Improvement Activities

All Improvement Activities (IA) can be easily reported with MDinteractive. After logging into your account and selecting MIPS Measures Reporting from the drop down menu and then selecting the tab for IA, just click “Add” to each activity that you performed for at least 90 consecutive days:

Improvement-Activities-attestation.png

Each activity is weighted either medium or high. To achieve the maximum 40 points for the Improvement Activity score, a clinician (that works in a group with 15 or fewer providers billing with the same TIN) may select either of these combinations:

  • 1 high-weighted activity OR
  • 2 medium-weighted activities

Clincians working on larger groups will need to attest to more activities:

  • 2 high-weighted activities OR
  • 1 high-weighted activity and 2 medium-weighted activities OR
  • 4 medium-weighted activities

 

ID: IA_EPA_1
Weighting: High
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record
Subcategory Name:

Expanded Practice Access

Activity Description:

Provide 24/7 access to MIPS eligible clinicians,  groups, or care teams for advice about urgent and emergent care (e.g., 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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_EPA_2
Weighting: Medium
Use of telehealth services that expand practice access
Subcategory Name:

Expanded Practice Access

Activity Description:

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.  

Activity Validation:

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

Suggested Documentation:

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) 

ID: IA_EPA_3
Weighting: Medium
Collection and use of patient experience and satisfaction data on access
Subcategory Name:

Expanded Practice Access

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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 

ID: IA_EPA_4
Weighting: Medium
Additional improvements in access as a result of QIN/QIO TA
Subcategory Name:

Expanded Practice Access

Activity Description:

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).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_1
Weighting: High
Participation in systematic anticoagulation program
Subcategory Name:

Population Management

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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).

ID: IA_PM_2
Weighting: High
Anticoagulant management improvements
Subcategory Name:

Population Management

Activity Description:

MIPS eligible clinicians and  groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities: 

Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic 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 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 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.

The performance threshold will increase to 75 percent for the second performance year and onward. Clinicians would attest that, 60 percent for the transition year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.

Activity Validation:

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

Suggested Documentation:

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 

ID: IA_PM_3
Weighting: High
RHC, IHS or FQHC quality improvement activities
Subcategory Name:

Population Management

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_4
Weighting: High
Glycemic management services
Subcategory Name:

Population Management

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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.

ID: IA_PM_5
Weighting: Medium
Engagement of community for health status improvement
Subcategory Name:

Population Management

Activity Description:

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 Validation:

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

Suggested Documentation:

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

ID: IA_PM_6
Weighting: Medium
Use of toolsets or other resources to close healthcare disparities across communities
Subcategory Name:

Population Management

Activity Description:

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 Validation:

Activity to improve health disparities

Suggested Documentation:

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

ID: IA_PM_7
Weighting: High
Use of QCDR for feedback reports that incorporate population health
Subcategory Name:

Population Management

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_8
Weighting: Medium
Participation in CMMI models such as Million Hearts Campaign
Subcategory Name:

Population Management

Activity Description:

Participation in CMMI models such as the Million Hearts Cardiovascular Risk Reduction Model

Activity Validation:

Involvement in a CMMI model including acceptance and model participation. (Could be obtained from CMMI)

Suggested Documentation:

CMMI documents confirming participation in model and submission of requested data

ID: IA_PM_9
Weighting: Medium
Participation in population health research
Subcategory Name:

Population Management

Activity Description:

Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.

Activity Validation:

Involvement in research to improve targeted patient population

Suggested Documentation:

Documentation confirming participation in research that identifies interventions, tools or processes that can improve a targeted patient population, e.g. email, correspondence, shared data, or research reports

ID: IA_PM_10
Weighting: Medium
Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
Subcategory Name:

Population Management

Activity Description:

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).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_11
Weighting: Medium
Regular review practices in place on targeted patient population needs
Subcategory Name:

Population Management

Activity Description:

Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional’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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_12
Weighting: Medium
Population empanelment
Subcategory Name:

Population Management

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_13
Weighting: Medium
Chronic care and preventative care management for empaneled patients
Subcategory Name:

Population Management

Activity Description:

Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:
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; plan of care for chronic conditions; and advance care planning;
Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target;
Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;
Use panel support tools (registry functionality) to identify services due;
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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_14
Weighting: Medium
Implementation of methodologies for improvements in longitudinal care management for high risk patients
Subcategory Name:

Population Management

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PM_15
Weighting: Medium
Implementation of episodic care management practice improvements
Subcategory Name:

Population Management

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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)

ID: IA_PM_16
Weighting: Medium
Implementation of medication management practice improvements
Subcategory Name:

Population Management

Activity Description:

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.

