MVP ID: G0054
Most applicable medical specialty(s):
Neurology, Neurosurgical, Vascular Surgery
The Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP focuses on the clinical theme of providing fundamental prevention and treatment of those patients at risk for or that have had a stroke.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 047 - Advance Care Plan
- Quality ID: 187 - Stroke and Stroke Rehabilitation: Thrombolytic Therapy
- Quality ID: 236 - Controlling High Blood Pressure
- Quality ID: 326 - Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
- Quality ID: 344 - Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
- Quality ID: 409 - Clinical Outcome Post Endovascular Stroke Treatment
- Quality ID: 413 - Door to Puncture Time for Endovascular Stroke Treatment
- Quality ID: 438 - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
- Quality ID: 441 - Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
- Quality ID: 487 - Screening for Social Drivers of Health
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- Activity ID: IA_AHE_9 - Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
- Activity ID: IA_BE_1 - Use of certified EHR to capture patient reported outcomes
- Activity ID: IA_BE_24 - Financial Navigation Program
- Activity ID: IA_BE_4 - Engagement of patients through implementation of improvements in patient portal
- Activity ID: IA_BE_6 - Regularly Assess Patient Experience of Care and Follow Up on Findings
- Activity ID: IA_BMH_15 - Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults
- Activity ID: IA_CC_13 - Practice Improvements to Align with OpenNotes Principles
- Activity ID: IA_CC_17 - Patient Navigator Program
- Activity ID: IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results
- Activity ID: IA_MVP - Practice-Wide Quality Improvement in MIPS Value Pathways
- Activity ID: IA_PCMH - Electronic submission of Patient Centered Medical Home accreditation
- Activity ID: IA_PM_13 - Chronic Care and Preventative Care Management for Empaneled Patients
- Activity ID: IA_PM_15 - Implementation of episodic care management practice improvements
Cost
Calculated by CMS using administrative claims data:
Population Health Measures
Select one population health measure to be scored by CMS using administrative claims data:
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Prevention of Information Blocking
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP) (Optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review
MVP Registration
- MVP Participants must register between April 1 – December 2, 2024 to report an MVP in 2024.
- To register, MVP Participants must select:
- The MVP they intend to report.
- 1 population health measure included in the MVP.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 2, 2024).
- Report on an MVP they didn’t register for during the 2024 performance year.
- Report on more than one MVP.