CMS SOM App. B, Tag G530

status, and must include, at a minimum, the following information:]

(2) The patient’s strengths, goals, and care preferences, including information that

may be used to demonstrate the patient's progress toward achievement of the goals

identified by the patient and the measurable outcomes identified by the HHA;

Interpretive Guidelines §484.55(c)(2)

Consistent with the principles of patient-centered care, the intent in identifying patient

strengths is to empower the patient to take an active role in his or her care. The HHA

must ask the patient to identify her or his own strengths and must also independently

identify the patient’s strengths to inform the plan of care and to set patient goals and

measurable outcomes. Examples of patient strengths identified by HHAs through

observation and by patient self-identification may include: awareness of disease status,

knowledge of medications, motivation and readiness for change, motivation/ability to

perform self-care and/or implement a therapeutic exercise program, understanding of a

dietary regimen for disease management, vocational interests/hobbies, interpersonal

relationships and supports, and financial stability.

The intent of assessing patient care preferences is to engage the patient to the greatest

degree possible to take an active role in their home care rather than placing the patient in

a passive recipient role by informing the patient what will be done for them and when.

“Patient goal” is defined as a patient-specific objective, adapted to each patient based on

the medical diagnosis, physician’s or allowed practitioner’s orders, comprehensive

assessment, patient input, and the specific treatments provided by the agency.

“Measurable outcome” is a change in health status, functional status, or knowledge,

which occurs over time in response to a health care intervention. Measurable outcomes

may include end-result functional and physical health improvement/stabilization, health

care utilization measures (hospitalization and emergency department use), and potentially

avoidable events. Because the nature of the change can be positive, negative, or neutral,

the actual change in patient health status can vary from patient to patient, ranging from

decline, no change, to improvement in patient condition or functioning.