| Measure ID |
Title |
Description |
Weight |
Subcategory ID |
|
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_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 |
|
IA_CC_14
|
Practice improvements that engage community resources to support patient health goals
|
Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:
Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or
Provide a guide to available community resources.
|
Medium |
Care Coordination |
|
IA_CC_2
|
Implementation of improvements that contribute to more timely communication of test results
|
Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.
|
Medium |
Care Coordination |
|
IA_CC_3
|
Implementation of additional activity as a result of TA for improving care coordination
|
Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.
|
Medium |
Care Coordination |
|
IA_CC_4
|
TCPI participation
|
Participation in the CMS Transforming Clinical Practice Initiative.
|
High |
Care Coordination |
|
IA_CC_5
|
CMS partner in Patients Hospital Improvement Innovation Networks
|
Membership and participation in a CMS Partnership for Patients Hospital Improvement Innovation Network.
|
Medium |
Care Coordination |
|
IA_CC_6
|
Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
|
Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).
|
Medium |
Care Coordination |
|
IA_CC_7
|
Regular training in care coordination
|
Implementation of regular care coordination training.
|
Medium |
Care Coordination |
|
IA_CC_8
|
Implementation of documentation improvements for practice/process improvements
|
Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).
|
Medium |
Care Coordination |