Index

MIPS - Improvement Activities

Quality Measures
Advancing Care Information Measures
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Measure ID Title Description Weight Subcategory ID
IA_BMH_3 Unhealthy alcohol use Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions. Medium Behavioral And Mental Health
IA_BMH_2 Tobacco use Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence. Medium Behavioral And Mental Health
IA_BMH_1 Diabetes screening Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication. Medium Behavioral And Mental Health
IA_BE_9 Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. Medium Beneficiary Engagement
IA_BE_8 Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. Medium Beneficiary Engagement
IA_BE_7 Participation in a QCDR, that promotes use of patient engagement tools. Participation in a QCDR, that promotes use of patient engagement tools. Medium Beneficiary Engagement
IA_CC_10 Care transition documentation practice improvements Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.). Medium Care Coordination
IA_CC_1 Implementation of use of specialist reports back to referring clinician or group to close referral loop Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group to close the referral loop or where the referring MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology. Medium Care Coordination
IA_BMH_8 Electronic Health Record Enhancements for BH data capture Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified). Medium Behavioral And Mental Health
IA_CC_11 Care transition standard operational improvements Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or Partner with community or hospital-based transitional care services. Medium Care Coordination
IA_CC_12 Care coordination agreements that promote improvements in patient tracking across settings Establish effective care coordination and active referral management that could include one or more of the following: Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/or Systematically integrate information from referrals into the plan of care. Medium Care Coordination
IA_CC_13 Practice improvements for bilateral exchange of patient information Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: Participate in a Health Information Exchange if available; and/or Use structured referral notes. Medium Care Coordination

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