Making the Person-Centered Care Plan the Next Frontier in Interoperability

By: Evelyn Gallego, MBA, MPH, CPHIMS , CEO & Founder EMI Advisors LLC, Co-Founder Gravity Project

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Maria has an intellectual disability and receives home-based support five days a week. Her individual service plan details how she likes her meals, which morning routines calm her, and which caregivers she trusts. When she lands in the emergency room at 2 AM, none of this is visible to the hospital team. Her mother is called in to translate. Again.

Maria’s story is not a rare event. It is the status quo.

Across the country, care teams caring for the same person cannot see each other's plans. Goals set by a home health nurse never reach the primary care provider. A person's preference for independent living never reaches the hospital discharge planner. Family caregivers are left to stitch the story together themselves. The result is medical errors, unnecessary visits, avoidable hospitalizations, and suboptimal care.

The person-centered care plan holds the most important information about a person's life. Yet, this information is rarely used as it lives in a single system, a single agency, a single workflow. It needs to follow the person.

How I Got Here

For those familiar with my data interoperability journey, you know it all started with care planning standards. Long before the Gravity Project, I helped develop the electronic Long-Term Services and Supports (eLTSS) Dataset, a 56-element specification for representing what a person needs, wants, and receives in home and community-based services (HCBS). Help with bathing. A ride to dialysis. Support managing a chronic condition. At the time, no shared vocabulary existed to represent the individual’s “Assessed Need”. These needs, captured through formal assessment, anchor the person-centered service plan.

The language gap is why I co-founded the Gravity Project in 2019. Gravity was not the destination. It was the vocabulary layer we had to build so that electronic person-centered plans could carry meaning across settings and disparate health IT systems. Seven years and thousands of participants later, Gravity Project has largely closed the gap. Now it is time to return to the care plan itself.

Why Now

Every value-based program of the last decade has required care coordination across providers and settings. The Medicare Shared Savings Program requires Accountable Care Organizations (ACOs) to adopt a patient-centered focus. The Conditions of Participation for home health and long-term care rest on comprehensive, person-centered care planning. The Medicaid Access Rule requires states to report on person-centered planning measures. The next generation of Centers for Medicare & Medicaid Services (CMS) Innovation Center models pushes further still. The ACCESS Model, launching July 2026, ties payment to chronic care outcomes and requires participants to exchange data bidirectionally with a health information exchange (HIE) and submit outcomes to CMS via an HL7® Fast Healthcare Interoperability Resources (FHIR®) based application program interface (API). And underneath all of it, the CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage, Medicaid, Children’s Health Insurance Program (CHIP), and Marketplace payers to stand up FHIR-based Patient Access, Provider Access, and Payer-to-Payer APIs. Care plan data is in scope.

Federal policy is driving care to be plan-driven, person-centered, and coordinated across teams, with care plan data exchanged through FHIR. Yet the infrastructure lags. Most care plans still live in one system and travel by fax.

The urgency is more acute in rural communities, where the care team is rarely in the same place. A patient may see a primary care provider in one county, a specialist two hours away, a home health nurse weekly, and a case manager by phone. Rural residents have higher rates of multiple chronic conditions, 70 percent of people 65 and older will need LTSS before they die, and rural communities are aging faster than the rest of the country. For these populations, a comprehensive shared care plan is essential.

The CMS Rural Health Transformation Program is the largest federal investment ever made in rural health delivery. In December 2025, CMS awarded $50 billion across all 50 states, with approved uses including digital health tools and regional collaborations. Federal interoperability rules, Medicaid reporting requirements, ONC certification criteria, and the new CMS Innovation models are drawing states, payers, HIEs, vendors, and providers toward FHIR-based exchange. These dollars can reinforce that convergence or fragment it.

The Rails Are Already Built

The good news: we are not starting from scratch. The U.S. Department of Health & Human Services (HHS) described a unified approach to health data exchange built on three building blocks: U.S. Core Data for Interoperability (USCDI), FHIR, and the Trusted Exchange Framework and Common Agreement (TEFCA). Care planning fits inside all three. USCDI v6 establishes Care Plan as a data class, building on Goals, Health Concerns, Problems, and Assessment and Plan of Treatment that have been in USCDI since v3. Care plans have long been a criterion in the ONC Health IT Certification program. TEFCA is operational, exchanging data nationally through Qualified Health Information Networks (QHINs).

Most importantly, care planning FHIR Implementation Guides (IGs) already exist:

• The eLTSS FHIR IG carries LTSS service plan data across case management, HCBS providers, and clinical providers.

• The Multiple Chronic Conditions (MCC) eCare Plan FHIR IG, developed with the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) and the Agency for Healthcare Research & Quality (AHRQ), supports shared longitudinal care planning for people with chronic kidney disease, type 2 diabetes, cardiovascular disease, chronic pain, and Long COVID.

• The Person-Centered Outcomes (PCO) FHIR IG captures whether a goal that matters to the person is being met, through Goal Attainment Scaling and patient-reported outcome measures.

Together, these three IGs represent the full arc of a person-centered plan: assessment, goals, interventions, and outcomes. What is missing is the connective tissue of coordinated implementation.

What Missouri Is Proving

Since HITECH, our team at EMI has helped shape the standards for care plans incorporated into federal policy and program workflows. That work has taught me one thing above all: standards only matter when they are implemented in real workflows, in real communities, with real accountability.

That is why the work we have been leading with the Missouri Department of Mental Health, Division of Developmental Disabilities, is so consequential. Beginning with a 2020 ONC Leading Edge Acceleration Project and scaled statewide with CMS HCBS funding, Missouri has implemented real-time, FHIR-based exchange of the state's Person-Centered Service Plan (PCSP) using the eLTSS FHIR IG. The plan moves, as structured data, across the state's systems, four health information networks, HCBS providers, and clinical providers, serving more than 15,000 individuals with intellectual and developmental disabilities.

It is the first statewide FHIR-based care plan implementation in the country.

Missouri has shown what the rest of the country is still debating: a state agency can serve as the source of truth for a person-centered plan and share it, in real time, with every provider on the team. And the implementation is feeding lessons back to HL7, shaping the next version of the eLTSS IG.

Missouri is the proof point. The opportunity now is to build from it, with new populations (older adults, multiple chronic conditions, behavioral health), new standards (MCC, PCO), and new sectors.

What We Need Now

No single organization can do this alone. It takes clinical providers, health systems, and ACOs. It takes community-based organizations, HCBS providers, state Medicaid agencies, HIEs, public health agencies, technology vendors, payers, and researchers. And most importantly, it takes the people and caregivers living with these plans. "What Matters Most" should stay at the center of every design choice.

The standards are necessary but not sufficient. What makes them real is shared implementation, tested use cases, governance that bridges sectors, and honest dialogue about what is working and what is not.

An Invitation

If you are implementing (or seriously thinking about implementing) FHIR-based care planning workflows, I want to hear from you. If you are designing a Rural Health Transformation Plan and wrestling with how to connect clinical, behavioral, social, and LTSS care, I want to hear from you. If you are a technology vendor ready to align with eLTSS, MCC, or PCO, I want to hear from you. And if you are a person or caregiver who has felt firsthand what a disconnected care plan costs, I especially want to hear from you!

My team and I at EMI are convening this conversation. We want to co-design the use cases. We want to bring implementers together to learn from each other and scale what works.

The standards are ready. The funding is available. The work ahead is ours to do together.

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