Continuity of care with a designated provider or member of the care team with whom the patient is able to get successive routine appointments.

Care management for chronic conditions including: • Systematic assessment of patient’s medical, functional, and psychosocial needs • System-based approaches to ensure timely receipt of all recommended preventive care services • Medication reconciliation with review of adherence and potential interactions • Oversight of patient self-management of medications.

Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

The plan of care should typically include, but is not limited to, the following elements:

• Problem list

• Expected outcome and prognosis

• Measurable treatment goals

• Symptom management

• Planned interventions

• Medication management

• Community/social services ordered

• How the services of agencies and specialists not connected to the practice will be directed/coordinated

• The individuals responsible for each intervention

• Requirements for periodic review and, when applicable, revision of the care plan.

1. Systematic assessment of beneficiary’s medical, functional, and psychosocial needs
2. Perform medication reconciliation with review of adherence and potential interactions
3. Creation of a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment, and an inventory of resources and supports
4. Electronically share the care plan as appropriate with other practitioners and providers
5. Provide beneficiary with a written or electronic copy of care plan and document its provision in the electronic medical record