Using QM Accelerator to Complete Improvement Activities

IA_PSPA_18

Measurement and Improvement at the Practice and Panel Level

Medium-Weighted

Description

• Regularly review measures of quality, utilization, patient satisfaction and other measures; and/or
• Use relevant data sources to create benchmarks and goals for performance at the practice or panel levels.

MIPS eligible clinicians can apply the measurement and quality improvement to address inequities in quality and outcomes for underserved populations, including racial, ethnic, and/or gender minorities.

How to satisfy using

The dashboard allows users to view Quality and PI Metrics. It has drilldown capability to the patient level for all 43 measures. The dashboard displays how the practice/providers compare to the CMS established benchmarks on Quality Metrics. Users can quickly compare performance across providers and departments to identify gaps in care or workflow. This allows the practice to set internal quality goals.

IA_PM_11

Regular Review Practices in Place on Targeted Patient Population Needs

Medium-Weighted

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.

How to satisfy using

Use the dashboard to illustrate the specific patient populations that the Quality Measures satisfy (age, gender, chronic conditions) and assign to the practice and specific providers. Practices can then ensure specific patient populations are being given appropriate treatment. Note: Users may need to further identify populations for other demographic and health related social needs that may drive gaps and disparities in health conditions that MIPS Quality Measures do not address.

IA_PM_12

Population Empanelment

Medium-Weighted

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 “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.

How to satisfy using

The dashboard empanels patients to providers based on previous care given over the performance period. Users can view the active patient lists that are assigned to them for a given Quality Measure for the current year, sorted by provider or department. Users can proactively follow-up with patients who have not been given standard preventive care treatment for the Quality measures that focus on preventive care.

IA_PM_13

Chronic Care and Preventative Care Management for Empaneled Patients

Medium-Weighted

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:

• 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; and plan of care for chronic conditions.
• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP)
• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions.
• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due.
• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or
• 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.

How to satisfy using

There are Quality measures on the dashboard that identify patients with Chronic Conditions or who require Preventive Care. The dashboard allows users to identify preventive care or chronic care treatment that was not given. This information can be used to illustrate patients that need follow-up care or outreach.