MIPS Improvement Activities

Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:

• Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);
• Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or
• Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.

Functionality of 24/7 or expanded practice hours with access to medical records or ability to increase access through alternative access methods or same-day or next-day visits

1) Patient Record from EHR - A patient record from a certified EHR with date and timestamp indicating services provided outside of normal business hours for that clinician; or
2) Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen or services provided outside of normal business hours for that clinician including use of alternative visits; or
3) Same or Next Day Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen same-day or next-day to a consistent clinician for urgent or transitional care

Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.  

Documented use of telehealth services and participation in data analysis assessing provision of quality care with those services

1) Use of Telehealth Services - Documented use of telehealth services through:
   a)  claims adjudication (may use G codes to validate);
   b) certified EHR or
   c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient; and 
2) Analysis of Assessing Ability to Deliver Quality of Care - Participation in or performance of quality improvement analysis showing delivery of quality care to patients through the telehealth medium (e.g. Excel spreadsheet, Word document or others) 

Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.  

Development and use of access to care improvement plan based on collected patient experience and satisfaction data

1) Access to Care Patient Experience and Satisfaction Data - Patient experience and satisfaction data on access to care; and
2) Improvement plan - Access to care improvement plan 

As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).

Implementation of additional processes, practices, resources or technology to improve access to services, as a result of receiving QIN/QIO technical assistance

1) Relationship with QIN/QIO Technical Assistance - Confirmation of technical assistance and documentation of relationship with QIN/QIO; and
2) Improvement Activities - Documentation of activities that improve access including support on additional services offered

User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provided substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.

Evidence of user participation and implementation of website testing for the Quality Payment Program (QPP)

1) Documentation of input to improve the CMS Quality Payment Program website through product user-testing aimed at enhancing system and program accessibility, readability and responsiveness and
2) Provide feedback for developing tools and guidance for a more efficient and accessible clinician and practice QPP website experience.

Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program) for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).

Documented participation of patients in a systematic anticoagulation program.  Could be supported by claims.

1) Patients Receiving Anti-Coagulation Medications - Total number of patients receiving anti-coagulation medications; and
2) Percentage of that Total Participating in a Systematic Anticoagulation Program - Documented number of referrals to a coagulation/anti-coagulation clinic; number of patients performing patient self-reporting (PST); or number of patients participating in self-management (PSM).

Individual MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, their ambulatory care patients receiving warfarin are being managed by one or more of the following improvement activities:

• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;
• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;
• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or
• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.

Documented participation of patients being managed by one or more clinical practice improvement activities. Could be supported by claims.

1) Patients Receiving Anti-Coagulation Medications - Total number of outpatients prescribed oral Vitamin K antagonist therapy; and
2) Percentage of that Total Being Managed By a Clinical Practice Improvement Activity - Number of outpatients prescribed oral Vitamin K antagonist therapy and who are being managed by one or more of the four activities in the described in the activity description 

Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time. 

Participation in RHC, HIS, or FQHC occurs and clinical quality improvement occurs

1) Name of RHC, HIS or FQHC - Identified name of RHC, IHS, or FQHC in which the practice participates in ongoing engagement activities; and 
2) Continuous Quality Improvement Activities - Documented continuous quality improvement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality and benchmarking improvement that ultimately benefits patients

For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having: 

For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:
a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia; and
b) Is reassessed at least annually.

The performance threshold will increase to 75 percent for the second performance year and onward. 

Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.

Report listing patients who are diabetic and prescribed antidiabetic agents and have documented glycemic treatment goals based on patient-specific factors

1) Diabetic Patients Prescribed Antidiabetic Agents - Total number of outpatients who are diabetic and prescribed antidiabetic agents; and
2) Documented Percentage of Total with Glycemic Treatment Goals and Assessed at Least Annually - Number of outpatients, who are diabetic and prescribed antidiabetic agents, with documented glycemic treatment goals ; and the goals take into account patient-specific factors, including at least age, comorbidities, and risk for hypoglycemia; and are flagged for reassessment in following year.

Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition.  Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund. 

Activity to improve specific chronic condition within the community is being undertaken

1) Documentation of Partnership in the Community - Screenshot of website or other correspondence identifying key partners and stakeholders and relevant initiative including specific chronic condition; and
2) Steps for Improving Community Health Status - Report detailing steps being taken to satisfy the activity including, e.g., timeline, purpose, and outcome that is in compliance with the local QIO

Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Activity to improve health disparities

1) Resources Used to Improve Disparities - Resources used, e.g., Population Health Toolkit; and
2) Documentation of Steps - Report detailing activity as outlined by the local QIO

Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.

Involvement with a QCDR to generate local practice patterns and outcomes reports including vulnerable populations

Participation in QCDR for population health, e.g., regular feedback reports provided by QCDR that summarize local practice patterns and treatment outcomes, including vulnerable populations

Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome). 

Participation and use of QCDR, clinical data or other registries to improve quality of care

Participation in QCDR for quality improvement across patient populations, e.g., regular feedback reports provided by QCDR using data for quality improvement such as comparative analysis reports across patient populations

Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.

Participation in reviews of targeted patient population needs including access to reports and community resources

1) Targeted Patient Population Identification - Documentation of method for identification and ongoing monitoring/review for a targeted patient population; and
2) Report with Unique Characteristics - Reports that show unique characteristics of patient population and identification of vulnerable patients; and
3) Tailored Clinical Treatments - Medical records demonstrating ways clinical treatment needs are being tailored to meet unique needs including additional community resources, if necessary

Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team. Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management.

Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.

Functionality of patient population empanelment including use of panels for health management

1) Active Population Empanelment - Identification of "active population" of the practice with empanelment and assignment confirmation linking patients to MIPS eligible clinician or care team; and
2) Process for Updating Panel - Process for review and update of panel assignments

In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:

• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;
• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);
• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;
• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;
• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or
• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.

Management of empaneled patients' chronic and preventive care needs (could use EHR or medical records)

1) Individualized Plan of Care - Annual opportunity for development and/or adjustment of an individualized plan of care appropriate to age and health status; or
2) Condition-Specific Pathways - Use of condition-specific pathways for chronic conditions with evidence-based protocols, or
3) Pre-visit Planning - Use of pre-visit planning to optimize preventive care and team management; or
4) Panel Support Tools - Use of panel support tools to identify services that are due; or
5) Reminders and Outreach - Use of reminders and outreach to alert and educate patients about services due; or
6) Medication Reconciliation - Use of routine medication reconciliation

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:

• Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;
• Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or
• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.

Longitudinal care management to patients at high risk for adverse health outcome or harm

1) High Risk Patients - Identification of patients at high risk for adverse health outcome or harm; and
2) Use of Longitudinal Care Management - Documented use of longitudinal care management methods including at least one of the following:
    a) empaneled patient risk assignment and risk stratification into actionable risk cohorts; or
    b) personalized care plans for patients at high risk for adverse health outcome or harm; or
    c) evidence of use of on-site practice based or shared care managers to monitor and coordinate care for highest risk cohort

Provide episodic care management, including management across transitions and referrals that could include one or more of the following:

• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or
• Managing care intensively through new diagnoses, injuries and exacerbations of illness.

Provision of episodic care management practice improvements (could use medical records or claims)

1) Follow-Up on Hospitalizations, ED or Other Visits and Medication Management - Routine and timely follow-up to hospitalizations, ED or other institutional visits, and medication reconciliation and management (e.g. documented in medical record or EHR); or
2) New diagnoses, Injuries and Exacerbations - Care management through new diagnoses, injuries and exacerbations of illness (medical record)

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following:

• Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups;
• Integrate a pharmacist into the care team; and/or
• Conduct periodic, structured medication reviews.

Inclusion of medication management practice improvements

1) Documented Medication Reviews or Reconciliation - Patient medical records demonstrating periodic structured medication reviews or reconciliation; or
2) Integrated Pharmacist - Evidence of pharmacist integrated into care team; or
3) Reconciliation Across Transitions - Reconciliation and coordination of mediations across transitions of care; or
4) Medication Management Improvement Plan - Report detailing medication management practice improvement plan and outcomes, if available

Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.

Evidence supporting participation in a federally and/or privately funded research initiative to identify systems, tools, or strategies that improve patient outcomes for a targeted population.

1)Documentation of participation in a federally and/or privately funded research initiative; and
2)Documentation of the interventions, tools, or processes used in the research; and
3) Documentation of the identified target population, and health outcomes targeted.

Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.

Evidence of engagement with community health workers to provide a comprehensive link to community resources and family-based services with an emphasis on improving health, education, and self-sufficiency

1) Documentation of engagement with community health workers;and
2) A demonstrated link to community resources that promote family-based services i.e. paperwork, notes, etc.; and
3) Documentation of coordination with primary care and other clinicians to engage and support patients, use of health information technology, and employ quality measurement and improvement processes, e.g. NCQA Patient-Centered Connected Care(PCCC) Recognition Program or similar programs.

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.

Evidence supporting implementation of systematic preventive approaches in clinical practice for abnormal blood glucose 

1) Total stratified number of Medicarepatients at risk for abnormal bloodglucose; and
2) Percentage of each demographicgroup and the total screened forabnormal blood glucose as outlinedby the US Preventive Services TaskForce USPSTF) and/or American Diabetes Association (ADA) guidelines.

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.

Evidence supporting implementation of systematic preventive approaches in clinical practice for prediabetes

1) Total stratified number of Medicare patients at risk for abnormal blood glucose; and
2) Percentage of each demographic group and the total screened for abnormal blood glucose as outlined by the US Preventive Services Task Force USPSTF) and/or American Diabetes Association (ADA) guidelines.

Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.

Evidence supporting implementation of practices/processes to develop advance care planning, with evidence taking into account a patients' literacy level, language, communication preferences, and cognitive or functional limitations

1) Documentation of process implementation for advance care planning/policy or living will development within the medical record; and
2) Documentation of clinician education about advance care planning to address advance care planning needs; and
3) Documentation illustrating how care plan needs were translated into quality improvement; and
4) Documentation of how clinicians are educated regarding strategies for addressing end-of-life and palliative care needs

Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.

Functionality of providing information by specialist to referring clinician or inquiring clinician receives and documents specialist report

1) Specialist Reports to Referring Clinician - Sample of specialist reports reported to referring clinician or group (e.g. within EHR or medical record); or
2) Specialist Reports from Inquiries in Certified EHR - Specialist reports documented in inquiring clinicians certified EHR or medical records

Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.

Functionality of reporting abnormal test results in a timely basis with follow-up.

EHR reports, from certified EHR, or medical records demonstrating timely communication of abnormal test results to patient

Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.

Implementation of at least one recommended QIN-QIO activity related to care coordination

1) QIN/QIO Technical Assistance - Documentation of Quality Innovation Network- Quality Improvement Organization technical assistance; and
2) Activity Implementation - Documentation that at least one recommended care coordination activity has been implemented (e.g. report detailing activity, patients cohort, results)

Participation in the CMS Transforming Clinical Practice Initiative.

Active participation in TCP Initiative

Confirmation of participation in the TCP Initiative for that year (e.g. CMS confirmation email)

Membership and participation in a CMS Partnership for Patients Hospital Engagement Network.

Active participation in Partnership for Patients Hospital Engagement Network (HEN) initiative

Confirmation of participation in the Partnership for Patients Hospital Engagement Network (HEN) initiative for that year (e.g. CMS confirmation email)

Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).

Active participation in QCDR to promote standard practices, tools and processes for quality improvement

Participation in QCDR demonstrating promotion of standard practices, tools and processes for quality improvement, e.g., regular feedback reports provided by QCDR that demonstrate the use of QCDR data to promote use of standard practices, tools, and processes for quality improvement, including, e.g., preventative screenings

Implementation of regular care coordination training.

Inclusion of regular care coordination training in practice

Documentation of implemented regular care coordination training within practice, e.g., availability of care coordination training curriculum/training materials and attendance or training certification registers/documents

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).

Processes and practices are implemented to improve care coordination

Documentation of the implementation of practices/processes that document care coordination activities, e.g., documented care coordination encounter that tracks clinical staff involved and communications from date patient is scheduled through day of procedure

Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.

Individual care coordination plans are regularly developed and updated for at-risk patients and shared with beneficiary or caregiver

1) Individual Care Plans for At-Risk Patients - Documented practices/processes for developing regularly individual care plans for at-risk patients, e.g., template care plan; and
2) Use of Care Plan with Beneficiary - Patient medical records demonstrating care plan being shared with beneficiary or caregiver

In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.

Patient-centered, care transition action plan for is carried out for first 30 days following a discharge

Documentation of care transition practices/processes including a patient-centered action plan for first 30 days following a discharge

Establish standard operations to manage transitions of care that could include one or more of the following:

• Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or
• Partner with community or hospital-based transitional care services.

Functionality of information flow during transitions of care to ensure seamless transitions

1) Communication Lines with Local Settings - Documentation of formal lines of communication to manage transitions of care with local settings (e.g. community or hospital-based transitional care services) in which empaneled patients receive care to ensure documented flow of information and seamless transitions; or
2) Partnership with Community or Hospital-Based Transitional Care Services - Documentation showing partnership with community or hospital-based transitional care services

Establish effective care coordination and active referral management that could include one or more of the following:

• Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;
• Track patients referred to specialist through the entire process; and/or
• Systematically integrate information from referrals into the plan of care.

Functionality of effective care coordination and referral management

1) Care Coordination Agreements - Sample of care coordination agreements with frequently used consultant that establish documented flow of information and provides patients with information to set consistent expectations; or
2) Tracking of Patient Referrals to Specialists - Medical record or EHR documentation demonstrating tracking of patients referred to specialists through the entire process; or
3) Referral Information Integrated into the Plan of Care - Samples of specialist referral information systematically integrated into the plan of care

Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following:

• Participate in a Health Information Exchange if available; and/or
• Use structured referral notes.

Functionality of bilateral exchange of patient information to guide patient care

1) Participation in an HIE - Confirmation of participation in a health information exchange (e.g. email confirmation, screen shots demonstrating active engagement with Health Information Exchange; or
2) Structured Referral Notes - Sample of patient medical records including structured referral notes

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:

• Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.
• Including through the use of tools that facilitate electronic communication between settings;
• Screen patients for health-harming legal needs;
• Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or
• Provide a guide to available community resources.

Availability of formal links to community-based health and wellness programs potentially including availability of resource guides

1) Community-Based Chronic Disease Self-Management Programs - Documentation of community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which practices have formal referral links and have potential bidirectional flow of information; or
2) Provision of Community Resource Guides - Medical record demonstrating provision of a guide to community resources

Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:

• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;
• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;
• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or
• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.

Evidence of participation in a Perioperative Surgical Home (PSH) model that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care

1) Coordinate with care managers/navigators in preoperative clinic to plan and implement comprehensive post discharge plan of care that could take into account patients' post discharge environment and support system out of the hospital; and
2) Deploy perioperative clinic and care processes to reduce post -operative visits to emergency rooms; and
3) Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; and
4) Implement processes to ensure effective communications and education of patients' post-discharge instructions, taking into account patients' literacy level, language and communication preferences, and cognitive or functional impairments.

The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.

Evidence of collaboration and bidirectional flow between the primary care physician and behavioral health practices where EHRs share common patients.

1) Documentation of established bidirectional flow between primary care and behavioral health practices that share common patients or use the same EHR systems

Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.

Evidence of participation in a Patient Navigator Program (PNP), including engaging with Community Health Workers or Promotoras, designed to assist patients with communicating with health care providers regarding their questions, obtain information about their procedures/treatments and arrange for test or appointments. PNP should take into account patients' language and communication preferences, literacy level, and cognitive and physical disabilities.

1) Documentation of evidenced-based resources and tools to reduce avoidable hospital readmissions; and
2) Utilization of a patient-centered and team-based approach leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful; and
3) Implementation of systems, tools and strategies that encourage a more supportive recovery period.

In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care80 tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan. The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.

Evidence that a minimum of eight hours of training focused on relationship-centered care, open-ended inquiries, patient perspectives, and storytelling with an emphasis on active listening, empathy, and patient engagement is required. Demonstration of the ART (ask, respond, tell) communication technique should be utilized by the MIPS eligible clinician to engage patients and encourage them to participate in the development of a shared plan of care. Training to promote patient engagement in a shared plan of care may include interactive simulations and didactic instructions on how to implement improvement action plans while promoting

1) MIPS eligible clinicians and groups must demonstrate a minimum of eight hours of training utilizing the ask, respond, tell (ART) communication technique and;
2) Provide documentation promoting relationship-centered care, open-ended inquiries, patient perspectives, and storytelling the emphasizes active listening, empathy, and patient engagement in the development of a shared plan of care.

