2023 MIPS IA_PM_13: Chronic Care and Preventative Care Management for Empaneled Patients

Activity ID

Activity Weighting

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.

Objective

Suggested Documentation

Evidence of chronic and preventative care management for empaneled patients via an individualized plan of care as appropriate to age and health status, including a) health risk appraisal; b) gender, age, and condition-specific preventive care services (e.g., managing cardiovascular risk in patients with diabetes); and c) plan of care for chronic conditions (could use electronic health record [EHR] or medical records). Include at least one of the following elements:

1) Individualized plan of care – Documented indication of annual opportunity for development and/or adjustment of an individualized plan of care appropriate to age and health status (e.g., EHR alert or dated medical record note). Plan of care may include disease-specific services, such as Diabetes Self-Management Education and Support (DSME/S) services and Medical Nutrition Therapy (MNT); OR
2) Condition-specific pathways – Documented use of evidenced-based condition-specific pathways for chronic conditions (e.g., hypertension, diabetes, depression, asthma, heart failure). These might include, but are not limited to, the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP); OR
3) Pre-visit planning – Use of pre-visit planning to optimize preventive care and team management (e.g., workflow indicating pre-visit planning process); OR
4) Panel support tools – Use of panel support tools (e.g., registry or other technology) to identify services that are due in patient records; OR
5) Reminders and outreach – Use of reminders and outreach (e.g., phone calls, emails, postcards, patient portals) to alert and educate patients about services due and/or routine medication reconciliation (e.g., workflow indicating reminder and outreach process, outreach language, screenshot of reminders); OR
6) Risk prediction report – Documentation of the predictive analytical models used to predict risk, onset, and progression of chronic diseases for patient population.