PCO measures work in tandem with clinical care to help people living with complex health needs make progress toward a health goal that matters to them. PCO measures have three components:

• Identify a goal and document it in a structured way, using goal attainment scaling or a patient-reported outcome measure.
• Follow up on the goal.
• Assess achievement of the goal.

Clinicians across the care continuum and in community-based services can use this approach to identify what’s important to a person and support age-friendly care. Defining a person’s goals—and ensuring that their care is consistent with those goals—can reduce unwanted treatment, improve patient activation and lead to meaningful improvement.

Why It Matters

NCQA is currently moving the PCO measures for C-SNPs and D-SNPs through the HEDIS^® approval process, with the goal of incorporating the measures in Measurement Year (MY) 2027.  We are beginning with special needs plans because they have an existing practice to build on—they already include goal documentation as part of their care models. Plus, the Centers for Medicare & Medicaid Services (CMS) issued a new rule in August 2025 that requires goals to be person-centered and for care teams to follow up on the goals, which aligns with PCO measures.

“In the past ten years, NCQA has tested the PCO measures with over 30,000 patients and over 750 clinicians in a variety of care settings across 17 states,” says Daniela Lawton, NCQA’s Assistant Vice President of Quality Sciences Integration. “We’ve shown that clinicians are able to implement this approach and organizations are able to document and report the necessary data elements for the measures. We are excited to work toward incorporating the PCO measures into HEDIS.”

In Their Own Words: Partner Perspectives on PCO Measures

Our partners explain why they chose to participate in the D-SNP testing.

“Person-centered outcome measures are crucial for our membership as they empower members to take control of their health. This approach fosters better engagement and collaboration, ultimately leading to improved health outcomes. We volunteered for this testing process because our mission is to make a lasting difference in our members’ lives. Supporting our membership in developing their specific, member-driven goals and needs aligns perfectly with this mission. Through this testing, we have recognized that while members may fall within the same category, their individual needs can vary significantly. Generalized goals do not adequately address these unique needs. By focusing on member-driven and specific objectives, we can truly understand our members and provide the support they need to achieve their goals.”

Meghan Crane, MSW, LISW-S, CCM, Manager, Case Management, Integrated Care, CareSource

“Person-centered outcome measures represent a strategic evolution in how we define value and accountability in healthcare. For the D-SNP populations we serve, quality must extend beyond clinical indicators to reflect the goals, preferences and lived experiences that shape each member’s health journey. Our participation in NCQA’s testing initiative reflects our broader commitment to advancing a more integrated, person-centered model of care. By contributing insights from the communities we serve, we are helping shape the future of quality measurement while strengthening how person-centered principles are embedded across our long-term strategy, partnerships and performance framework.”

Dr. Christy Valentine Theard, President, Anthem Blue Cross and Blue Shield Medicaid, New York

“Person-centered outcome measures are especially important for the vulnerable populations we serve because they center care around what matters most to our members—their personal goals and lived experiences. Person-centered outcome goals help ensure we are supporting quality of life, independence and dignity.”

Esther Elefant RN, BSN, CRC, Director II of Health Care Management Services, Anthem Blue Cross and Blue Shield, New York

Lessons Learned from D-SNP Testing

NCQA evaluated PCO measures with two D-SNPs to assess whether goal conversations and documentation are feasible and can be integrated into existing SNP workflows. We provided technical assistance and reviewed data submissions to identify areas for improvement.

“Our testing confirms that the PCO measures are feasible, adaptable to diverse systems and capable of driving person-centered care,” says Lawton. “Goal identification had the highest compliance among D-SNPs. Performance rates for goal follow-up and goal achievement were lower, which is consistent with our past testing efforts.”

Here are some of the lessons learned that can help clinicians as they prepare to implement PCO measures:

1. Focus on what matters to the person. A patient managing diabetes may be more motivated to feel well so they can attend a family event, rather than focusing solely on lab numbers. Ask probing questions to understand why the goal matters to them.
2. Identify a specific task or activity. Singular goals give people a clear focus. Rather than “get more active,” a person with diabetes might choose walking as the specific activity they want to increase.
3. Set a realistic time frame. All goals should be timebound. For example, walking 10–14 minutes daily for the next two months is more actionable than an open-ended commitment to move more.
4. Don’t expect perfection. Build wiggle room into the patient’s goal, so a missed day doesn’t mean failure. Adding “on average” can also help it feel less daunting. For example, setting a goal to walk 10 minutes daily, on average, over two months leaves wiggle room for a 5-minute or a 15-minute daily walk—giving the patient options without derailing progress.
5. Document all follow up discussions. Goal progress should be documented at every visit—even when the patient hasn’t advanced. During testing, we discovered that some clinicians were not documenting the follow-up conversation if the patient did not make enough progress toward their goal. If progress is stalling, check in: Is the goal still realistic? Use that conversation, not just the outcome, as the clinical record.

What’s Next

NCQA recently completed a public comment period for HEDIS MY 2027, which included a recommendation to add PCO measures for D-SNPs and C-SNPs. Institutional SNPs are not included. Next, the recommendation will move through NCQA’s committee process for consideration and approval.

We also see movement toward digitalization of goal-directed care through Health Level Seven (HL7^®), which presents opportunities to standardize the documentation required for the PCO measures. NCQA is participating in the HL7 Patient Care Work Group and co-developed the Person-Centered Outcome Implementation Guide (IG). The IG defines the standards for transmission of data in an interoperable format, such as Fast Interoperability Healthcare Resources (FHIR^®). It includes the steps to document goal-directed care, such as recording a goal, using goal attainment scaling or patient-reported outcome measures to track goals over time and goal follow-up. The IG should be released in the spring.

Learn More

The graphic below provides a high-level overview of PCO measures and how they work. Visit our resource page to learn more about PCO measures and how to implement them in your organization.

Acknowledgements

NCQA developed person-centered outcome measures with support from The John A. Hartford Foundation, The SCAN Foundation and the Gordon and Betty Moore Foundation.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HL7^® and FHIR^® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

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“We started developing PCO measures in 2015 to improve healthcare for patients with complex care needs,” says Julie Seibert, NCQA’s Assistant Vice President, Behavioral Health. “This project builds upon that work by updating the measures for adults with IDD and providing practitioners with tools to incorporate quality measures that align with person-centered goals into the treatment process.”

This initiative stems from NCQA’s partnership with IEC (Institute for Exceptional Care) on the IIDDEAL (Individuals with IDD Engaged, Aligned and Leading) project to conduct an environmental scan and work with self-advocates to build consensus on which quality measures are most appropriate and applicable for people with IDD. Read our blog post to learn more about our work with IIDDEAL.

How Can PCO Measures Support People with IDD?

Healthcare for adults with IDD is fragmented, costly and may not reflect what matters most to them. Quality measures can help improve care, yet NCQA’s environmental scan for the IIDDEAL project found only two quality measures that focus on adults with IDD—and many measures that exclude this population.

“Narrowly focused clinical outcome measures fail to capture the full range of treatment needs for people with IDD,” says Seibert. “That’s why it’s important to focus on person-centered goals.”

What Are the Goals of the Project?

Funding from the WITH Foundation will help NCQA collaborate with self-advocates and IEC to refine and adapt the PCO measures and resources for practitioners serving adults with IDD.

The project has three goals:

1. Equip practitioners with tailored tools and training to integrate the PCO approach.
2. Empower adults with IDD to identify person-centered goals.
3. Use PCO measures to assess care provided to adults with IDD.

NCQA will convene expert work groups that include individuals with IDD, caregivers, payers and clinicians serving adults with IDD to review updates to the PCO measures and resources and provide feedback. We will also develop online continuing education to show practitioners how to use the PCO measures and apply best practices for working with adults with IDD.

“We are working toward broad adoption of PCO measures and we’ve already incorporated them into some of our Accreditation and Recognition programs,” says Seibert. “We are grateful to the WITH Foundation for helping us advance the use of PCO measures to provide effective, high-quality, person-centered care for people with IDD.”

Learn more about NCQA’s PCO measures and their impact.

About the WITH Foundation

The WITH Foundation is committed to transforming healthcare to make it more inclusive and equitable for people with IDD. Since 2002, it has awarded over $17 million in funding to support organizations and projects that promote comprehensive and accessible healthcare for adults with IDD. Visit the WITH Foundation website to learn more.

The post NCQA Receives WITH Foundation Grant to Expand Use of Person-Centered Outcome Measures appeared first on NCQA.

Organization: Group Health Cooperative of South Central Wisconsin

Rating: 4.5 out of 5 Stars

Product Line: Commercial

State: WI

NCQA Health Plan Accreditation Status: Accredited

Group Health Cooperative of South Central Wisconsin’s Quality Story

Group Health Cooperative of South Central Wisconsin (GHC-SCW) is a non-profit, member-owned health plan providing high-quality health care and member-centered service to 70,000 members. As the first HMO in Dane County, Wisconsin, GHC-SCW pioneered a shift in the health care landscape by bringing health insurance and care delivery together.

What does earning a 4.5-star rating from NCQA’s Health Plan Ratings mean to your organization?

Earning a 4.5-star rating from NCQA for our commercial plan is a direct reflection of the commitment to excellence, compassion and constant pursuit of improvement shown by our care teams, administrative staff and every individual who works to serve our members and our community. This achievement highlights the high-quality, safe and compassionate care we provide to our members. Our team understands the meaning and value behind the NCQA rating, supports the efforts that led to this success and proudly celebrates this shared accomplishment.

