assessments to determine the physical, psychosocial, nutrition, language, cultural, and other needs of Program-eligible beneficiaries enrolled in the Organization involved. (IV) Development and at least annual updating of individualized care plans that incorporate at least the medical, social, and functional needs, preferences, and care goals of Program-eligible beneficiaries enrolled in the Organization. (V) Coordination and delivery of non-clinical services, such as transportation, aimed at improving the adherence of Program-eligible beneficiaries enrolled in the Organization with care recommendations. (VI) Services, such as transplant evaluation, palliative care, evaluation for hospice eligibility, and vascular access care. (VII) In the case of an individual who, while enrolled in the Organization, receives confirmation that a kidney transplant is imminent, the provision by an interdisciplinary care team described in subclause (I) of counseling services to such individual on preparation for and potential challenges surrounding such transplant. (VIII) Delivery of benefits and services in alternative settings, such as the home of the Program-eligible beneficiary enrolled in the Organization, in coordination with the provider or other appropriate stakeholder involved in such delivery serving on an interdisciplinary care team described in subclause (I). (IX) Use of patient reminder systems. (X) Education programs for patients, families, and caregivers. (XI) Use of health care advice resources, such as nurse advice lines. (XII) Use of team-based health care delivery models that provide comprehensive and continuous medical care, such as medical homes. (XIII) Co-location of providers and services. (XIV) Use of a demonstrated capacity to share electronic health record information across sites of care. (XV) Use of programs to promote better adherence to recommended treatment regimens by individuals, including by addressing barriers to access to care by such individuals. (XVI) Defined protocols to facilitate the