Implementation of practices/processes for developing regular individual care plans

Activity ID


Activity Weighting


Subcategory Name

Care Coordination

Activity Description

Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.


Individual care coordination plans are regularly developed and updated for at-risk patients and shared with beneficiary or caregiver

Suggested Documentation

1) Individual Care Plans for At-Risk Patients - Documented practices/processes for developing regularly individual care plans for at-risk patients, e.g., template care plan; and
2) Use of Care Plan with Beneficiary - Patient medical records demonstrating care plan being shared with beneficiary or caregiver

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