2023 MIPS IA_PM_14: Implementation of methodologies for improvements in longitudinal care management for high risk patients

Activity ID

Activity Weighting

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.

Objective

Suggested Documentation

Evidence of longitudinal, or relationship-based, care management of patients at high-risk for adverse health outcomes as defined by the eligible clinician. Include both of the following elements:

1) List of 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; b) personalized care plans for patients at high risk for adverse health outcome or harm; or c) evidence of use of care managers to monitor and coordinate care for highest risk cohorts.

Example/Information

A cardiologist practice learns that a high percentage of their congestive heart failure (CHF) patients are being re-admitted to the hospital within 30 days of a previous admission for CHF. The cardiology group undertakes practice changes to minimize total CHF hospital admissions. Initially, they identify their population in a manner most appropriate to their practice. Examples might include the stage of CHF or patients with any hospital admission within a certain period of time. Then they team with their nursing staff to create a plan that includes an initial discussion with each patient and plans for monitoring weight and diet daily and on a regular basis by phone, email, or electronic medical record patient portal. Additionally, the patients in the cohort are given access to a direct nursing phone line for questions or with specific concerns such as sudden weight gain. An example of a goal would be identification of sudden weight gain with subsequent temporary increases in diuretic dosing, all completed at home.