psychosocial, nutrition, language, cultural, and other needs of Program-eligible beneficiaries assigned to or who elect 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 assigned to or who elect the Organization, including a discussion on reconsideration of the method and location of dialysis. (V) Coordination and furnishing of non-clinical coordination benefits, such as transportation, aimed at improving the adherence of Program-eligible beneficiaries assigned to or who elect the Organization with care recommendations. (VI) As appropriate, coordination services, such as transplant evaluation, palliative care, evaluation for hospice eligibility, and vascular access care. (VII) In the case of an individual who, during an assignment to, or an election of an ESRD Fee-For-Service Integrated Care model offered by an Organization, receives confirmation that a kidney transplant is imminent, the provision of counseling services by an interdisciplinary care team described in subclause (I) to such individual on preparation for and potential benefits and risks associated with such transplant. (VIII) Delivery of benefits and services in settings alternative to traditional clinical settings, such as the home of the Program-eligible beneficiary. (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, including prescription drug, by individuals, including by addressing