Person-Centered Outcome Measures

With support from The John A. Hartford Foundation, The SCAN Foundation, and Gordon and Betty Moore Foundation, the National Committee for Quality Assurance (NCQA) joined forces with individuals and families, research experts and care organizations to develop the person-centered outcome (PCO) measures:

  • Measure 1: Goal Identification
  • Measure 2: Goal Follow-up
  • Measure 3: Goal Achievement

Person-centered outcomes” are personalized, structured, measurable goals identified by a person with complex health status or their care partner around what matters most to them at that time. These person-centered outcomes can be used for both care planning and quality measurement. NCQA identified two methods of tracking progress toward person-centered outcomes:

  • Goal attainment scaling: A structured approach to goal-setting that was originally developed for use in mental health settings[1] and has been widely used in rehabilitation [2,3] and geriatrics.[4,5] Using a continuum of five possible outcomes, an individual works with their clinician to define what it means to achieve the goal. To learn more about NCQA’s work around goal attainment scaling, please view our white paper Advancing Best Practices for Goal Attainment Scaling.
  • Patient-reported outcome measures (PROMs): Standardized questionnaires that allow individuals to report on how they function or feel with respect to their health, quality of life, mental well-being or health care experience that can be associated with the individuals goal.
  1. Kiresuk, T. J. (1968). Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal, 4(6), 443-453.
  2. Bovend’Eerdt, T. J. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clinical Rehabilitation, 23(4), 352-361.
  3. Turner-Stokes, L. (2009). Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clinical Rehabilitation.
  4. Morrow-Howell, N. Y. (1998). A standardized menu for goal attainment scaling in the care of frail elders. The Gerontologist, 38(6), 735-742.
  5. Rockwood, K. S. (1993). Use of goal attainment scaling in measuring clinically important change in the frail elderly. Journal of Clinical Epidemiology, 46(10), 1113-1118.

Building on Best Practices

We’ve built this approach based on our research on best practices to goal setting with older adults and adults with complex care needs and the work of national experts. We’ve found the best approach to goal setting includes having specific, measurable goals and a system in place to follow-up and revise goals as necessary.

Implementing Person-Centered Outcome Measures

“The whole point of my goal was to be able to get out and be more physically active, to the point where it doesn’t feel like a chore anymore. I’m not struggling to get out and be functional. And it’s amazing. Because going from not being able to do anything at all, to slowly starting to feel like my old self again, is kind of a miracle. I was able to play with my nieces and I was actually able to keep up. I feel better.”

Individual who completed the PCO approach with their clinician

To date, the NCQA PCO measures have been successfully tested in multiple care delivery settings (e.g., certified community behavioral health clinics, behavioral health homes, home-based primary care practice, home and community-based services (HCBS) programs, serious illness programs) in over 30 practices, with more than 300 clinicians (e.g., physicians, nurses, social workers, peer navigators, and care managers) and 9,800 individuals. The most recent phase of work (April 2021-March 2024), funded by The John A. Hartford Foundation and The SCAN Foundation, included measure testing with 17 sites across six states (California, Texas, Arizona, Ohio, New Jersey, and Tennessee). Findings from our testing suggest that individuals, care partners and providers found value in setting personalized measurable goals in care visits and that the person-centered outcome approach was feasible. The approach improves the care planning process and provides valuable data on the range of goals that are important to adults and their care partners.

Implementing Person-Centered Outcome Measures in Behavioral Health

Behavioral health encompasses a wide range of mental health and substance use conditions, therefore it can be challenging to develop standardized outcome metrics that can uniformly apply across various conditions and treatment environments. Although goals are often documented in many behavioral health settings, they frequently fail to report outcomes of goal achievement. However, the PCO measures enable the identification and tracking of progress towards these goals within a standardized framework, enhancing clarity in outcome reporting. Additionally, the PCO measures offer flexibility for individuals with chronic behavioral health conditions in recognizing incremental, nonlinear treatment outcomes. The adoption of the PCO measures can support behavioral health care settings in delivering person-centered care and bridge a significant gap in the quality measurement of behavioral health care services.

To learn more about the use and benefits of the PCO measures for behavioral healthcare please view our Behavioral Health Overview.

Between 2022 and 2024, NCQA certified community behavioral health clinics (CCBHCs) to test the feasibility, validity, and reliability of the person-centered outcomes approach with a behavioral health population. These sites included programs working with adults in outpatient mental and substance use settings, individuals with serious mental illness, and/or those involved in the justice system. Participating sites indicated that these measures improved patient engagement, assisted the clinician in identifying barriers to goal achievement and discussing activities or services that may be beneficial to them in meeting their goals.

“These measures are great. It sets a visual on the progress that is being made. We will be using this method as an ongoing practice. We have been able to identify that 1) it meets standards for many of our audits and 2) that clients have a better understanding of their goal.”

Participating Behavioral Health Clinician

Training Materials and Person-Centered Outcomes Approach Toolkit


We have developed free, self-led training modules that provide continued education credit for physicians, nurses and social workers to support clinicians implementing the PCO approach. Due to significant interest from behavioral health organizations, each training has two versions, one for primary care and long-term services and supports clinicians and the other for behavioral health. See below for links to our trainings on our Education Learning Management System.


Based on our learnings, NCQA has also developed a toolkit to support the implementation of the PCO approach and measures in organizations caring for people with complex health status and can serve as a standalone resource or companion to the online training modules. Each module in the toolkit outlines the steps needed to implement the PCO approach successfully including how to identify and document a SMART goal and how to use either goal attainment scaling or a PROM to track and follow-up on goals overtime.

Related Publications

Promoting Health Equity

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. The PCO measures drive care that matters to people and encourages organizations throughout the care continuum to work together in an integrated manner to help people achieve their health outcome goals. By organizing the healthcare system around what matters to people, their families and their community, we have the opportunity to deliver care that produces better health outcomes, in a more efficient, equitable and more cost-effective way.

NCQA has developed messaging around the measures that resonates with and demonstrates value for diverse populations and viewpoints, recruited and engaged organizations serving diverse populations for measure testing, and will be including comparison of race, ethnicity, preferred language, and social needs in measure testing analyses to understand the impact of these measures.

To learn more about how the PCO measures promote health equity, please view our PCO and Health Equity overview or view our Health Innovation Summit presentations:

What’s Next?

With funding from The John A. Hartford Foundation and The SCAN Foundation, NCQA is continuing this work through continued dissemination and implementation of the person-centered outcome measures to improve care in health plans.

This next phase of the work aims to

  • Identify structured processes for goal tracking and data reporting to accelerate the addition of the PCO measures to HEDIS® via a learning collaborative with three to five Special Needs Plans.
  • Build demand for the PCO measures via an outreach campaign with clear messages for State Medicaid programs, health plans and consumer advocacy leadership as well as populations who experience significant health disparities and barriers to accessing quality care.

NCQA will lead this work in collaboration with patient partners and a diverse multi-stakeholder advisory panel.

For information on how the PCO measures can impact your organization, please see our PCO Measures Overview or watch our March 28 Culmination Webinar where we shared the findings from our most recent learning collaboratives.

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