What strategic priorities guided your journey toward achieving a 4.5-star rating?

Setting targets. We set a goal to reach the NCQA 90th percentile for HEDIS^® measures related to diabetes, hypertension and adult preventive care (e.g., cancer screenings, immunizations.) We also focused on building member trust and providing a positive experience to drive improvement in CAHPS^® scores.

Improving reporting capabilities. We transformed our reporting capabilities to allow department staff to monitor meaningful, real-time data.

Focusing on continuous improvement. These efforts were strengthened by our use of Lean principles and tools to ensure that our work is aligned with delivering better clinical outcomes and a positive member experience.

What unique processes or tools have you implemented to improve patient experience or clinical outcomes?

We are both a health plan and a care delivery system, so our quality teams maintain a close presence in clinics, enabling ongoing collaboration, education and two-way feedback. These relationships drive progress across clinical quality and patient experience initiatives. Clinically, we enhanced awareness of continuous glucose monitors among members and providers, including outreach to eligible members, provider training and piloting the monitors internally to deepen our understanding of how they work. We also strengthened collaborative care practices across clinical teams to better coordinate treatment.

What lessons did you learn that could help other health plans improve performance?

One key lesson is the vital importance of addressing social determinants of health, which play a significant role in closing care gaps. By identifying and actively addressing barriers, we can deliver more effective, equitable care and achieve better outcomes. Another important insight is the value of incorporating member feedback to help shape programs that truly reflect and respond to members’ needs.

How does your organization cultivate a culture of quality?

We place our members at the heart of everything we do, leveraging our integrated care model to deliver personalized, proactive care. Our culture is built on strong collaboration, a commitment to excellence and a mindset of continuous improvement that is guided by Lean principles. This approach empowers our workforce at every level to eliminate waste, streamline processes and focus on delivering the best possible health outcomes. Staff input is highly valued and encouraged, driving initiatives that not only improve clinical outcomes, but also enhance the overall member experience.

What are your next steps to continue improving HEDIS and CAHPS scores?

We will maintain HEDIS and CAHPS improvement as core components of our strategic plan, keeping these metrics aligned with our True North to deliver exceptional quality and service, and ensure ongoing focus on what matters most to our organization and members.

Learn More

Explore the 2025 Health Plan Ratings and find out how we calculate the ratings.

Learn more about NCQA’s Health Plan Accreditation.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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Real-time Visual Notes created by Ink Factory.

Thanks to everyone who attended this year’s Health Innovation Summit and made it a success! And if you couldn’t be there, keep reading for takeaways from the keynote session, Setting the Bar: Quality and Impact in Behavioral Health Innovation.

Moderator Geoffrey Neimark of Community Care Behavioral Health led a conversation with industry experts—Kate McEvoy of the National Association of Medicaid Directors and Michael Tang of Cityblock Health—about the risks and opportunities technology brings to behavioral health, especially for underserved populations.

Many factors contribute to the demand for behavioral health services: COVID pandemic isolation and social disconnection; overuse of alcohol, opioids and stimulants; the destigmatizing of behavioral conditions; increased behavioral health screening; the negative impact of social media. Unfortunately, the increase in demand coincides with a decrease in the number of practitioners.

“Behavioral health is primed to leverage technology to solve some of the access challenges,” says Neimark. “But there are also concerns about quality, equity and trust.”

Leveraging Technology in Behavioral Health

Telehealth is an effective way to improve access to behavioral health and substance use disorder care. Tang shared the story of a patient with schizophrenia who struggled to remember to take his pills every day and wanted to receive his medications through a shot. “I can supervise the patient virtually, even though I’m not in their home. Within minutes, I was on a virtual visit with him to assess his needs and discuss the medication,” says Tang.

McEvoy shared how Medicaid programs have embraced the use of technology to smooth the path to eligibility, improve access to services and supports through telehealth and enable better support and coordination of care for people with complex co-occurring needs.

“We recognize that different entities within state government—Medicaid, child welfare, departments of intellectual disability, the education system—all connect with children and families, but it’s been challenging to share data and coordinate efforts,” says McEvoy. “Interoperability can help identify needs and focus on those with the highest level of acuity.”

Risks of Using Technology and AI

Using AI with patients is a risk. “Many of our members come from minoritized communities and have distrust about new technologies. One of our core principles is that equity has to come first,” says Tang. “AI is part of care, but it’s not just AI by itself. It’s AI and humans working together to build trust and build relationships. We’re defining our AI governance processes and thinking cautiously about having AI work with our members.”

McEvoy also cautioned about the risk of relying too much on technology. “We’ve gone so far down the path with individualized home interventions, especially for older adults. We’re reexamining some programs to make sure we’re not contributing to social isolation, loneliness and depression.”

