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 including a discussion on care are regularly developed and updated for at-risk patients and shared with beneficiary or caregiver
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, including consideration of a patient's goals and priorities, social risk factors, language and communication preferences, physical or cognitive limitations, as well as desired outcomes of care.