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15 Improvement Activities to Consider with Last Minute MIPS Reporting

If you're scrambling to report your 2017 MIPS performance year data, you're not alone. With the deadline quickly approaching, a number of practices are looking at how to report their 2017 data in order to avoid the 4% penalty on their 2019 Medicare Part B claims. With 2017 being the transition year to MIPS, eligible clinicians must submit data for 1 Quality Measure or 1 Improvement Activity for 1 Patient over a 90 day period.

Here we've defined fifteen improvement activities under the Merit-based Incentive Payment System that a practice would typically capture during a normal workflow when a Certified Electronic Health Record (EHR) software is being utilized.

1. Use of certified EHR to capture patient reported outcomes

Activity weighting: Medium

Activity ID: IA_BE_1

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.

 

2. Unhealthy alcohol use

Activity weighting: Medium

Activity ID: IA_BMH_3

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.

 

3. Tobacco use

Activity weighting: Medium

Activity ID: IA_BMH_2

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.

 

4. Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record

Activity weighting: High

Activity ID: IA_EPA_1

Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following: Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care); Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management

 

5. Practice improvements for bilateral exchange of patient information

Activity weighting: Medium

Activity ID: IA_CC_13

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.

 

6. Measurement and improvement at the practice and panel level

Activity weighting: Medium

Activity ID: IA_PSPA_18

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.

 

7. Integration of patient coaching practices between visits

Activity weighting: Medium

Activity ID: IA_BE_23

Provide coaching between visits with follow-up on care plan and goals.

 

8. Implementation of practices/processes for developing regular individual care plans

Activity weighting: Medium

Activity ID: IA_CC_9

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

 

9. Use of patient safety tools

Activity weighting: Medium

Activity ID: IA_PSPA_8

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.

 

10. Use of telehealth services that expand practice access

Activity weighting: Medium

Activity ID: IA_EPA_2

Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.

 

11. Engagement of patients through implementation of improvements in patient portal

Activity weighting: Medium

Activity ID: IA_BE_4

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. 

 

12. Engagement of new Medicaid patients and follow-up

Activity weighting: High

Activity ID: IA_AHE_1

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.

 

13. Electronic Health Record Enhancements for Behavioral Health data capture

Activity weighting: Medium

Activity ID: IA_BMH_8

Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).

 

14. Diabetes Screening

Activity weighting: Medium

Activity ID: IA_BMH_1

Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.

 

15. Depression Screening

Activity weighting: Medium

Activity ID: IA_BMH_4

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.

Visit the Quality Payment Program website here to view all of the improvement activities available to your practice.

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