IA Measures

Improvement activities breakdown

Care Coordination

Activity Weighting
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#IA_CC_12 Care coordination agreements that promote improvements in patient tracking across settings

Description :

Establish effective care coordination and active referral management that could include one or more of the following: Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/or Systematically integrate information from referrals into the plan of care.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_10 Care transition documentation practice improvements

Description :

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.).
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_11 Care transition standard operational improvements

Description :

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.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_5 CMS partner in Patients Hospital Improvement Innovation Networks

Description :

Membership and participation in a CMS Partnership for Patients Hospital Improvement Innovation Network.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_3 Implementation of additional activity as a result of TA for improving care coordination

Description :

Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_8 Implementation of documentation improvements for practice/process improvements

Description :

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_2 Implementation of improvements that contribute to more timely communication of test results

Description :

Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_9 Implementation of practices/processes for developing regular individual care plans

Description :

Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_1 Implementation of use of specialist reports back to referring clinician or group to close referral loop

Description :

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.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_13 Practice improvements for bilateral exchange of patient information

Description :

Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: Participate in a Health Information Exchange if available; and/or Use structured referral notes.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_14 Practice improvements that engage community resources to support patient health goals

Description :

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or Provide a guide to available community resources.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_7 Regular training in care coordination

Description :

Implementation of regular care coordination training.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium

#IA_CC_4 TCPI participation

Description :

Participation in the CMS Transforming Clinical Practice Initiative.
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    High

#IA_CC_6 Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination

Description :

Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).
  • Subcatagory Name :

    Care Coordination
  • Activity Weighting :

    Medium