In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.

Functionality of patient reported outcomes in certified EHR

1) Patient Reported Outcomes in EHR - Report from the certified EHR, showing the capture of PROs or the patient activation measures performed; or
2) Separate Queue for Recognition and Review - Documentation showing the call out of this data for clinician recognition and review (e.g. within a report or a screen-shot)

Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision-making capabilities.

Use of QCDR that shows performance of activities promoting shared clinical decision making capabilities

Participation in QCDR to support clinical decision making, e.g., regular feedback reports provided by QCDR that document performance of activities promoting shared clinical decision-making capabilities

Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.

Use of QIN-QIO to implement self-management training programs

Documentation from QIN-QIO of eligible clinician or group's engagement and use of services to assist with, e.g., self management training program(s) such as diabetes

Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.

Functionality of patient portal that includes patient interactive features

Documentation through screenshots or reports of an enhanced patient portal, e.g. portal functions that provide up to date information related to chronic disease health or blood pressure control, interactive features allowing patients to enter health information, and/or bidirectional communication about medication changes and adherence

Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information... that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973.

Practice website/tools are regularly updated and enhanced and are Section 508 compliant

1) Regular Updates and Section 508 Compliance Process - Documentation of regular updates and Section 508 compliance process for the clinician's patient portal or website; and
2) Compliant Website/Tools - Screenshots or hard copies of the practice's website/tools showing enhancements and regular updates in compliance with section 508 of the Rehabilitation Act of 1973

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. 

Patient experience and satisfaction data on beneficiary engagement is collected and follow up occurs through an improvement plan

1) Follow-Up on Patient Experience and Satisfaction - Documentation of collection and follow-up on patient experience and satisfaction (e.g. survey results); and
2) Patient Experience and Satisfaction Improvement Plan - Documented patient experience and satisfaction improvement plan

Participation in a QCDR, that promotes use of patient engagement tools. 

Participation in QCDR promoting use of engagement tools

Participation in QCDR that promotes use of patient engagement tools, e.g., regular feedback reports provided by the QCDR detailing activities promoting the use of patient engagement tools

Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. 

Participation in QCDR promoting collaborative learning network interactive opportunities

Participation in QCDR that promotes interactive collaborative learning network opportunities, e.g., regular feedback reports provided by the QCDR that promote interactive collaborative learning networks

Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. 

Use of patient experience data from the QCDR to inform and advance improvements in beneficiary engagement

Participation in QCDR to inform and advance improvements in beneficiary engagement , e.g., regular feedback reports provided by the QCDR that show participation in the use of patient experience measures/activities in informing and advancing beneficiary engagement

Participation in a QCDR, that promotes implementation of patient self-action plans. 

Participation in a QCDR to promote implementation of patient self-action plans

Participation in QCDR that promotes implementation of patient self-action plans, e.g., regular feedback reports provided by the QCDR that show the promotion and use of patient self action plans

Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. 

Participation in a QCDR to promote use of processes and tools to engage patients to adhere to treatment plans

Participation in QCDR promoting engagement of patients for adherence to treatment plans, e.g., regular feedback reports provided by the QCDR showing the promotion of processes and tools that engage patients for adherence to treatment plans

Use evidence-based decision aids to support shared decision-making.

Use of evidence based decision aids to support shared decision-making with beneficiary

Documentation (e.g. checklist, algorithms, tools, screenshots) showing the use of evidence-based decision aids to support shared decision-making with beneficiary

Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.

Conduct of regular assessments of patient care experience

Documentation (e.g. survey results, advisory council notes and/or other methods) showing regular assessments of the patient care experience to improve the experience

Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way).  Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.

Functionality of methods to engage patients and families in improving the system of care

Documentation showing patient and family engagement, e.g. meeting agendas and summaries where patients families have been engaged, survey results from patients and/or families; and improvements made in the system of care

Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.

Inclusion of patients, family and caregivers in plan of care and prioritizing goals for action, as documented in certified EHR.

Report from the certified EHR, showing the plan of care and prioritized goals for action with engagement of the patient, family and caregivers, if applicable

Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.

Functionality of evidence based techniques to promote self-management into usual care

Documented evidence-based techniques to promote self-management into usual care; and evidence of the use of the techniques (e.g. clinicians' completed office visit checklist, EHR report of completed checklist)

Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).

Use of tools to assist patient self-management

Documentation in patient record or EHR showing use of Patient Activation Measure, How's My Health, or similar tools to assess patients need for support for self-management

Provide peer-led support for self-management.

Use of peer-led self-management

Documentation in medical record or EHR of peer-led self-management program

Use group visits for common chronic conditions (e.g., diabetes).

Use of group visits for chronic conditions. Could be supported by claims.

Medical claims or referrals showing group visit and chronic condition codes in conjunction with care provided

Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.

Use of condition-specific chronic disease self-management programs or coaching or link to community programs

1) Chronic Disease Self-Management Support Program - Documentation from medical record or EHR showing condition specific chronic disease self-management support program or coaching; or
2) Community Chronic Disease Self-Management Support Program - Documentation of referral/link of patients to condition specific chronic disease self-management support programs in the community

Provide self-management materials at an appropriate literacy level and in an appropriate language.

Provision of self-management materials appropriate for literacy level and language

Documented provision in EHR or medical record of self-management materials, e.g., pamphlet, discharge summary language, or other materials that include self management materials appropriate for the patient's literacy and language

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.

