Person-Centered Outcome Measures (GID-E, GIF-E, GIA-E)

  1. Person-Centered Outcome – Goal Identification (GID-E). The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal.
  2. Person-Centered Outcome – Goal Follow-up (GIF-E). The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and followed up on the goal.
  3. Person-Centered Outcome – Goal Achievement (GIA-E). The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and achieved the goal.

Why It Matters

There is growing consensus that health care should be guided by individuals’ goals and preferences, particularly for adults with complex care needs.1 Individuals with multiple chronic conditions, functional limitations and/or behavioral health or social challenges are classified as having complex care needs, a group that comprises a substantial portion of the U.S. population. Using 2011 Medicare Expenditure Panel Survey (MEPS) data, researchers found that more than 194 million U.S. adults (76.4 percent) had at least one of the twelve selected classifications of chronic conditions, and approximately 131 million U.S. adults (51.4 percent) reported multiple chronic conditions.2 These individuals often face trade-offs when determining the appropriate course of treatment and frequently require services and supports beyond traditional medical care.2,3

Many quality measures focus on a single condition or disease and are typically based on evidence from clinical trials which underrepresent individuals with complex care needs. The causes and nature of complex care needs are varied and diverse, resulting in health-related concerns, experiences and preferences for care that may not align with single-disease guideline-based care.4,5

The PCO measures address limitations of traditional clinically focused outcome measures by individualizing assessment around the outcomes each person identifies as most important. This goal-based approach helps clinicians better understand what individuals value, as well as their preferences related to their conditions, potential treatments and associated tradeoffs, which can help fill an important gap in accountability for whole-person care.6 Individuals who perceive their visit as person-centered receive fewer diagnostic tests and referrals and lower rates of hospital utilization.7 One study found that incorporating goal-based care into the clinical workflow resulted in a statistically significant reduction in treatment burden (p<0.05); individuals in the intervention group were more likely to have medications stopped (52.0% vs. 33.8%) and had fewer diagnostic tests ordered (80.8% vs. 86.4%).8

Developed with financial support from The John A. Hartford Foundation and The SCAN Foundation. 

Historical Results – National Averages

Performance results for this measure are currently unavailable.

References

  1. Boeykens, D., Boeckxstaens, P., De Sutter, A., Lahousse, L., Pype, P., De Vriendt, P., Van de Velde, D., & Primary Care Academy. (2022). Goal-oriented care for patients with chronic conditions or multimorbidity in primary care: A scoping review and concept analysis. PLOS ONE, 17(2), e0262843. https://doi.org/10.1371/journal.pone.0262843
  2. Watson, K. B., Wiltz, J. L., Nhim, K., Kaufmann, R. B., Thomas, C. W., & Greenlund, K. J. (2025). Trends in multiple chronic conditions among US adults, by life stage, Behavioral Risk Factor Surveillance System, 2013–2023. Preventing Chronic Disease, 22, E15. https://doi.org/10.5888/pcd22.240539
  3. Ouellet, G. M., Ouellet, J. A., & Tinetti, M. E. (2024). Challenges in health care for persons with multiple chronic conditions-Where to go and how to get there? JAMA Network Open, 7(10), e2439837. https://doi.org/10.1001/jamanetworkopen.2024.39837
  4. Perron, M.-E., Hudon, C., Roux-Lévy, P.-H., & Poitras, M.-E. (2024). Shared decision-making with patients with complex care needs: A scoping review. BMC Primary Care, 25(1), 390. https://doi.org/10.1186/s12875-024-02633-9
  5. Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Torroella Carney, M., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-centered care planning for people living with or at risk for multiple chronic conditions. JAMA Network Open, 7(10), e2439851. https://doi.org/10.1001/jamanetworkopen.2024.39851
  6. Jennings, L. A., & Mold, J. W. (2024). Person-centered, goal-oriented care helped my patients improve their quality of life. Journal of the American Board of Family Medicine, 37(3), 506–511. https://doi.org/10.3122/jabfm.2023.230394R1
  7. Clay, A. M., & Parsh, B. (2016). Patient- and family-centered care: It’s not just for pediatrics anymore. AMA Journal of Ethics, 18(1), 40–44. https://doi.org/10.1001/journalofethics.2016.18.1.medu3-1601
  8. Tinetti, M. E., Naik, A. D., & Dodson, J. A. (2016). Moving From Disease-Centered to Patient Goals-Directed Care for Patients With Multiple Chronic Conditions: Patient Value-Based Care. JAMA Cardiology, 1(1), 9–10. https://doi.org/10.1001/jamacardio.2015.0248

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