| Measure ID |
Title |
Description |
Weight |
Subcategory ID |
|
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_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_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_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_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_12
|
Population empanelment
|
Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.
Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management.
Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the "active population" of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define "active patients" operationally, but generally, the definition of "active patients" includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.
|
Medium |
Population Management |
|
IA_PM_11
|
Regular review practices in place on targeted patient population needs
|
Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.
|
Medium |
Population Management |
|
IA_PM_10
|
Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
|
Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).
|
Medium |
Population Management |
|
IA_PM_1
|
Participation in systematic anticoagulation program
|
Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program)for 60 percent of practice patients in year 1 and 75 percent of practice patients in year 2 who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).
|
High |
Population Management |