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Chronic Care and Preventative Care Management for Empaneled Patients

Activity ID

IA_PM_13

Activity Weighting

Medium

Subcategory Name

Population Management

Activity Description

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.

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

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