; (v) a plan for— (I) working with community-based organizations, including faith-based organizations and aging and disability organizations; (II) improving community-based supports for family caregivers; and (III) increasing the number of individuals within the target population or populations who— (aa) have communicated their wishes regarding medical treatment using State or locally recognized forms, such as advance directives or portable medical orders; (bb) have comprehensive care plans that are concrete and actionable; and (cc) have access to community-based palliative care services