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The care team performs the following for at least 75 percent of the patients for the patients identified in Elements A and B:
3.C.1 Conducts pre-visit preparations
3.C.2 Collaborates with the patient/family to develop an individualized care plan, including treatment goals that are reviewed and updated at each relevant visit
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3.C.3 Gives the patient/family a written plan of care
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3.C.4 Assesses and addresses barriers when patient has not met treatment goals
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3.C.5 Provides patient/family a clinical summary at each relevant visit
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3.C.6 Identifies patients/families who might benefit from additional care management support
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3.C.7 Follows up with patients/families who have not kept important appointments
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