Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved 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. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.
Improve understanding of targeted populations’ unique needs to tailor clinical treatments, address structural inequities, and better utilize community resources.
Evidence of participation in identification and reviews of targeted patient population needs. Include all of the following elements:
1) Targeted patient population identification – Documentation of method/s for identification and ongoing monitoring of a targeted patient population (e.g., policy or protocol), including stratification of patient data by demographic characteristics and, as needed, health-related social needs to appropriately identify differences among populations and assess drivers of gaps and inequities, as well as identifying interventions appropriate for the needs the targeted population; AND
2) Review of targeted population’s unique characteristics and needs – Report that compiles information on the unique characteristics of the targeted patient population, including inequities in relevant outcomes; ways to tailor clinical treatments to meet needs and reduce inequities (e.g., clinicians treating Black men, who have a higher incidence of prostate cancer, may choose to evaluate that population for consistency of screening); and lists of community resources that can further support patients with these needs outside of the clinical setting; AND
3) Implementation Report – Report with action plan detailing steps the practice has taken to address the results of its targeted population identification and needs assessment.
- Health-related social needs (HRSN) screening tools that meet the recommended criteria for this activity include:
- The Centers for Medicare & Medicaid Services’ Accountable Health Communities screening tool: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.
- National Association of Community Health Centers’ Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) assessment: https://www.nachc.org/wp-content/uploads/2020/04/PRAPARE-One-Pager-9-2-16-with-logo-and-trademark.pdf
- Health Lead’s Screening Tool: https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/
- Background on identifying and addressing health-related social needs at primary care settings: https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/social-needs-tool.pdf.