The Person-Centered Outcomes Approach Toolkit 

There is broad agreement that individuals’ priorities and health goals should guide their care, especially among adults with complex needs who face trade-offs in determining the right course of treatment. The National Committee for Quality Assurance (NCQA) joined forces with individuals and families, research experts, and care organizations, with support from The John A. Hartford Foundation (JAHF) and The SCAN Foundation (TSF) to develop the person-centered outcomes approach and measures to improve and incentivize care for the large and growing group of people with complex health status by capturing and measuring outcomes that matter to them.

Implementation of the person-centered outcomes approach requires multi-stage practice change, including training team members on the approach, adapting workflows and using quality improvement methods to achieve practice change and develop documentation structures. This toolkit is designed to support the implementation of the person-centered outcomes approach in organizations that care for people with complex health status. Each module outlines the steps needed to implement the person-centered outcomes approach successfully.

  • Module 1 introduces the person-centered outcomes approach and measures.
  • Module 2 summarizes the goal setting process and how clinicians can identify what matters most to an individual through a values conversation.
  • Module 3 describes the goal attainment scaling method and how clinicians can use goal attainment scaling to track progress on a goal identified as most important to an individual.
  • Module 4 provides background on Patient-Reported Outcome Measures (PROMs), the second method for tracking goal progress, and how clinicians can use PROMs to assess if an individual is progressing on their identified goals.
  • Each module has a resource section that contains forms and resources to support implementation of the person-centered outcomes approach.

This document was produced independently by NCQA with financial support from The John A. Hartford Foundation and The SCAN Foundation.

The John A. Hartford Foundation, based in New York City, is a private, nonpartisan philanthropy dedicated to improving the care of older adults. Established in 1929, the Foundation has three priority areas: creating age-friendly health systems, supporting family caregiving, and improving serious illness and end-of-life care. For more information, visit www.johnahartford.org and follow @johnahartford.

The SCAN Foundation envisions a society where all of us can age well with purpose. We pursue this vision by igniting bold and equitable changes in how older adults age in both home and community. For more information, please visit www.TheSCANFoundation.org.

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