Person-Centered Care Planning: Monitoring and Supporting Goal Attainment

March 9, 2016 · Jessica Briefer French

(NOTE: This is the final post in a three-part blog series evaluating person-centered care planning)

supporting goal

When people have multiple chronic conditions or permanent functional limitations, a cure isn’t often in the cards, so the focus becomes maintaining quality of life. Because everyone has different priorities, quality of life can only be defined by the individual. But NCQA’s research shows there is a way for care managers to help people achieve their quality-of-life goals: 1) make a plan with the individual, 2) monitor progress, 3) offer encouragement and 4) adjust the plan when necessary.

Successful organizations know that many factors influence a person’s ability to meet health goals—personal (motivation and readiness to change), environmental (stable housing, accessible transportation, social resources), clinical (drug interactions and side effects). Good care management identifies ways to support the individual and overcome barriers to success.researchpic2

For instance, one woman’s goal is to “keep moving, reduce pain and continue to go to church.” She and her care manager agree on a goal of losing 15 pounds over 6 months. They identify barriers—environmental (lack of transportation to a gym), habitual (snacking on junk food), financial (the gym is expensive). They then agree on how to knock those barriers down: transportation vouchers and admission tickets to a local pool; encouragement from the care manager to eat healthfully and exercise regularly.

Reaching the Goal

Reaching the goal also requires consistent monitoring and support. The care manager assesses progress and adjusts for setbacks or challenges.

Monitoring progress can be tailored to the individual’s needs. It may be formal, such as a comprehensive reassessment every 6 months. It may also be informal, such as a phone call or casual check-in.

Members of the care team can play a role, too. A personal care assistant who is in the home several days a week can be the “early warning system” of a changing condition (lower-than-usual energy level) or circumstances (the family caregiver is ill).

We know that people with complex needs—severe mental illness, cognitive or functional limitations, multiple chronic conditions—may never be cured. But we can help them preserve, or even improve, their quality of life. If care managers set a plan in motion, track its progress and meet emerging threats, they can build a relationship with the individual to ensure success.

Previous Posts: Read the first two parts of the series.

Part 1: “Do We Agree on What Matters Most?”

Part 2: “Eliciting and Negotiating Goals”


More information:

Setting Goals with Vulnerable People: A Collaborative Approach

Policy Approaches to Advancing Person-Centered Outcome Measurement

Goals to Care: How to keep the person in “person-centered”


Supported by grants from The SCAN Foundation and The John A. Hartford Foundation:


The SCAN Foundation—advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence. For more information, visit


The John A. Hartford Foundation, based in New York City, is a private, nonpartisan philanthropy dedicated to improving the care of older adults. For more information, please

SCANJohn Hartford FoundationNCQA

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