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The care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care plan that includes the following features for at least 75 percent of the patients identified in Element A:
4.B.1 Incorporates patient preferences and functional/lifestyle goals.
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4.B.2 Identifies treatment goals.
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4.B.3 Assesses and addresses potential barriers to meeting goals.
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4.B.4 Includes a self-management plan.
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4.B.5 Is provided in writing to the patient/family/caregiver.
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