Activity Validation:

Inclusion of medication management practice improvements

Suggested Documentation:

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

ID: IA_CC_1
Weighting: Medium
Implementation of use of specialist reports back to referring clinician or group to close referral loop
Subcategory Name:

Care Coordination

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_2
Weighting: Medium
Implementation of improvements that contribute to more timely communication of test results
Subcategory Name:

Care Coordination

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_3
Weighting: Medium
Implementation of additional activity as a result of TA for improving care coordination
Subcategory Name:

Care Coordination

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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)

ID: IA_CC_4
Weighting: High
TCPI participation
Subcategory Name:

Care Coordination

Activity Description:

Participation in the CMS Transforming Clinical Practice Initiative.

Activity Validation:

Active participation in TCP Initiative

Suggested Documentation:

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

ID: IA_CC_5
Weighting: Medium
CMS partner in Patients Hospital Engagement Network
Subcategory Name:

Care Coordination

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_6
Weighting: Medium
Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
Subcategory Name:

Care Coordination

Activity Description:

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).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_7
Weighting: Medium
Regular training in care coordination
Subcategory Name:

Care Coordination

Activity Description:

Implementation of regular care coordination training.

Activity Validation:

Inclusion of regular care coordination training in practice

Suggested Documentation:

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

ID: IA_CC_8
Weighting: Medium
Implementation of documentation improvements for practice/process improvements
Subcategory Name:

Care Coordination

Activity Description:

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).

Activity Validation:

Processes and practices are implemented to improve care coordination

Suggested Documentation:

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

ID: IA_CC_9
Weighting: Medium
Implementation of practices/processes for developing regular individual care plans
Subcategory Name:

Care Coordination

Activity Description:

Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_10
Weighting: Medium
Care transition documentation practice improvements
Subcategory Name:

Care Coordination

Activity Description:

Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_11
Weighting: Medium
Care transition standard operational improvements
Subcategory Name:

Care Coordination

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_CC_12
Weighting: Medium
Care coordination agreements that promote improvements in patient tracking across settings
Subcategory Name:

Care Coordination

Activity Description:

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.

Activity Validation:

Functionality of effective care coordination and referral management

Suggested Documentation:

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

ID: IA_CC_13
Weighting: Medium
Practice improvements for bilateral exchange of patient information
Subcategory Name:

Care Coordination

Activity Description:

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

Participate in a Health Information Exchange if available; and/or

Use structured referral notes.

Activity Validation:

Functionality of bilateral exchange of patient information to guide patient care

Suggested Documentation:

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

ID: IA_CC_14
Weighting: Medium
Practice improvements that engage community resources to support patient health goals
Subcategory Name:

Care Coordination

Activity Description:

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/or

Provide a guide to available community resources.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_1
Weighting: Medium
Use of certified EHR to capture patient reported outcomes
Subcategory Name:

Beneficiary Engagement

Activity Description:

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.

Activity Validation:

Functionality of patient reported outcomes in certified EHR

Suggested Documentation:

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)

ID: IA_BE_2
Weighting: Medium
Use of QCDR to support clinical decision making
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_3
Weighting: Medium
Engagement with QIN-QIO to implement self-management training programs
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_4
Weighting: Medium
Engagement of patients through implementation of improvements in patient portal
Subcategory Name:

Beneficiary Engagement

Activity Description:

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.