Pre-visit agenda shared with patient

Documentation of a letter, email, portal screenshot, etc. that shows a pre-visit agenda was shared with patient

Provide coaching between visits with follow-up on care plan and goals.

Use of coaching between visits with follow-up on care plan and goals. Could be supported by claims.

Documentation of:
1) Use of Coaching Codes - Medical claims with codes for coaching provided between visits; or
2) Coaching Plan and Goals - Copy of documentation provided to patients (e.g. letter, email, portal screenshot) that includes coaching on care plan and goals

In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.

Demonstration by eligible clinicians and groups that their practice provides an estimate of the cost to the patient of the types of health care services it will furnish in advance (for services that can be scheduled in advance) and financial counseling to patients or their caregiver about cost of care with evidence that an exploration of different payment options were discussed. Financial counseling may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.

Demonstration by eligible clinicians and groups that their practice provides an estimate in advance of the cost to the patient of the types of health care services it will furnish (for services that can be scheduled in advance) and financial counseling to patients or their caregiver about costs of care with evidence that an exploration of different payment options, e.g. documented work with a financial counselor or patient navigator as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals were discussed.

Please note: a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns.

Participation in an AHRQ-listed patient safety organization. 

Participation in an AHRQ-listed patient safety organization

Documentation from an AHRQ-listed patient safety organization (PSO) confirming the eligible clinician or group's participation with the PSO. PSOs listed by AHRQ are here: http://www.pso.ahrq.gov/listed

In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results.

Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module, or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty-specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.

Participation in MOC Part IV including a local, regional, or national outcomes registry or quality assessment program and performance of monthly activities to assess and address practice performance

1) Participation in Maintenance of Certification from ABMS Member Board - Documentation of participation in Maintenance of Certification (MOC) Part IV from an ABMS member board including participation in a local, regional or national outcomes registry or quality assessment program; and
2) Monthly Activities to Assess Performance - Documented performance of monthly activities across practice to assess performance in practice by reviewing outcomes, addressing areas of improvement, and evaluating the results

For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS®, or the American Board of Family Medicine (ABFM) Performance in Practice Modules.

Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity.

Certificate or letter of participation from an IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity, for eligible clinicians or groups not participating in MOC Part IV

Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetycu...).Note:  This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Administration of the AHRQ survey of Patient Safety Culture and submission of data to the comparative database

Survey results from the AHRQ Survey of Patient Safety Culture, including proof of administration and submission

Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.

Annual registration in the prescription drug monitoring program of the state and participation for a minimum of 6 months

1) Activation/Registration of an PDMP Account - Documentation evidencing activation/registration of an PDMP account (e.g. an email), and
2) Participation in PDMP - Evidence of participating in the PDMP, i.e., accessing/consulting (e.g. copies of patient reports created, with the PHI masked)

Clinicians would attest to reviewing the patients’ history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days.  For the transition year, clinicians would attest to 60 percent review of applicable patient’s history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient’s history performance.

Provision of consulting with PDMP before issuance of a controlled substance schedule II opioid prescription that lasts longer than 3 days

1) Number of Issuances of CSII Prescription - Total number of issuances of a CSII prescription that lasts longer than 3 days over the same time period as those consulted; and
2) Documentation of Consulting the PDMP - Total number of patients for which there is evidence of consulting the PDMP prior to issuing an CSII prescription (e.g. copies of patient reports created, with the PHI masked)

Use of QCDR data, for ongoing practice assessment and improvements in patient safety.

Use of QCDR data for ongoing practice assessment and improvements in patient safety

Participation in QCDR that promotes ongoing improvements in patient safety, e.g., regular feedback reports provided by the QCDR that promote ongoing practice assessment and improvements in patient safety

In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.

Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.

Use of tools by specialty practices in tracking specific meaningful patient safety and practice assessment measures

Documentation of the use of patient safety tools, e.g. surgical risk calculator, that assist specialty practices in tracking specific patient safety measures meaningful to their practice

Completion of the American Medical Association’s STEPS Forward program.

Completion of AMA STEPS Forward program

Certificate of completion from AMA's STEPS Forward program

Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine.

Completion of training and obtaining approved waiver for provision of medication assisted treatment of opioid use disorders using buprenorphine

1) Waiver - SAMHSA letter confirming waiver and physician prescribing ID number; and
2) Training - Certificate of completion of training to prescribe and dispense buprenorphine dated during the selected reporting period

Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).

Participation in CAHPS or other supplemental questionnaire

1) CAHPS - CAHPS participation report; or
2) Other Patient Supplemental Questionnaire Items - Other supplemental patient safety questionnaire items, e.g., cultural competence or health information technology item sets

Participation in designated private payer clinical practice improvement activities.

Participation in private payer clinical practice improvement activities

Documents showing participation in private payer clinical practice improvement activities

Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.

Participation in Joint Commission Ongoing Professional Practice Evaluation initiative

Practice documents that show participation in Joint Commission's Ongoing Professional Practice Evaluation initiative

Participation in other quality improvement programs such as Bridges to Excellence or American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.

Participation in other quality improvement programs such as Bridges to Excellence

Documentation from Bridges to Excellence or other similar program confirming participation in its improvement program(s)

Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include:

• Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.
• Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient).
• Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.
• Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws.
• Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.
• Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.
• Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line.
• Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions.  
• Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.
• Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance.

Functionality of an antibiotic stewardship program

Documentation of implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics and identifies improvement actions

Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.

