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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/person-centered-care
January 01, 2025 - Plans should specify the type and intensity of services to be delivered and treatment goals they target … The care plans incorporate the patient's treatment goals. … A patient's care plan for OUD treatment may include some or all the following elements: Goals: Includes … the patient's self-defined short- and long-term health and life goals and the action plan to achieve … members of the team should become skilled at introducing the process of developing life and health goals
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/monitor-patient-and-program-progress/tracking-patient-outcomes
February 01, 2024 - to achieve those goals progresses over time. … Treatment Plans and Goals. … For some, their main goal may be to reduce use of opioids, rather than stopping altogether. … need any additional supports or strategies to meet these goals. … While decreasing or eliminating substance use is often the primary goal of treatment, providers should
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/monitor-patient-outcomes/tracking-patient-outcomes
May 29, 2025 - continued substance use is not a reason to discontinue providing medications for OUD because the primary goal … Patients' Treatment Goals: Progress toward patients' personal goals are useful to monitor, although … Patient's priority goal(s): It is important for patients to set goals for themselves such as reuniting … These goals may be the most motivating and rewarding to patients, which may help them stay in treatment … Patient reported goals for medications for opioid use disorder: A theory of proximal goal attainment.
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/patient-centered-care-plans
June 01, 2022 - medication-assisted treatment (MAT) patient’s care plan may include some or all of the following elements:
Goals … : Includes the patient’s self-defined short- and long-term health and life goals and the action plan … responsibilities —Identifies the members of the patient’s care team and notes who is responsible for specific goals … members of the team should become skilled at introducing the process of developing life and health goals
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integrationacademy.ahrq.gov/products/ibh-lexicon/functional-definition
January 01, 2025 - Practice teamwork is tailored to the needs of each patient and situation
Goal … Practice team members work together in biopsychosocial assessment and care
Goal: Teams … Care plans include (among other things): Goals of care with assigned team roles —specific goals and team … members responsible for achieving those care goals or tasks are identified. … But the goal is an integrated practice with its functions sustained financially. 35 Common differences
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integrationacademy.ahrq.gov/sites/default/files/2020-06/AHRQ_Lexicon_Collateral_Terms.pdf
January 01, 2020 - Primary Care
INTEGRATED BEHAVIORAL
HEALTH & PRIMARY CARE:
TERMS TO KNOW
WHAT TO WORK TOWARD: General Goals … Goals are quality health care, improved patient experience, and better use of
resources.
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/track-patients-and-monitor-their-outcomes
January 01, 2025 - If patients are not reaching treatment goals, treatment should be modified—this is often referred to … a system to track and monitor patients through treatment so patients who are not reaching treatment goals … For some conditions, instruments can be used to track progress toward treatment goals. … monitoring of treatment response, side effects, and how treatments are fitting the patient's life, goals
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integrationacademy.ahrq.gov/sites/default/files/2021-10/Treatment_plan_v1_7_16.pdf
January 01, 2021 - Referring Provider:
Diagnosis:
Problems:
Long Term Goals … Discharge Criteria:
Problem(s):
Short Term Goal
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/develop-shared-care-plan
August 01, 2025 - Team members must act in coordination toward a common goal to provide quality integrated care and avoid … A shared care plan may include some or all of the following elements: Team roles and goals—the team members … responsible for specific goals or tasks, including a list of other providers in the larger health network … The patient's short-term and long-term health goals and the action plan for achieving them. … One or more members of the team should become skilled at introducing the process of developing health goals
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/monitor-patient-and-program-progress/approaches-quality-improvement
April 01, 2024 - also known as “performance measures”) will help identify areas in need of improvement; set measurable goals … The measures used will vary based on the program’s goals, model, and capacity for analysis. … After selecting an area for improvement, the practice needs to create goals or objectives for the desired … These goals should be SMART ( S- Specific, M- Measurable, A- Achievable, R- Realistic/Relevant, T … encounter staff resistance. 7 The stages of a PDSA Cycle are 7, 8 : Plan —Identify the purpose and goal
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/pharmacotherapy
January 01, 2018 - When choosing medication, the goal should be to balance the risks and benefits of the medication, along … With the goal of harm reduction and removing barriers to treatment, these agreements might include the … It should also highlight the patient’s goals for treatment and adjustments that will be made if he or … These tests are supposed to help assess patient progress toward treatment goals, not to serve as a basis … Assess progress against treatment goals and revise these goals as needed using shared decisionmaking
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/monitor-patient-outcomes/approaches-to-quality-improvement
January 01, 2018 - also known as "performance measures") will help identify areas in need of improvement; set measurable goals … The measures used will vary based on the practice's goals, model, and capacity for analysis. … After selecting an area for improvement, create goals or objectives for the desired changes. … These goals should be SMART ( S- Specific, M- Measurable, A- Achievable, R- Realistic/Relevant, T … likely to encounter staff resistance. 8 The stages of a PDSA Cycle are: 9 Plan —Identify the purpose and goal
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/prevent-and-respond-to-recurrence
April 28, 2025 - Encouraging patients to set small, incremental goals can be more manageable than focusing on the overwhelming … These smaller goals can help patients feel empowered and maintain their focus on recovery.
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integrationacademy.ahrq.gov/sites/default/files/2020-06/AHRQ_Lexicon_Collateral_Snapshot.pdf
January 01, 2020 - The plan sets goals,
outlines treatments (including patient self-management), and documents progress
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/plan-integrate-mat-for-oud/developing-implementation-plan
June 01, 2022 - What are your goals? Define the scope of the goals and objectives you seek to achieve.
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integrationacademy.ahrq.gov/sites/default/files/2022-11/AcademyProjectSummary-11-22-2022.pdf
January 01, 2022 - Project Purpose, Goals and Objectives: The goal of this project is to provide continued
support for … health and primary care, and to increase the number of providers
capable of doing so, with the ultimate goal
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/chronic-pain
January 01, 2019 - Chronic pain treatment goals should be to reduce pain, maximize functioning, and improve quality of life … Aim to understand the patient's goals for pain relief. … Ask patients about their goals and expectations for function.
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integrationacademy.ahrq.gov/news-and-events/news/nam-action-collaborative-combatting-substance-use-and-opioid-crises
June 10, 2024 - The primary goal of the implementation pilot is to gather learnings on the feasibility and utility of … existing requirements, standards, and/or priorities, your team can make progress towards achieving your goals
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integrationacademy.ahrq.gov/sites/default/files/2020-06/Lexicon.pdf
January 01, 2020 - Goal is
100%--as in “standard work”.
5
6A. … Goal is
100%--as in “standard work”.
7. … Team roles and goals—specific goals and team members responsible for specific goals or tasks
2. … Goal is 100%--as in
“standard work”. … Goal is 100%--as in “standard
work”.
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/establish-protocols-identify-patients-who-could-benefit-integrated-care
February 01, 2025 - Staff members who understand the goals of integration can play an important role in connecting patients … Use the following steps to guide your workflow development: Reflect on your goal and your current performance … toward that goal. … For example, assess your current depression screening rate and set a goal for improving that rate. … As you learn from each successive small test of change, try your workflow on a larger scale with the goal