2024 MIPS IA_PM_18: Provide Clinical-Community Linkages

Activity ID

Activity Weighting

Subcategory Name

Population Management

Activity Description

Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and selfsufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA PatientCentered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.

Objective

Help patients and families access the right community resources for improving/maintaining health, education, and self-sufficiency with support from community health workers.

Suggested Documentation

Evidence of engagement with community health workers to provide a comprehensive link to community resources and family-based services with an emphasis on improving health, education, and self-sufficiency. Include all of the following elements:

1) Community health worker engagement – Documentation of active engagement with community health workers to collaborate in helping patients served by the practice address risk factors related to social determinants of health (e.g., electronic health records referencing community health worker engagement, paperwork related to engagement of community health workers); AND

2) Coordination and patient engagement – Documentation of coordination with primary care and other eligible clinicians to engage and support patients (e.g., use of health information technology); AND

3) Measure and monitoring – Evidence of use of quality measurement and improvement processes (e.g., National Committee for Quality Assurance’s Patient-Centered Connected Care [PCCC] Recognition Program or similar programs) to continuously improve engagement and coordination with community health workers and other clinicians in an effort to improve patient wellbeing and health (e.g., dashboards, reports).

Example/Information

A primary healthcare practice may work with community health workers to help patients with limited English language skills understand and adhere to new plans for diet and medication, learn how to use and manage medical equipment, and provide information on local support groups for people with diabetes. The community health workers report back to the eligible clinicians at the primary healthcare practice; the eligible clinicians then communicate as relevant to other eligible clinicians providing care to the patients and monitor to improve community health worker engagement and the outcomes of the patients they see.

Information

• Centers for Disease Control and Prevention’s (CDC’s) Community Health Workers Toolkit: https://www.cdc.gov/dhdsp/pubs/toolkits/chwtoolkit.htm
• Association of State and Territorial Health Officials Clinical to Community Connections: https://www.astho.org/Community-Health-Workers/