2024 MIPS IA_AHE_11: Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients

Activity ID


Activity Weighting


Subcategory Name

Achieving Health Equity

Activity Description

Create and implement a plan to improve care for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients by understanding and addressing health disparities for this population. The plan may include an analysis of sexual orientation and gender identity (SO/GI) data to identify disparities in care for LGBTQ+ patients. Actions to implement this activity may also include identifying focused goals for addressing disparities in care, collecting and using patients’ pronouns and chosen names, training clinicians and staff on SO/GI terminology (including as supported by certified health IT and the Office of the National Coordinator for Health Information Technology US Core Data for Interoperability [USCDI]), identifying risk factors or behaviors specific to LGBTQ+ individuals, communicating SO/GI data security and privacy practices with patients, and/or utilizing anatomical inventories when documenting patient health histories.


Begin to address disparities in health care and health outcomes for LGBTQ+ people by creating and implementing a plan to improve care for lesbian, gay, bisexual, transgender, and queer patients.

Suggested Documentation

Evidence of a practice-wide review and implementation of a plan to improve care for LGBTQ+ patients. Include the following:

1) Review - Documentation of a practice-wide review of existing tools and policies; AND

2) Assessment memo - Completion of an assessment memo summarizing the results of the above review; AND

3) Plan to Improve Care for LGBTQ+ patients - A new or updated plan, which includes actions, intended outcomes, and timeline for completion for the eligible clinician's practice; this plan must identify ways in which issues and gaps identified in the review can be addressed and should include target goals and milestones, and the eligible clinician or practice should also consider including training on sexual orientation and gender identity; AND

4) Plan Implementation - Report with results from implementing the new or updated plan for improving care for LGBTQ+ patients.


A practice-wide review indicated that existing website and human-resources documents do not mention a commitment to inclusion of LGBTQ+ people, and that electronic medical records data on sexual orientation and gender identity are frequently incomplete. The practice updated its website and human-resources materials to reflect its commitment to caring for LGBTQ+ patients, and trained clinicians on best practices for gathering and documenting sexual orientation and gender identity data in health records.



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