Technology and Health Literacy

While technology can provide many benefits, it’s not for everyone. Behavioral health organizations need to be thoughtful about how and where they implement technology, and consider limitations on broadband access or digital literacy.

“We’ve been surprised by the level of digital literacy of our members. People are texting and using their smartphones all the time,” says Tang. “But it is also situational. Sometimes our members can’t afford to pay their phone bill, so we need to be flexible and offer different ways for them to access services that are not technology dependent.”

Often, trust isn’t just about technology, it’s about the system itself. Having trusted messengers is also important. Community health workers or peer support specialists that share the same cultural background, speak the same language and have similar lived experience can build trust and, where appropriate, help facilitate the use of technology.

Evaluating the Use of Technology

Behavioral health organizations should consider these questions as they adopt new technologies:

• Who is the technology for—and who might it leave out?
• When is the technology solution appropriate—or inappropriate?
• Is the technology culturally responsive?
• Does the technology assume a certain level of digital literacy?
• How does the technology protect privacy and dignity?

“Technology cannot replace relationships. I’ve long been an advocate of group psychotherapy. It’s effective, it’s cost efficient, it amplifies access and it addresses social disconnection,” says Neimark. “I think we’re going to see a combination of growth in technology and growth in the human connection part of therapy.”

Join Us Next Year

Mark your calendar for the 2026 Health Innovation Summit, October 4–7, in Atlanta, Georgia. We hope to see you there!

The post Technology in Behavioral Health: Risks and Opportunities appeared first on NCQA.

Picture this scenario: A woman with diabetes visits her doctor and receives a prescription. But once she’s home, she struggles. She doesn’t fully understand the instructions for taking the medication because English isn’t her first language, and she doesn’t know anyone who can help her translate. She also worries about being able to afford both the medication and groceries.

On paper, her care plan looks complete—in reality, it’s falling short. That’s why whole-person care matters.

Whole-Person Care Is More Than Responding to Symptoms

Health is shaped by a person’s mental health, daily stresses, cultural background, ability to communicate and more. Whole-person care recognizes these factors and addresses them alongside appropriate medical needs.

When providers account for social and behavioral health factors as well as medical conditions, care becomes more relevant. A care plan that includes counseling, access to food resources and language support is far more likely to help this woman than merely prescribing medication.

Building an Integrated Platform

Of course, care coordination doesn’t happen on its own; it requires an integrated platform that brings together patients, health care professionals and health plans. When information flows, patients don’t have to repeat their stories, and care teams can see the full picture.

An effective platform does more than store data. A truly effective platform:

• Tracks medical, behavioral and social needs in real time.
• Stores language preferences for all health plan members.
• Clearly and succinctly presents the most critical needs relevant to members.
• Sends reminders and prompts so important steps aren’t missed.
• Allows seamless hand-offs between clinicians.

Strong platforms generate insights from member interactions and care delivery, then evolve based on what they learn—that’s what makes them dynamic and valuable. Internal innovation becomes even more powerful when paired with the health plan partner perspective. Plans might see patterns across populations and bring a systemwide view of areas where members struggle. When platform intelligence and partner insights come together, the results are meaningful, providing lasting improvements that make care more connected and effective.

Omnichannel Outreach: Meeting People Where They Are

But even the best-designed platform won’t work if patients aren’t engaged. Omnichannel outreach can fill communication gaps that hinder the ability to provide meaningful care. By offering multiple ways to connect—phone call, text, email, secure messaging portal, letter, home visit—care teams can reach members in ways that fit their daily lives.

For some members, a quick text reminder is enough. For others, a call from a trusted coordinator makes the difference. For members with limited internet access, a mailed letter or in-person visit may be the most reliable touchpoint.

Respecting communication preferences also means honoring language needs. A message that arrives in a patient’s preferred language, or a call that connects them directly to bilingual staff, can prevent misunderstandings that put health at risk. Warm transfers—connecting a member immediately to the right resource—can build trust, reduce frustration and prevent a lost care opportunity.

Done well, omnichannel outreach prevents people from slipping through the cracks.

Working Together With Health Plans

Health plans are essential partners in whole-person care. They bring in resources that extend beyond clinic walls; for example, transportation services, SDOH solutions and care management programs.

Partnership helps close gaps quickly. A health plan might identify members who are overdue for preventive screenings. The care team, using omnichannel outreach, can contact a member through their preferred method of communication—and even schedule the appointment during the same interaction. When plans and providers align, member interactions are easier, and members receive more support.

Health plans also strengthen the feedback loop with insights that help technology evolve in ways that reflect real-world needs. Feedback shapes how integrated platforms grow to not only meet today’s needs, but to anticipate tomorrow’s challenges.

The Future Is Connected

If overall member health and health care delivery are key objectives, whole-person care is a necessary component. Care integration—linking people, processes and technology—creates a system where members feel supported across every dimension of health.

