| Measure ID |
Title |
Description |
Weight |
Subcategory ID |
|
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_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_PM_14
|
Implementation of methodologies for improvements in longitudinal care management for high risk patients
|
Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:
Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;
Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or
Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.
|
Medium |
Population Management |
|
IA_PM_15
|
Implementation of episodic care management practice improvements
|
Provide episodic care management, including management across transitions and referrals that could include one or more of the following:
Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or
Managing care intensively through new diagnoses, injuries and exacerbations of illness.
|
Medium |
Population Management |
|
IA_PM_16
|
Implementation of medication management practice improvements
|
Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following:
Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups;
Integrate a pharmacist into the care team; and/or
Conduct periodic, structured medication reviews.
|
Medium |
Population Management |
|
IA_PM_5
|
Engagement of community for health status improvement
|
Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.
|
Medium |
Population Management |
|
IA_PM_6
|
Use of toolsets or other resources to close healthcare disparities across communities
|
Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.
|
Medium |
Population Management |
|
IA_PM_8
|
Participation in CMMI models such as Million Hearts Campaign
|
Participation in CMMI models such as the Million Hearts Cardiovascular Risk Reduction Model
|
Medium |
Population Management |
|
IA_PM_9
|
Participation in population health research
|
Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.
|
Medium |
Population Management |
|
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 |