Create a Goal resource conforming to the Gravity SDOH Goal profile, setting Goal.category to the appropriate Gravity SDOH category code that matches the associated SDOH Condition
Set Goal.description using a CodeableConcept from the Gravity SDOH Goal value set (SNOMED CT-based codes) that describes the desired outcome (e.g., food security, stable housing)
Link the Goal to the driving SDOH Condition using Goal.addresses referencing the Condition resource
Set Goal.lifecycleStatus to proposed initially, then update to active when the care plan is activated, and completed or cancelled at resolution
Populate Goal.target with a target measure and due date where appropriate, and Goal.expressedBy to indicate whether the goal was set by the patient or a care team member
Known gotchas
The Gravity SDOH Goal profile requires Goal.addresses to reference an SDOH Condition — a Goal without this link is not a valid SDOH Goal and will fail profile conformance validation
Goal codes must come from the Gravity-curated SDOH Goal value sets which are organized by SDOH domain (food security, housing, etc.) — using generic clinical goal codes without checking the Gravity value set binding will result in validation failures
Goal lifecycle management is often neglected: goals should be updated to completed or entered-in-error when the social need resolves, or when the associated SDOH Condition is resolved, to keep the patient's goal list accurate
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp