Improvement Activities
Report Activities
- Make section(s) from the list of Improvements provided by CMS, or use the recommendations below. (You may use improvements from pervious MIPS reporting years.)
- Execute your selected activity for at least 90 consecutive days. Requirements will vary per selection.
- Retain all evidence of the implementation or completion of your selection.
Attest Activities – Search for the improvement that you elected to implement during reporting and select it, from the list, to indicate your compliance.
If you are asked to produce proof of your implementation you must supply record of policy, registration, or performance of the activity. If you are using a ChiroTouch application to complete your improvement you may provide screenshots to outline this process. This proof will vary per selection.
To earn full credit in the Improvement Activities category, participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2019):
- 2 high-weighted activities
- 1 high-weighted activity and 2 medium-weighted activities
- 4 medium-weighted activities
High weighted activities earn 20 points, medium weighted activities earn 10 points (unless special status applies, see below). You are striving to earn a total of 40 points in this category.
Special Status
You will receive double points for each high- or medium-weighted activity you submit if you are an individual clinician, group, or virtual group who holds any of these special statuses:
- Small practice
- Non-patient facing
- Rural
- Health Professional Shortage Area (HPSA)
Check your general MIPS participation status to verify if any of the above applies to you or your group.
Recommendations
From the many available options, you may select any Improvement Activities that you feel best fit into your daily flow. In order to assist you in your selection and help you most easily complete the IA requirement, we have provided the following suggestions.
Choose 1 high-weight and 2 mid-weight objectives, or choose 4 mid-weight objectives from the following:
Achieving Health Equality (High = 20 points)
Complete List of Improvement Activities
Additional improvements in access as a result of QIN/QIO TA As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).
The resource(s) below may assist you in performing this improvement activity:
Participation in a 60-day or greater effort to support domestic or international humanitarian needs. Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.
The resource(s) below may assist you in performing this improvement activity:
As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).
The resource(s) below may assist you in performing this improvement activity:
Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website)
The resource(s) below may assist you in performing this improvement activity:
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.
The resource(s) below may assist you in performing this improvement activity:
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.).
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.
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.
Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.
Completion of the American Medical Association's STEPS Forward program.
The resource(s) below may assist you in performing this improvement activity:
Engage patients and families to guide improvement in the system of care.
Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.
Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.
Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.
Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.
The resource(s) below may assist you in performing this improvement activity:
Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.
Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following: Train appropriate staff on interpretation of cost and utilization information; and/or Use available data regularly to analyze opportunities to reduce cost through improved care
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).
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.
Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).
Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: Train all staff in quality improvement methods; Integrate practice change/quality improvement into staff duties; Engage all staff in identifying and testing practices changes; Designate regular team meetings to review data and plan improvement cycles; Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families.
Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.
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.
Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).
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.
Provide a pre-visit development of a shared visit agenda with the patient.
Provide coaching between visits with follow-up on care plan and goals.
Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.
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).
The resource(s) below may assist you in performing this improvement activity:
Measure and improve quality at the practice and panel level that could include one or more of the following: Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.
Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.
The resource(s) below may assist you in performing this improvement activity:
- https://www.volunteerhq.org/?gclid=CjwKEAiAq8bEBRDuuOuyspf5oyMSJAAcsEyWZaFfXI0W9Vx0ilJ7T71N4JDPJNqwspbfjb3J3wML7hoCHN_w_wcB
- http://www.internationalmedicalrelief.org/upcoming-medical-missions-trips/?gclid=CjwKEAiAq8bEBRDuuOuyspf5oyMSJAAcsEyWcB5sdn68QyyasyzJyapu-UjX975Lze7OHu3EEirFpxoCRdzw_wcB
- http://www.ifrevolunteers.org/volunteer-abroad/?gclid=CjwKEAiAq8bEBRDuuOuyspf5oyMSJAAcsEyWpbkY0_obWlhEz7CAs4FRBmOuUJMl_vRDjrpV15SFFRoC6Irw_wcB
- http://www.projecthope.org/where-we-work/humanitarian-missions/
- https://www.volunteerforever.com/article_post/medical-volunteer-abroad-programs-for-doctors-nurses-pre-med-students
- http://www.medicalteams.org/take-action/volunteer/disaster-response-volunteering
Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
The resource(s) below may assist you in performing this improvement activity:
Participation in a QCDR, that promotes implementation of patient self-action plans.
Participation in a QCDR, that promotes use of patient engagement tools.
Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.
Participation in an AHRQ-listed patient safety organization.
The resource(s) below may assist you in performing this improvement activity:
Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).
The resource(s) below may assist you in performing this improvement activity:
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0621.pdf
- https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/
- https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/downloads/hospitalhcahpsfactsheet201007.pdf
Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.
Participation in designated private payer improvement activities.
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.
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.
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.
Implementation of regular care coordination training.
The resource(s) below may assist you in performing this improvement activity:
Use evidence-based decision aids to support shared decision-making.
The resource(s) below may assist you in performing this improvement activity:
Use group visits for common chronic conditions (e.g., diabetes).
In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.
Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator.
The resource(s) below may assist you in performing this improvement activity: