Improving the Health Care Experience: Measuring What Matters to People Measuring Quality for Adults with Complex Needs

Person Driven Outcomes

With funding from The John A. Hartford Foundation and The SCAN Foundation, NCQA has developed an approach to individualized measurement for complex populations that is based on measuring how well organizations are helping individuals achieve personalized goals for their health and life. We call this approach person-driven outcomes . 

Person-Driven Outcomes Approach:

  1. Identify a person-centered goal using a goal inventory as a conversation starter 
  2. Identify an individualized approach to measuring the goal using NCQA’s What Matters Most digital application 
  3. Follow-up and measure progress on the goal 

Building on Best Practices in Goal Setting 

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

Piloting Person Driven Outcomes 

From March 2016 to October 2017, NCQA and seven organizations collaborated pilot the person-driven outcome approach. Findings from this pilot suggest that patients, caregivers, and providers found value in setting personalized measurable goals in care visits and the person-driven outcome approach was feasible. 

“I have found that in doing some of the things that we put down, there’s strength in me” (Patient)

“…using that tool was probably the first time…some of these people were asked what they wanted” (Nurse Care Manager)

These approaches improve the care planning process and provide valuable data on the range of goals that are important to adults and their caregivers. They can move us toward a more personalized approach to quality measurement for people with complex needs. 

What’s Next? 

With funding from The John A. Hartford Foundation and The SCAN Foundation, NCQA is continuing this work and conducting a demonstration. The three-year demonstration will measure quality of care by evaluating how well health care organizations help individuals achieve what matters most to them. 

This project will involve over 800 individuals, including patients, caregivers, and clinicians. Collaborating organizations include: 

  • Priority Health (Grand Rapids, MI) 
  • Kaiser Permanente Northwest (Portland, OR) 
  • Community Health Plan of Washington (Seattle, WA) 
  • MedStar Good Samaritan Hospital Center for Successful Aging (Baltimore, MD) 

The demonstration project aims to more fully test these approaches across organizations and demonstrate the importance, reliability, validity and usability of quality measures derived from the use of person-driven outcomes. 

For more information contact Erin Giovannetti at

Get Involved 

NCQA recently developed a mobile iPad application and a web-based portal for the person-driven outcomes approach and now seeks organizations to pilot this approach. Users will be able to collect and manage person-driven outcome data through this digital platform. The platform also allows the user to: 

  • Collect information using the mobile iPad application 
  • Generate reports for both patients and providers on the person-driven outcome
  • Generate a text summary of the outcomes for the patient’s medical record 
  • View and manage patient-level data through the web-based portal 

For more information, contact Eshane Wang at