Activity Validation:

Functionality of patient portal that includes patient interactive features

Suggested Documentation:

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

ID: IA_BE_5
Weighting: Medium
Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
Subcategory Name:

Beneficiary Engagement

Activity Description:

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...? redirect=/InfoTechGenInfo/07_Section508.asp 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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_6
Weighting: High
Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_7
Weighting: Medium
Participation in a QCDR, that promotes use of patient engagement tools.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

Participation in QCDR promoting use of engagement tools

Suggested Documentation:

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

ID: IA_BE_8
Weighting: Medium
Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

Participation in QCDR promoting collaborative learning network interactive opportunities

Suggested Documentation:

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

ID: IA_BE_9
Weighting: Medium
Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_10
Weighting: Medium
Participation in a QCDR, that promotes implementation of patient self-action plans.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_11
Weighting: Medium
Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_12
Weighting: Medium
Use evidence-based decision aids to support shared decision-making.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_13
Weighting: Medium
Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

Conduct of regular assessments of patient care experience

Suggested Documentation:

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

ID: IA_BE_14
Weighting: Medium
Engage patients and families to guide improvement in the system of care.
Subcategory Name:

Beneficiary Engagement

Activity Description:

Engage patients and families to guide improvement in the system of care.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_15
Weighting: Medium
Engagement of patients, family and caregivers in developing a plan of care
Subcategory Name:

Beneficiary Engagement

Activity Description:

Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_16
Weighting: Medium
Evidenced-based techniques to promote self-management into usual care
Subcategory Name:

Beneficiary Engagement

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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)

ID: IA_BE_17
Weighting: Medium
Use of tools to assist patient self-management
Subcategory Name:

Beneficiary Engagement

Activity Description:

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).

Activity Validation:

Use of tools to assist patient self-management

Suggested Documentation:

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

ID: IA_BE_18
Weighting: Medium
Provide peer-led support for self-management.
Subcategory Name:

Beneficiary Engagement

Activity Description:

Provide peer-led support for self-management.

Activity Validation:

Use of peer-led self-management

Suggested Documentation:

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

ID: IA_BE_19
Weighting: Medium
Use group visits for common chronic conditions (e.g., diabetes).
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_20
Weighting: Medium
Implementation of condition-specific chronic disease self-management support programs
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_21
Weighting: Medium
Improved practices that disseminate appropriate self-management materials
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BE_22
Weighting: Medium
Improved practices that engage patients pre-visit
Subcategory Name:

Beneficiary Engagement

Activity Description:

Provide a pre-visit development of a shared visit agenda with the patient.

Activity Validation:

Pre-visit agenda shared with patient

Suggested Documentation:

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

ID: IA_BE_23
Weighting: Medium
Integration of patient coaching practices between visits
Subcategory Name:

Beneficiary Engagement

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_1
Weighting: Medium
Participation in an AHRQ-listed patient safety organization.
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Participation in an AHRQ-listed patient safety organization.

Activity Validation:

Participation in an AHRQ-listed patient safety organization

Suggested Documentation:

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

ID: IA_PSPA_2
Weighting: Medium
Participation in MOC Part IV
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Participation in Maintenance of Certification (MOC) Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_3
Weighting: Medium
Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity.
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS®

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_4
Weighting: Medium
Administration of the AHRQ Survey of Patient Safety Culture
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

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...)

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_5
Weighting: Medium
Annual registration in the Prescription Drug Monitoring Program
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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)

ID: IA_PSPA_6
Weighting: High
Consultation of the Prescription Drug Monitoring program
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Clinicians would attest that, 60 percent for the transition year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days.

Activity Validation:

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

Suggested Documentation:

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)

ID: IA_PSPA_7
Weighting: Medium
Use of QCDR data for ongoing practice assessment and improvements
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_8
Weighting: Medium
Use of patient safety tools
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_9
Weighting: Medium
Completion of the AMA STEPS Forward program
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

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

Activity Validation:

Completion of AMA STEPS Forward program

Suggested Documentation:

Certificate of completion from AMA's STEPS Forward program

ID: IA_PSPA_10
Weighting: Medium
Completion of training and receipt of approved waiver for provision of opioid medication-assisted treatments
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_11
Weighting: High
Participation in CAHPS or other supplemental questionnaire
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

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).

Activity Validation:

Participation in CAHPS or other supplemental questionnaire

Suggested Documentation:

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

ID: IA_PSPA_12
Weighting: Medium
Participation in private payer CPIA
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Participation in designated private payer clinical practice improvement activities.

