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Ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record

In recalculating expenditures for the benchmark year, CMS would apply the same calculation methodology applied in recalculating expenditures for the corresponding performance year, in accordance with the proposed new section of the regulation at 425.674

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