When the perspective of care shifts to become holistic, people can be more engaged, follow through on treatment and achieve better outcomes. Providers, health plans and patients can all benefit from a connected network. Ultimately, care integration is about treating the person, not just the symptoms. And when the system connects in ways that feel seamless and supportive, everyone wins.

This blog is brought to you by MedWatchers and the views expressed are solely those of the sponsor.

The post Care Integration: Connecting People, Processes and Technology appeared first on NCQA.

Real-time Visual Notes created by Ink Factory.

The conversation continues at the Health Innovation Summit with an inspiring keynote session on reducing health disparities. Moderator Tamara Thomas of Aledade joined Donald Erwin and Alexandria Johnson of St. Thomas Community Health Center and Danielle Brooks of AmeriHealth Caritas to discuss practical, data-driven approaches to reducing health disparities.

“Our session is called Disrupting Disparities: Playbooks for Change. But we’re not talking about football plays—we’re talking about saving lives and doing so inclusively,” says Thomas. “When we think about the importance of these playbooks, it is much like football. You need to have a strategy, you need to have teamwork and sometimes you need to have the courage to call a different play when the old ones aren’t working. And today in health care, we need some new plays.”

How Collecting Data Helped Uncover Patient Needs

St. Thomas Community Health Center is a federally qualified health center (FQHC) in New Orleans that serves more than 22,000 patients each year across seven clinics. It has also earned NCQA’s Patient-Centered Medical Home Recognition.

Reducing No-Show Rates

In 2021, the no-show rate for appointments at St. Thomas was 35%. The team tried emails, text reminders and phone calls to patients, but nothing seemed to make a difference. They decided to start collecting data to understand what patients really wanted. Every time a patient requested an appointment, the staff noted the date they wanted to be seen, the practitioner they wanted to see and the type of appointment.

When they looked at the data, they identified a significant gap: 40% of patients wanted same-day care and 22% wanted next-day care, but St. Thomas had 3-4 week wait times for primary care appointments. The team made a drastic change to their scheduling practice to accommodate same-day and next-day care and the no-show rate decreased from 35% to 15%.

Improving Clinic Wait Times

Next, the team decided to tackle wait times in the clinics. “For our patient population, it’s crucial that we run on time because they have to get back to work or they have to get back to their children,” says Johnson. “When our clinic runs late, we force our patients to choose between getting the medical care they need or making sure they keep their job or meet their kids’ needs.”

Once again, the team at St. Thomas looked at the data: How long patients sat in the waiting room, how long it took to triage them, how long the patients waited to see the provider. And they found opportunities to improve at every step along the way. For example, they found that patients spent an average of 19 minutes with a practitioner, but appointments were only scheduled for 15 minutes. By extending scheduled appointment times to 20 minutes, they were able to improve timeliness.

“Patients are the experts in their own health care. If you listen to their voices clearly enough, you’re going to get a healthy dose of humility because they know what they’re talking about,” says Erwin. “They’ve told us a hundred times: ‘Stop trying to think for us.’ ‘Stop trying to think about what we want, or what we should want.’ So, we’re listening. And we still work every day to earn the trust of the folks in our community.”

The Power of Partnerships

Too often, health care operates in silos. Having opportunities to partner with industry stakeholders and the community can provide context to see if the solutions we are developing will actually work. Brooks shared her experience participating in NCQA’s Perinatal Health Measurement Advisory Panel, which gathered a wide range of perspectives—payers, care delivery organizations, patients, doulas, advocates—to focus on developing perinatal health measures from a perspective of lived experience.

“Data is wonderful, but data is imperfect and there can be bias in data,” says Brooks. “I can look at as much data as I want, but I also need that context and quantitative learning that comes from listening to the stories of the people in the room.”

Brooks also stressed the importance of viewing health care policy in a historical context. “These disparities are real. We can choose to act on them now, or they’ll get worse over time,” says Brooks. “What may be the policy today, may not be tomorrow. We need to continue to focus on communities, to take solace and learn from those that have gone before us.”

Donald Erwin Receives NCQA’s Health Quality Award

NCQA’s Founder and President, Peggy O’Kane made a surprise appearance at the end of the keynote session to present Erwin with the Health Quality Award. O’Kane first met Erwin when she visited New Orleans in the aftermath of Hurricane Katrina. The two worked closely together in the years that followed, helping to increase the number of FQHCs and patient-centered medical homes in Louisiana, and improving access to care for uninsured and under-insured people.

“My visits to St. Thomas were among the most moving experiences I’ve had in my career,” says O’Kane. “Donald Erwin is a true servant leader. He has dedicated his career to the pursuit of high-quality care for all—especially those who are too often left behind due to barriers in access, health status or lived experience. His tireless work, collaborative spirit and visionary leadership have improved countless lives. I am privileged to recognize him and his team’s work.”

