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IA Measures

Improvement activities breakdown

Population Management

Activity Weighting
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IA_PM_2 Anticoagulant Management Improvements

Description:

Individual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities:
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    High

IA_PM_3 RHC, IHS or FQHC quality improvement activities

Description:

Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (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.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    High

IA_PM_4 Glycemic management services

Description:

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.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    High

IA_PM_5 Engagement of community for health status improvement

Description:

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.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_6 Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities

Description:

Address inequities in health outcomes by using population health data analysis tools to identify health inequities in the community and practice and assess options for effective and relevant interventions such as Population Health Toolkit or other resources identified by the clinician, practice, or by CMS. Based on this information, create, refine, and implement an action plan to address and close inequities in health outcomes and/or health care access, quality, and safety.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_7 Use of QCDR for feedback reports that incorporate population health

Description:

Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    High

IA_PM_11 Regular review practices in place on targeted patient population needs

Description:

Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved 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. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_12 Population empanelment

Description:

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
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_13 Chronic Care and Preventative Care Management for Empaneled Patients

Description:

In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_14 Implementation of methodologies for improvements in longitudinal care management for high risk patients

Description:

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_15 Implementation of episodic care management practice improvements

Description:

Provide episodic care management, including management across transitions and referrals that could include one or more of the following:
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_16 Implementation of medication management practice improvements

Description:

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following:
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_17 Participation in Population Health Research

Description:

Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_18 Provide Clinical-Community Linkages

Description:

Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_19 Glycemic Screening Services

Description:

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_20 Glycemic Referring Services

Description:

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium

IA_PM_21 Advance Care Planning

Description:

Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.
  • Subcategory Name:

    Population Management
  • Activity Weighting:

    Medium