Use of decision support and treatment protocols to manage workflow in the team to meet patient needs

Documentation (e.g. checklist, algorithm, screenshot) showing use of decision support and standardized treatment protocols to manage workflow in the team to meet patient needs

In order to receive credit for this activity, a MIPS eligible clinician must conduct or build the capacity to conduct analytic activities to manage total cost of care for the practice population. Examples of these activities could include:

• Train appropriate staff on interpretation of cost and utilization information;
• Use available data regularly to analyze opportunities to reduce cost through improved care. An example of a platform with the necessary analytic capability to do this is the American Society for Gastrointestinal (GI) Endoscopy’s GI Operations Benchmarking Platform.

Use of analytic capabilities to manage total cost of care for practice population

1) Staff Training - Documentation of staff training on interpretation of cost and utilization information (e.g. training certificate); or
2) Cost/Resource Use Data - Availability of cost/resource use data for the practice population that is used regularly to analyze opportunities to reduce cost

Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that could include one or more of the following:

• Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or
• Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.   

Measure and improve quality at the practice and panel level

1) Quality Improvement Program/Plan at Practice and Panel Level - Copy of a quality improvement program/plan or review of quality, utilization, patient satisfaction and other measures to improve one or more elements of this activity; or
2) Review of and Progress on Measures - Report showing progress on selected measures, including benchmarks and goals for performance using relevant data sources at the practice and panel level

Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following such as:

• Multi-Source Feedback;
• Train all staff in quality improvement methods;
• Integrate practice change/quality improvement into staff duties;
• Engage all staff in identifying and testing practices changes;
• Designate regular team meetings to review data and plan improvement cycles;
• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or
• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.

Implementation of a formal model for quality improvement and creation of a culture in which staff actively participates in one or more improvement activities

1) Adopt Formal Quality Improvement Model and Create Culture of Improvement - Documentation of adoption of a formal model for quality improvement and creation of a culture in which staff actively participate in improvement activities; and
2) Staff Participation - Documentation of staff participation in one or more of the six identified; including, training, integration into staff duties, identifying and testing practice changes, regular team meetings to review data and plan improvement cycles, share practice and panel level quality of care, patient experience and utilization data with staff, or share practice level quality of care, patient experience and utilization data with patients and families

Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following:   

• Make responsibility for guidance of practice change a component of clinical and administrative leadership roles;
• Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or
• Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.

Functionality of leadership engagement in regular guidance and demonstrated commitment for implementing improvements

1) Clinical and Administrative Leadership Role Descriptions - Documentation of clinical and administrative leadership role descriptions include responsibility for practice improvement change (e.g. position description); or;
2) Time for Leadership in Improvement Activities - Documentation of allocated time for clinical and administrative leadership participating in improvement efforts, e.g. regular team meeting agendas and post meeting summary; or;
3) Population Health, Quality, and Health Experience Incorporated into Performance Reviews - Documentation of population health, quality and health experience metrics incorporated into regular practice performance reviews, e.g., reports, agendas, analytics, meeting notes

Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).

Functionality of fall screening and assessment programs

1) Implementation of a Falls Screening and Assessment Program - Implementation of a falls screening and assessment program that uses valid and reliable tools to identify patients at risk for falls and address modifiable risk factors, for example, the STEADI program for identification of falls risk; and
2) Implementation Progress- Documentation of progress made on falls screening and assessment after implementation of tool

Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year-by-year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Completion with a passing score of all the modules of the Centers for Disease Control and Prevention (CDC) course "Applying CDC's Guideline for Prescribing Opioids" that reviews the 2016 "Guideline for Prescribing Opioids for Chronic Pain"

Documented participation in and completion of all Centers for Disease Control and Prevention (CDC) course "Applying CDC's Guideline for Prescribing Opioids" that reviews the 2016 "Guideline for Prescribing Opioids for Chronic Pain."

NOTE: The CDC continues to develop additional training modules. With this in mind, all modules available at the stated start date of the eligible clinician or group's attestation period must be completed in order to attest to this IA.

Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Completion with a passing score of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course.

NOTE: Eligible clinicians and groups cannot attest to both IA_PSPA_23 and IA_PSPA_24 for the same QPP Year.

Documented participation in and completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Find course at https://www.train.org/cdctrain/course/1075730/compilation

NOTE: Eligible clinicians and groups cannot attest to both IA_PSPA_23 and IA_PSPA_24 for the same QPP Year.

Completion of greater than 50 percent of the modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis, but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Completion of greater than 50 percent of the modules of the Centers for Disease Control and Prevention antibiotic stewardship course.

NOTE: Eligible clinicians and groups cannot attest to both IA_PSPA_23 and IA_PSPA_24 for the same QPP Year.

Documented participation in and completion of greater than 50 percent of the modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Find course at https://www.train.org/cdctrain/course/1075730/compilation

NOTE: Eligible clinicians and groups cannot attest to both IA_PSPA_23 and IA_PSPA_24 for the same QPP Year.

Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.

Demonstration of transparency of costs at the point-of-order for ordering providers for laboratory and/or radiographic orders

Documentation (screen shot, report from EHR, written display procedure) of laboratory and radiographic costs at the point-of-order.

A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient’s primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.

Demonstration of communication from the eligible clinician/group providing unscheduled care for a clinically significant adverse drug event to the patient's primary care provider

1) Documentation of an unscheduled clinically significant adverse event, defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.
2) Documentation of communication of the event to the patient's primary care clinician within 48 hours of the unscheduled event

For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.

Implementation of a process to treat an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, e.g. including patients taking vitamin K antagonists (warfarin)

1) Documentation of a process to target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient's anticoagulation; and
2) The plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). Note: an invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.

Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria:

• The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;
• The activity must have specific, measurable aim(s) for improvement;
• The activity must include interventions intended to result in improvement;
• The activity must include data collection and analysis of performance data to assess the impact of the interventions; and
• The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.

Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement

Documentation that the activity addresses a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;

• The activity must have specific, measurable aim(s) for improvement;
• The activity must include interventions intended to result in improvement;
• The activity must include data collection and analysis of performance data to assess the impact of the interventions; and The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements and provide participant completion information.

Clinicians attest that they are consulting specified applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018. This activity is for clinicians that are early adopters of the Medicare AUC program (2018 performance year) and for clinicians that begin the Medicare AUC program in future years as specified in our regulation at §414.94. The AUC program is required under section 218 of the Protecting Access to Medicare Act of 2014.  Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.

Documentation of attestation and consultation of specified applicable AUC through a qualified clinical decision support mechanism 

Documentation of consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018: 

• Evidence of early adoption of theMedicare AUC program (PY2018Performance Year); or
• Copies of reports (paper copy,screen shots, etc.) to the orderingclinician that can be used to assesspatterns of image-ordering andimprove upon those patterns toensure that patients are receiving themost appropriate imaging for theirindividual condition.

Participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI).
The program uses a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for PCI patients by implementing quality improvement strategies:

• Radial-artery access,
• Bivalirudin, and
• Use of vascular closure devices.

Documented participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI)

1) Documentation of participation inthe PCI Bleeding Campaign

In order to receive credit for this activity, MIPS eligible clinicians must provide both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use for patients who are prescribed both benzodiazepines and opioids. Education must be completed for at least 75 percent of qualifying patients and occur:
(1) at the time of initial co-prescribing and again following greater than 6 months of co- prescribing of benzodiazepines and opioids; or
(2) at least once per MIPS performance period for patients taking concurrent opioid and benzodiazepine therapy.

Eligible clinicians and groups must provide both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use for patients who are prescribed both benzodiazepines and opioids.

Education must be completed for at least 75 percent of qualifying patients and occur as follows:
1) at the time of initial co-prescribingand again following greater than 6 months of co- prescribing of benzodiazepines and opioids, or
2)at least once per MIPSperformance period for patientstaking concurrent opioid andbenzodiazepine therapy.

In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain via clinical decision support (CDS). For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.

MIPS eligible clinicians and groups must utilize the Centers for Disease Control (CDC)Guidelinefor PrescribingOpioids forChronic Pain viaclinical decisionsupport (CDS).

1) Eligible clinicians or groups utilizing CDS must build the capability directly into the clinician workflow and document the support decision making on patients during the 90 day or year-long attestation period at the point of care; and
2) Document specific examples of how the guideline is incorporated into a CDS workflow. This may include, but is not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.

Functionality of practice in seeing new and follow-up Medicaid patients in a timely manner including patients dually eligible

1) Timely Appointments for Medicaid and Dually Eligible Medicaid/Medicare Patients - Statistics from certified EHR or scheduling system (may be manual) on time from request for appointment to first appointment offered or appointment made by type of visit for Medicaid and dual eligible patients; and
2) Appointment Improvement Activities - Assessment of new and follow-up visit appointment statistics to identify and implement improvement activities

Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.

Participation in a QCDR and demonstrated performance of activities for use of standardized processes for screening for social determinants of health including use of supporting tools into certified EHR technology

1) QCDR for Standardizing Screening Processes - Participation in QCDR for standardizing screening processes for social determinants, e.g., regular feedback reports from QCDR showing screening practices for social determinants; and
2) Integration of Tools into Certified EHR (suggested) - Integration of one or more of the following tools into practice as part of the EHR, e.g., http://www.cdc.gov/socialdeterminants /tools/index.htm showing regular referral to one or more of these tools

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.

Participation in a QCDR and demonstrated performance of activities to promote use of patient-report outcome tools and corresponding collection of PRO data

Participation in QCDR, for use of patient-reported outcome tools, e.g., regular QCDR feedback reports demonstrating use of patient-reported outcome tools and corresponding collection of PRO data, e.g., use of PHQ-2 or PHQ-9 and PROMIS instruments

Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).

Participation in a QCDR and demonstrated performance of activities for use of standard questionnaires for assessing improvement in health disparities related to functional health status

Participation in QCDR, to use of standard questionnaires for assessing improvements in health disparities, e.g., regular feedback reports from QCDR, demonstrating performance of activities for using standard questionnaires for assessing improvements in health disparities related to functional health status

MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.

Participation in clinical trials, research alliances or community-based participatory research (CPBR), documentation of research aims and results

1) Documentation of participation by clinician leadership in clinical trials, research alliances, or community-based participatory research (CBPR) to identify tools, research or processes focused on minimizing disparities in healthcare access, care quality, affordability, or outcomes; and
2) Documentation of intended or actual aims and outcomes

MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.

Participation as a preceptor for clinicians-in-training that encourage clinical rotations in community practices in small underserved, or rural areas

Documentation of participation as a preceptor for clinicians-in-training that encourages clinical rotations in community practices in small underserved, or rural areas. Examples of eligible clinicians anticipated to serve as a preceptor 2018 would include; medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists.

In order to receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by providing literature and/or facilitating a conversation about this topic using resources such as the “Think About Your Eyes” campaign and/or referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology’s EyeCare America and the American Optometric Association’s VISION USA. This activity is intended for:

• Non-ophthalmologists / optometrists who refer patients to an ophthalmologist/optometrist;
• Ophthalmologists/optometrists caring for underserved patients at no cost; or
• Any clinician providing literature and/or resources on this topic.

This activity must be targeted at underserved and/or high-risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams.