Join Us Next Year

Mark your calendar for the 2026 Health Innovation Summit, October 4-7, in Atlanta, Georgia!

The post Disrupting Disparities With Data—And a Focus on Community appeared first on NCQA.

• 76% of adults report having at least one or more chronic conditions that impact their well-being—many that could be addressed through behavior change.
• U.S. adults report feeling physically unhealthy 4 days and mentally unhealthy 5 days in an average month.
• Only 51% of adults and 24% of children meet the guidelines for daily physical activity.

Digital health and wellness tools provide flexibility and accessibility, but they can also present risk. “With so many organizations entering into the digital health and wellness market, we need proof that these solutions actually improve people’s health and well-being,” says Vik Wadhwani, NCQA’s Chief Product and Transformation Officer. “It’s time to take a look at how we define success, and create a shared vision of what a high-quality, high-impact program looks like.”

Innovations in Wellness and Condition Management Working Group

“Health care is a resource constrained environment,” says Wadhwani. “Improving the overall health and well-being of a population has always been about managing health risk, but many organizations focus on patients experiencing the highest risk, instead of engaging with lower risk populations to help them stay healthy.”

NCQA recently invited organizations to join a working group to explore how the health care field should deliver, manage and assess interventions to support wellness, health promotion and condition management. The group included perspectives from payers, employers, vendors and solution providers, industry experts, health systems, clinicians and patients.

“So much of health happens outside the walls of health care. Empowering and supporting people to make healthy choices is key to improving population health and quality outcomes,” says Rachel Harrington, NCQA’s Senior Product Strategist. “We want to help shape the conversation in a collaborative way and understand how quality programs can elevate clinical and business best practice going forward.”

NCQA develops standards, measures and tools to support an integrated, effective, efficient health care quality ecosystem. The working group will help us understand current trends in wellness and condition management, define evidence-based best practices and identify ways that organizations can help people feel engaged and empowered to manage their own health.

What We’ve Learned So Far

The working group met for the first time on September 24. Participants welcomed the opportunity to engage and discuss how they can work together to bridge the gaps between health plans, employers, vendors and health systems to improve the patient experience. Here are some key themes from the conversation.

• Wellness is a continuum. People don’t classify themselves as healthy or sick; they live on a continuum that changes from day to day. Programs should adapt to their changing needs.
• Simplicity is key. Programs should have a simple design, focus on patient activation and engagement and encompass preventive screenings as well as healthy behaviors. As one participant said, “Programs must be engaging enough to become routine.”
• AI is top of mind. Organizations are interested in exploring use cases, such as risk segmentation and personalized engagement, as well as AI guardrails and risk mitigation.
• There’s no substitute for human connection. Technology should support human interaction, not replace it. Participants warned against the desire to “over-automate” and risk alienating staff and patients.
• Data lag is a major pain point. Organizations don’t want to wait for results. Successful programs must include timely data sharing among health plans, employers, health systems and vendors.
• Measurement is challenging. Barriers to measuring patient engagement include limited data access, linking patient goals to longer term outcomes and the need to customize approaches to meet patients where they are.
• Behavior change is the ultimate goal. Metrics that focus on behavior change have more value than technology milestones (e.g., app usage, click rates). As one participant shared, “Tech metrics can help fine-tune the journey, but they aren’t outcomes.”

“We have a diverse group of organizations trying to meet the needs of diverse groups of people, so naturally, there’s going to be spirited discussion and debate,” says Harrington. “The purpose of the working group is to find areas of alignment and build consensus around approaches that will yield the best results for patients.”

What’s Next

The working group will continue to meet over the coming months, so stay tuned for future updates!

Curious to learn more about how wellness programs are designed, implemented and evaluated? Join our upcoming webinar series Whole Care, Better Outcomes: Acting at the Intersection of Wellness and Quality. Each session will share a different case study, and include time for open discussion. Register for the first webinar on October 30, featuring Sharecare.

If your organization is interested in working through the real-world challenges of data flow and measuring outcomes, considering participating in our Learning Collaborative starting this fall. Contact Jeni Soucie, Senior Manager, Product Management, for more information.

Thanks to Our Partners

NCQA appreciates the insights from the participants in the Innovations in Wellness and Condition Management Stakeholder Working Group.

The post Defining Best Practices in Wellness and Digital Patient Engagement: What We’ve Learned So Far appeared first on NCQA.

• Over $730 billion in U.S. health care spending is linked to modifiable risk factors such as high blood pressure and poor diet.
• In 2023, 76% of adults in the U.S. reported having at least one or more chronic conditions that could significantly impact their well-being.
• Every $1 spent on wellness programs can save the health system around $3 in medical costs.

Solutions focused on digital, patient-centered wellness and condition management can help employers, payers and health systems meet the needs of their populations—but meaningful engagement must be the priority.

