Index

MIPS - Improvement Activities

Quality Measures
Advancing Care Information Measures
Hints for Choosing Improvement Activities

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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_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_ERP_2 Participation in a 60-day or greater effort to support domestic or international humanitarian needs. Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater. High Emergency Response And Preparedness
IA_ERP_1 Participation on Disaster Medical Assistance Team, registered for 6 months. Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response. Medium Emergency Response And Preparedness
IA_EPA_4 Additional improvements in access as a result of QIN/QIO TA As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator). Medium Expanded Practice Access
IA_EPA_3 Collection and use of patient experience and satisfaction data on access Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. Medium Expanded Practice Access
IA_EPA_2 Use of telehealth services that expand practice access Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients. Medium Expanded Practice Access
IA_EPA_1 Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following: Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care); Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management High Expanded Practice Access
IA_PSPA_1 Participation in an AHRQ-listed patient safety organization. Participation in an AHRQ-listed patient safety organization. Medium Patient Safety And Practice Assessment
IA_PSPA_10 Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine. Medium Patient Safety And Practice Assessment
IA_PSPA_11 Participation in CAHPS or other supplemental questionnaire Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets). High Patient Safety And Practice Assessment
IA_PSPA_12 Participation in private payer CPIA Participation in designated private payer clinical practice improvement activities. Medium Patient Safety And Practice Assessment

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