare Plan FHIR IG STU1 which provided high-level guidance for Goals and measuring outcomes. As goal-directed care is growing in use and being incorporated into payment programs, the need for data standards around implementation and reporting are necessary. This IG will support implementers, researchers, and evaluators of goal-directed care planning to improve health outcomes.

[1] https://www.aarp.org/content/dam/aarp/ppi/2019/08/long-term-services-and-supports.doi.10.26419-2Fppi.00079.001.pdf

[2] https://www.ncqa.org/wp-content/uploads/NCQA-Person-Centered-Outcomes-Approach-Toolkit_2024.pdf