Activity Validation:

Participation in private payer clinical practice improvement activities

Suggested Documentation:

Documents showing participation in private payer clinical practice improvement activities

ID: IA_PSPA_13
Weighting: Medium
Participation in Joint Commission Evaluation Initiative
Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Participation in Joint Commission Ongoing Professional Practice Evaluation initiative

Activity Validation:

Participation in Joint Commission Ongoing Professional Practice Evaluation initiative

Suggested Documentation:

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

ID: IA_PSPA_14
Weighting: Medium
Participation in Bridges to Excellence or other similar program
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Participation in other quality improvement programs such as Bridges to Excellence

Activity Validation:

Participation in other quality improvement programs such as Bridges to Excellence

Suggested Documentation:

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

ID: IA_PSPA_15
Weighting: Medium
Implementation of antibiotic stewardship program
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics

Activity Validation:

Functionality of an antibiotic stewardship program

Suggested Documentation:

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

ID: IA_PSPA_16
Weighting: Medium
Use of decision support and standardized treatment protocols
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_17
Weighting: Medium
Implementation of analytic capabilities to manage total cost of care for practice population
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following:

Train appropriate staff on interpretation of cost and utilization information; and/or

Use available data regularly to analyze opportunities to reduce cost through improved care.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_18
Weighting: Medium
Measurement and improvement at the practice and panel level
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Measure and improve quality at the practice and panel level 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.

Activity Validation:

Measure and improve quality at the practice and panel level

Suggested Documentation:

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

ID: IA_PSPA_19
Weighting: Medium
Implementation of formal quality improvement methods, practice changes or other practice improvement processes
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

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:
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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_20
Weighting: Medium
Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_PSPA_21
Weighting: Medium
Implementation of fall screening and assessment programs
Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

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).

Activity Validation:

Functionality of fall screening and assessment programs

Suggested Documentation:

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

ID: IA_AHE_1
Weighting: High
Engagement of new Medicaid patients and follow-up
Subcategory Name:

Achieving Health Equity

Activity Description:

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_AHE_2
Weighting: Medium
Leveraging a QCDR to standardize processes for screening
Subcategory Name:

Achieving Health Equity

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_AHE_3
Weighting: Medium
Leveraging a QCDR to promote use of patient-reported outcome tools
Subcategory Name:

Achieving Health Equity

Activity Description:

Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_AHE_4
Weighting: Medium
Leveraging a QCDR for use of standard questionnaires
Subcategory Name:

Achieving Health Equity

Activity Description:

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).

Activity Validation:

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

Suggested Documentation:

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

ID: IA_ERP_1
Weighting: Medium
Participation on Disaster Medical Assistance Team, registered for 6 months.
Subcategory Name:

Emergency Response & Preparedness

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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.

ID: IA_ERP_2
Weighting: High
Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
Subcategory Name:

Emergency Response & Preparedness

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BMH_1
Weighting: Medium
Diabetes screening
Subcategory Name:

Behavioral and Mental Health

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BMH_2
Weighting: Medium
Tobacco use
Subcategory Name:

Behavioral and Mental Health

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BMH_3
Weighting: Medium
Unhealthy alcohol use
Subcategory Name:

Behavioral and Mental Health

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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.

ID: IA_BMH_4
Weighting: Medium
Depression screening
Subcategory Name:

Behavioral and Mental Health

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BMH_5
Weighting: Medium
MDD prevention and treatment interventions
Subcategory Name:

Behavioral and Mental Health

Activity Description:

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.

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BMH_6
Weighting: High
Implementation of co-location PCP and MH services
Subcategory Name:

Behavioral and Mental Health

Activity Description:

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

Activity Validation:

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

Suggested Documentation:

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

ID: IA_BMH_7
Weighting: High
Implementation of integrated PCBH model
Subcategory Name:

Behavioral and Mental Health

Activity Description:

Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that 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 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 certified health information technology functionality to support active care management and outreach to patients in treatment; and/or
Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.

Activity Validation:

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)

Suggested Documentation:

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

ID: IA_BMH_8
Weighting: Medium
Electronic Health Record Enhancements for BH data capture
Subcategory Name:

Behavioral and Mental Health

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).

Activity Validation:

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

Suggested Documentation:

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

ID: NA
Weighting: N/A
Implementation of Patient-Centered Medical Home model
Subcategory Name:

NA

Activity Description:

Implementation of the patient-centered medical home model to continually improve comprehensive care coordination and accessibility within the primary care setting. This may include implementing a wide range of practice and patient focused standards that pertain to the care coordination, patient-centeredness, comprehensiveness of care, systems based on safety and quality, among others.

Activity Validation:

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

Suggested Documentation:

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

Register with MDinteractive