| Measure ID |
Title |
Description |
Weight |
Subcategory ID |
|
IA_PM_13
|
Chronic care and preventative care management for empanelled patients
|
Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:
Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning;
Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target;
Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;
Use panel support tools (registry functionality) to identify services due;
Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or
Routine medication reconciliation.
|
Medium |
Population Management |
|
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_2
|
Anticoagulant management improvements
|
MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities:
Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;
Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;
For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or
For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.
The performance threshold will increase to 75 percent for the second performance year and onward.
Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.
|
High |
Population Management |
|
IA_PM_3
|
RHC, IHS or FQHC quality improvement activities
|
Participating in a Rural Health Clinic (RHC), Indian Health Service (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.
|
High |
Population Management |
|
IA_PM_4
|
Glycemic management services
|
For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:
For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:
a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and
b) Is reassessed at least annually.
The performance threshold will increase to 75 percent for the second performance year and onward.
Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.
|
High |
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_7
|
Use of QCDR for feedback reports that incorporate population health
|
Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.
|
High |
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 |