About the Innovations in Wellness and Condition Management Working Group

NCQA’s goal is to inform and shape best practices in digital wellness, condition management and patient engagement. We are convening a Working Group of participants from across the health ecosystem: providers, health systems, vendors focused on wellness and digital condition management, payers, patient advocates, policymakers, employers. We welcome participation from organizations that are familiar with NCQA, including current customers, and from those who have not yet engaged with us.

Participants will join an initial convening in September, with the potential for additional engagement in the coming months. Key discussion topics will include:

• Best practices for delivering wellness, health promotion and condition management services.
• Current challenges and emerging opportunities for improving patient engagement and outcomes.
• Demonstrating meaningful return on investment.
• Whether wellness and health promotion are distinct from condition management or part of a unified strategy.

Participants will share information about their approach to digital patient engagement and patient-centered wellness and condition management solutions. Information shared with NCQA will be confidential. NCQA will use the information to support updates to existing programs or development of new programs to help ensure they align with industry needs.

Why NCQA?

For 35 years, NCQA has been a trusted voice in health care quality and performance measurement. Our experience positions us to help set benchmarks that promote fairness, safety, transparency and improved health outcomes across populations.

The Working Group will help NCQA identify, refine and validate emerging needs in patient engagement, wellness and condition management. It is a unique opportunity to:

• Shape the future of how health care defines “best in class” solutions and frameworks for engaging patients on wellness and condition management.
• Share lessons learned and emerging practices.
• Collaborate and network with peers across the industry.
• Inform NCQA’s future and updated offerings in patient engagement, wellness and condition management.

Participating organizations will be listed on NCQA’s website and social media, and can promote their role in the Working Group with joint media releases with NCQA and independently, with NCQA-approved statements.

Apply Today!

Our goal is to recruit up to 30 organizations to participate. If you’re interested in joining the Working Group, review the Working Group Request for Participation for more information. Applicants must provide information about their organization’s size, scope and role in patient engagement, wellness and condition management, relevant experience and key personnel.

Submit your application here. The application deadline is September 10, and the first meeting will be held virtually on September 24. Organizations must cover their expenses related to participation in the Working Group.

The post Apply to Join NCQA’s Innovations in Wellness and Condition Management Stakeholder Working Group appeared first on NCQA.

Peers are another avenue of support in the behavioral care system—their shared experience related to mental health, addiction and recovery helps them build trust relationships. Many studies show the benefits of peer support: decreased days in inpatient care, increased engagement in outpatient treatment, reduced readmission rates and lower relapse rates.

“There’s a stigma associated with receiving mental health and substance use treatment,” says Chrissy Craig, NCQA’s Senior Health Care Analyst. “Because of their lived experience, peers can connect with people who may not be ready to engage in traditional treatment approaches. They can build trust and encourage individuals to get the help they need.”

HEDIS and Peer Support

Recognizing the importance of peer support, NCQA has added it as an option for follow-up care in four HEDIS^® measures:

• Follow-Up After Emergency Department Visit for Substance Use (FUA).
• Follow-Up After Hospitalization for Mental Illness (FUH).
• Follow-Up After Emergency Department Visit for Mental Illness (FUM).
• Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) (MY 2026).

“Peer support can help alleviate the behavioral health workforce shortage and provide timely access to care, but adequate reimbursement is a challenge,” says Sarah Sweeney, NCQA’s Assistant Director, Behavioral Health. “Including peer support as follow-up care in HEDIS demonstrates its value, and can further legitimize its role in behavioral health.”

Peer Support in Action

Peer support was a hot topic at the 2025 Health Quality Forum. Here are some real-world insights from NCQA’s panel, Innovative Solutions in Behavioral Health:

• Peer support is about building a relationship and focusing on what matters to the individual.
• People struggle to stay in recovery. Being able to talk to someone who went through something similar—and is in recovery—can be a powerful inspiration.
• Peers live in the communities they serve and meet people where they are—and that doesn’t necessarily happen on a 9 to 5 schedule.
• There are many examples of when peer support can be effective:
  • With the family of a child with a significant mental health challenge, or who is lost in the system.
  • With parents who have lost custody of a child and don’t have the support they need.
  • With adolescents and young adults in mental health or substance use treatment in an inpatient or partial hospitalization program.
  • With people in shelters or living in homeless encampments who may need help getting services and support.
• Peer support can help alleviate issues of access and availability of care by connecting people with services.
• Behavioral health organizations need more leaders with lived experience who understand the system’s limitations and can help develop innovative solutions.

Learn More

Visit NCQA’s Behavioral Health Resource Center to learn more about our programs and research.

Read our white paper Defining the Behavioral Health Workforce: The Need for a Standardized Typology.

 HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post How Peer Support Can Help Close the Gaps in Behavioral Healthcare appeared first on NCQA.

