; and (ii) that is in State or locally recognized forms that are used for the purpose of assuring that providers can follow the plan across care settings, such as advance directives or portable treatment orders. (G) Referrals to providers, including medical and social service providers, who deliver care consistent with the plan. (H) Providing culturally and educationally appropriate training for the individual and family caregivers to support their ability to carry out the plan. (I) A multidimensional assessment of the individual’s strengths and limitations. (J) An assessment of the individual’s paid and unpaid supports, including family caregivers. (K) Comprehensive medication review and management (including, if appropriate, counseling and self-management support). (L) Visits to the patient in all sites of care (including the home, a hospital, and a nursing home) as needed to respond appropriately to problems and concerns. (M) Additional services, consistent with the care plan, that the interdisciplinary team believes would assist the eligible individual and family caregivers in more effectively managing their health condition. (N) 24-Hour access to emergency support in person or via telephone or telemedicine with the individual’s medical record and care plan available to the responder. (O) Care coordination and communication across health care and social service settings and providers, including involvement of the interdisciplinary team to evaluate quality and address concerns over time. (P) Such other palliative and other services that the Secretary determines appropriate. (4) Applicable provider defined In this subsection, the term applicable provider means a hospice program (as defined in section 1861(dd)(2)) or other provider of services (as defined in section 1861(u)) or supplier (as defined in section 1861(d)) that— (A) furnishes services through an interdisciplinary team