Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements: 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by: a. Patient communication b. Health professional assessments; 2. Identify gaps in the achievement of health and life plan; 3. Health status evaluations, interventions, and outcomes; 4. Action plans: a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals. 5. Medication Management; 6. Identify community/social services and family support; 7. Advanced directives