Implementing measurement-based care supports person-centered care and makes it easier to evaluate care quality. My work at NCQA focuses on improving behavioral health outcomes—one way to do that is to get more clinicians to deliver measurement-based care.

I’m a clinical psychologist who was trained in measurement-based care in graduate school. No one taught me that it was a novel approach—I thought it was the norm. After I finished my PhD and started working in the real world, I discovered that it’s the exception.

What Is Measurement-Based Care?

The Interdepartmental Serious Mental Illness Coordinating Committee says measurement-based care is “a clinical process that uses standardized, valid, repeated measurements to track a client’s progress over time and to inform treatment, utilizing a shared patient-provider treatment-planning and treatment decision-making process.” It is often used interchangeably with measurement-informed care, which offers a more flexible approach to tracking treatment progress and making care decisions.

The goal is to measure consistently across patients and care settings using standardized measures. Measurements are repeated at regular intervals to track a patient’s symptoms, response to treatment and overall progress. Consistent measurement helps reveal patterns (whether a patient is worsening, stagnating or improving.) Most important, patients and clinicians work together to determine if a treatment approach is effective, or if it needs to be adjusted.

Benefits of Measurement-Based Care

• Improves treatment outcomes for a variety of conditions—including higher rates of response and remission, and lower rates of relapse.
• Provides concrete data to inform adjustments to treatment, such as changing medications or intensifying support.
• Improves communication and increases engagement by providing a structure for clinicians and patients to discuss treatment progress and goals.
• Increases provider accountability and transparency through objective data to show measurable improvements for value-based reimbursements.
• Enhances research efforts and supports analysis of real-world effectiveness of interventions and treatment response.

Support Is High, But Adoption Is Slow

Key professional organizations and federal agencies (e.g., the American Psychiatric Association, the Substance Abuse and Mental Health Services Administration, the Centers for Medicare & Medicaid Services) support measurement-based care, but studies show that fewer than 20% of behavioral health clinicians implement it—even though clinicians believe it enhances clinical decision making, strengthens therapeutic relationships and increases focus and efficiency of encounters.

One major barrier to adoption of measurement-based care is EHR integration—systems are simply not designed to capture, manage and share this type of data. Lack of interoperability and data standardization contribute to the problem. Clinicians also need more training on how to implement measurement-based care, and time in their schedules to do it. Reimbursement limitations can also impede adoption.

How NCQA’s Work Supports Measurement-Based Care

I’d like to highlight two areas where NCQA’s work supports adoption of measurement-based care.

HEDIS Measures for Depression Care. NCQA developed five measures related to depression care—two are focused on the prenatal and postpartum periods; three focus on the general population:

• Depression Screening and Follow-up for Adolescents and Adults (DSF-E). The percentage of members 12 years of age and older who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care within 30 days.
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E). The percentage of members 12 years of age and older with a diagnosis of depression and an outpatient visit with a PQH-9 (Patient Health Questionnaire) score present in their record.
• Depression Remission or Response for Adolescents and Adults (DRR-E). The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 4–8 months of the elevated score.

HEDIS measures encourage clinicians to measure and track patients’ progress over time—an important component of measurement-based care. These measures are reported using Electronic Clinical Data Systems, so they require integration with EHRs.

Person-Centered Outcome Measures for Behavioral Health. With support from The John A. Hartford Foundation, The SCAN Foundation and The Gordon and Betty Moore Foundation, NCQA developed Person-Centered Outcome measures to identify and track progress against patient-defined goals within a standardized framework. These measures have three components:

• Identify a goal and document it using goal attainment scaling or a patient-reported outcome measure.
• Follow up on the goal.
• Measure achievement of the goal.

The PCO measures were initially designed for individuals with complex care needs, but NCQA adapted them for behavioral health and tested them in Certified Community Behavioral Health Clinics to understand the opportunities and implementation challenges.

Conclusion

Measurement-based care is a collaborative effort that empowers patients to make progress toward their goals and achieve better outcomes. Support from key organizations and robust research evidence underscore its importance, but slow adoption highlights the need for systemic change. By addressing barriers to implementation, we can pave the way for a future where measurement-based care becomes the standard of care in behavioral health.

Learn More

• Get more information about HEDIS Depression Screening measures.
• Read about PCO Measures for Behavioral Health.
• Take one of our free online courses.
  • Identifying and Developing a Person-Centered Outcome Goal (Behavioral Health Version)
  • Using Goal Attainment Scaling to Document and Track Person-Centered Outcome Goals (Behavioral Health Version)
  • Using Patient-Reported Outcome Measures to Document and Track Person-Centered Outcome Goals (Behavioral Health Version)
• Download the Person-Centered Outcomes Approach Toolkit.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post Measurement-Based Care in Behavioral Health: Let’s Keep Moving Forward appeared first on NCQA.