| Measure ID |
Title |
Description |
Weight |
Subcategory ID |
|
IA_PCMH
|
Patient Centered Medical Home Attestation
|
I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.
|
|
|
|
IA_AHE_4
|
Leveraging a QCDR for use of standard questionnaires
|
Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).
|
Medium |
Achieving Health Equity |
|
IA_AHE_3
|
Leveraging a QCDR to promote use of patient-reported outcome tools
|
Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).
|
Medium |
Achieving Health Equity |
|
IA_AHE_2
|
Leveraging a QCDR to standardize processes for screening
|
Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.
|
Medium |
Achieving Health Equity |
|
IA_AHE_1
|
Engagement of new Medicaid patients and follow-up
|
Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.
|
High |
Achieving Health Equity |
|
IA_BMH_1
|
Diabetes screening
|
Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.
|
Medium |
Behavioral And Mental Health |
|
IA_BMH_2
|
Tobacco use
|
Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.
|
Medium |
Behavioral And Mental Health |
|
IA_BMH_3
|
Unhealthy alcohol use
|
Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.
|
Medium |
Behavioral And Mental Health |
|
IA_BMH_4
|
Depression screening
|
Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.
|
Medium |
Behavioral And Mental Health |
|
IA_BMH_5
|
MDD prevention and treatment interventions
|
Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.
|
Medium |
Behavioral And Mental Health |
|
IA_BMH_6
|
Implementation of co-location PCP and MH services
|
Integration facilitation, and promotion of the colocation of mental health services in primary and/or non-primary clinical care settings.
|
High |
Behavioral And Mental Health |
|
IA_BMH_7
|
Implementation of integrated PCBH model
|
Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following:
Use evidence-based treatment protocols and treatment to goal where appropriate;
Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;
Ensure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health;
Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;
Use of a registry or certified health information technology functionality to support active care management and outreach to patients in treatment; and/or
Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.
|
High |
Behavioral And Mental Health |