Documentation of patient engagement by non-ophthalmologists/optometrists on the importance of comprehensive eye examinations targeted at underserved and/or high risk populations or documentation of ophthalmologists/optometrists providing care for patients at no-cost for underserved and/or high risk populations.

1) Documentation providing evidence that targeted, underserved, and/or high-risk populations are engaged in their ocular health with the aim of improving their access to comprehensive eye exams; and/or
2) Documentation that a discussion with the patient regarding the significance of annual comprehensive eye exams (when indicated) with evidence that ophthalmic resources were distributed to promote ocular health; and/or
3) Demonstrated promotion of the significance of comprehensive eye exams (referring patients to resources and providing no-cost eye exams) via ophthalmic resources with evidence that a conversation about this topic was conducted using resources such as the “Think About Your Eyes” Campaign, American Academy of Ophthalmology’s EyeCare America, and the American Optometric Association’s VISION USA. Evidence of use of these resources in support of this Improvement Activity may include screenshots of a notation in the medical chart, or copies of the ocular literature provided to the patient; and/or
4) Documentation of providing a free eye exam to the patient.

Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.

Participation in Disaster Medical Assistance Team or Community Emergency Responder Team for at least 6 months as a volunteer

Documentation of participation in Disaster Medical Assistance or Community Emergency Responder Teams for at least 6 months including registration and active participation, e.g., attendance at training, on-site participation, etc.

Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.

Participation in domestic or international humanitarian volunteer work of at least a continuous 60 days duration

Documentation of participation in domestic or international humanitarian volunteer work of at least a continuous 60 days duration including registration and active participation, e.g., identification of location of volunteer work, timeframe, and confirmation from humanitarian organization

Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.

Performance of diabetes screening for patients with schizophrenia or bipolar disease who are using antipsychotic medication

Report from certified EHR, documentation from medical charts, or claims showing regular practice for diabetes screening of patients with schizophrenia or bipolar disease who are using antipsychotic medications

Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.

Performance of regular engagement in integrated prevention and treatment interventions including tobacco use screening and cessation interventions for patients with co-conditions of behavioral or mental health and at risk factors for tobacco dependence

Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice of tobacco screening for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence

Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions. 

Performance of regular engagement in integrated prevention and treatment interventions for patients with co-occurring conditions of behavioral or mental health and at risk factors for unhealthy alcohol use

Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice for unhealthy alcohol use screening for patients with co-occurring conditions of behavioral or mental health conditions.

Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.

Performance of regular engagement in integrated prevention and treatment interventions including depression screening and follow-up plan for patients with co-conditions of behavioral or mental health

Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice for depression screening and follow-up plan for these patients with co-conditions of behavioral or mental health

Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.

Performance of regular engagement in integrated prevention and treatment interventions including suicide risk assessment for mental health patients with co-conditions of behavioral or mental health

Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice for screening including suicide risk assessment for mental health patients with co-occurring conditions of behavioral or mental health conditions

Integration facilitation and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings.

Integration of facilitation and promotion of mental health and substance use disorder services in primary and/or non-primary clinical care settings

Documentation of integration and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings, e.g., list of NPIs that participate as behavioral health specialists, mental health clinicians or primary care clinicians in co-located setting or patient claims showing mental health and substance use disorder services collocated in primary and/or non-primary clinical care settings

Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following:

• Use evidence-based treatment protocols and treatment to goal where appropriate;
• Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;
• Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;
• Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;
• Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;
• Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or
• Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.

Provision of integrated behavioral health services to support patients with behavioral health needs and poorly controlled chronic conditions (May use certified EHR, QCDR, clinical registry or medical records)

Documented integration of behavioral health services with primary care to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions program and services including one or more of the six activities described in the activity description

Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).

Use of EHR to capture additional data on behavioral health populations and use data for additional decision-making

Screen shots from certified EHR or from other software/tools integrated with the certified EHR and reports showing how additional behavioral health data is captured and used for additional decision-making

Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example:  NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.

Demonstration by MIPS eligible clinicians and groups that integrated prevention and treatment interventions with documented screening and brief counseling occurred on a regular basis. Documentation of referral or feedback/acknowledgment from referred provider

Screen shots from certified EHR or from other software/tools demonstrating integrated prevention and treatment interventions (i.e., evidence of screening and brief counseling for patient with co-occurring conditions of mental health and substance abuse). For the intent of this IA,-co-occurring conditions are defined as the diagnosed coexistence of both a mental health and a substance use disorder.

In order to receive credit for this activity, MIPS eligible clinicians must complete a collaborative care management training program, such as the American Psychological Association (APA) Collaborative Care Model training program available as part of the Centers for Medicare & Medicaid Services (CMS) Transforming Clinical Practice Initiative (TCPI), available to the public, in order to implement a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice.

Completion of a collaborative care management training program by eligible clinicians or groups such as he American Psychological Association (APA) Collaborative Care Model training program available as part of the Centers for Medicare & Medicaid Services (CMS) Transforming Clinical Practice Initiative (TCPI), available to the public.

1) MIPS eligible clinicians and groups must complete a collaborative care management training program, such as the American Psychological Association (APA) Collaborative Care Model training program available as part of the Centers for Medicare & Medicaid Services (CMS) Transforming Clinical Practice Initiative (TCPI), available to the public and;
2) Documented implementation of a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice.

N/A

Performance of standards and expectation that pertain to the patient-centered medical home model.

1) Documented implementation of patient-centered medical home activities and improvements that pertain to care coordination, patient-centeredness, or comprehensiveness of care, among others; or
2) Documented recognition as a patient-centered medical home from accredited body, combined with continual improvements