117 STAT. 2344
PUBLIC LAW 108–173—DEC. 8, 2003 ‘‘(B) Notification that the organization offering a program may contact the beneficiary directly concerning such participation. ‘‘(C) Notification that participation in a program is voluntary. ‘‘(D) A description of the method for the beneficiary to participate or for declining to participate and the method for obtaining additional information concerning such participation. ‘‘(3) VOLUNTARY PARTICIPATION.—A targeted beneficiary may participate in a chronic care improvement program on a voluntary basis and may terminate participation at any time. ‘‘(e) CHRONIC CARE IMPROVEMENT PROGRAMS.— ‘‘(1) IN GENERAL.—Each chronic care improvement program shall— ‘‘(A) have a process to screen each targeted beneficiary for conditions other than threshold conditions, such as impaired cognitive ability and co-morbidities, for the purposes of developing an individualized, goal-oriented care management plan under paragraph (2); ‘‘(B) provide each targeted beneficiary participating in the program with such plan; and ‘‘(C) carry out such plan and other chronic care improvement activities in accordance with paragraph (3). ‘‘(2) ELEMENTS OF CARE MANAGEMENT PLANS.—A care management plan for a targeted beneficiary shall be developed with the beneficiary and shall, to the extent appropriate, include the following: ‘‘(A) A designated point of contact responsible for communications with the beneficiary and for facilitating communications with other health care providers under the plan. ‘‘(B) Self-care education for the beneficiary (through approaches such as disease management or medical nutrition therapy) and education for primary caregivers and family members. ‘‘(C) Education for physicians and other providers and collaboration to enhance communication of relevant clinical information. ‘‘(D) The use of monitoring technologies that enable patient guidance through the exchange of pertinent clinical information, such as vital signs, symptomatic information, and health self-assessment. ‘‘(E) The provision of information about hospice care, pain and palliative care, and end-of-life care. ‘‘(3) CONDUCT OF PROGRAMS.—In carrying out paragraph (1)(C) with respect to a participant, the chronic care improvement organization shall— ‘‘(A) guide the participant in managing the participant’s health (including all co-morbidities, relevant health care services, and pharmaceutical needs) and in performing activities as specified under the elements of the care management plan of the participant; ‘‘(B) use decision-support tools such as evidence-based practice guidelines or other criteria as determined by the Secretary; and
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