MIPS - Improvement Activities

Quality Measures
Advancing Care Information Measures
Hints for Choosing Improvement Activities


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

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