| IA_EPA_1 | Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record | High | Increase patient access to eligible clinicians who work in an outpatient setting with the goal of reducing unnecessary emergency room visits. | Details |
| IA_EPA_2 | Use of telehealth services that expand practice access | Medium | Improve health outcomes by expanding patient access to telehealth services that are delivered through standardized processes. | Details |
| IA_EPA_3 | Collection and use of patient experience and satisfaction data on access | Medium | Develop an improvement plan informed by patient experience and satisfaction data, including any differences across demographic groups, so that eligible clinicians can use data-driven approaches to improve patient access and quality of care. | Details |
| IA_EPA_4 | Additional improvements in access as a result of QIN/QIO TA | Medium | Use learnings from engagement with Quality Innovation Network-Quality Improvement Organization (QIN-QIO) technical assistance to design, plan, and initiate implementation of new activities, ultimately improving access to services or care coordination. | Details |
| IA_EPA_5 | Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/) | Medium | Help CMS improve the content provided on the Quality Payment Program (QPP) website. | Details |
| IA_PM_2 | Anticoagulant management improvements | High | Improve patient understanding and adherence while reducing the risk of medication errors and adverse drug events. | Details |
| IA_PM_3 | RHC, IHS or FQHC quality improvement activities | High | Improve quality of care and formal quality improvement and reporting for Native Americans, Alaskan Natives, populations served by Rural Health Clinics (RHC), and Federally Qualified Health Centers (FQHC). | Details |
| IA_PM_4 | Glycemic management services | High | Improve diabetes care by defining and documenting individualize glycemic control goals. | Details |
| IA_PM_5 | Engagement of community for health status improvement | Medium | Improve specific chronic condition health outcomes for community populations served by an eligible clinician or practice by implementing evidence-based practices and partnership with a Quality Improvement Organization (QIO). | Details |
| IA_PM_6 | Use of toolsets or other resources to close healthcare disparities across communities | Medium | Decrease healthcare inequities and improve health status in underserved communities. | Details |
| IA_PM_7 | Use of QCDR for feedback reports that incorporate population health | High | Increase knowledge of practice patterns and treatment outcomes to better serve patients, including vulnerable populations. | Details |
| IA_PM_11 | Regular review practices in place on targeted patient population needs | Medium | Improve understanding of targeted populations’ unique needs to tailor clinical treatments, address structural inequities, and better utilize community resources. | Details |
| IA_PM_12 | Population empanelment | Medium | Strengthen patient-clinician relationships, making it possible to provide comprehensive, patient-centered primary care. | Details |
| IA_PM_13 | Chronic care and preventative care management for empaneled patients | Medium | Improve effectiveness, efficiency, and patient-centeredness of preventive and chronic care provided to empaneled patients. | Details |
| IA_PM_14 | Implementation of methodologies for improvements in longitudinal care management for high risk patients | Medium | Improve health outcomes and patient-centeredness of care for patients at high-risk for adverse health outcomes or harm. | Details |
| IA_PM_15 | Implementation of episodic care management practice improvements | Medium | Use episodic care management to improve quality of care and communication across referrals and transitions of care. | Details |
| IA_PM_16 | Implementation of medication management practice improvements | Medium | Maximize the efficiency, effectiveness, and safety of care across settings by strengthening medication management. | Details |
| IA_PM_17 | Participation in Population Health Research | Medium | Contribute to the development of evidence-based interventions, tools, or processes for improving health outcomes. | Details |
| IA_PM_18 | Provide Clinical-Community Linkages | Medium | Help patients and families access the right community resources for improving/maintaining health, education, and self-sufficiency with support from community health workers. | Details |
| IA_PM_19 | Glycemic Screening Services | Medium | Screen more patients at risk for diabetes. | Details |
| IA_PM_20 | Glycemic Referring Services | Medium | Refer more patients with pre-diabetes to a recognized preventive program to help prevent or slow disease progression. | Details |
| IA_PM_21 | Advance Care Planning | Medium | Increase the frequency and quality of advanced care planning and documentation. | Details |
| IA_CC_1 | Implementation of use of specialist reports back to referring clinician or group to close referral loop | Medium | Improve clinician-to-clinician communication to prevent delayed and/or inappropriate treatment while increasing patient satisfaction and adherence to treatment. | Details |
| IA_CC_2 | Implementation of improvements that contribute to more timely communication of test results | Medium | Reduce risk of patient harm that occurs when abnormal test results are not delivered in a timely way. | Details |
| IA_CC_7 | Regular training in care coordination | Medium | Utilize preferred practice patterns within your practice to improve care coordination. | Details |
| IA_CC_8 | Implementation of documentation improvements for practice/process improvements | Medium | Develop and utilize processes that improve care coordination outcomes. | Details |
| IA_CC_9 | Implementation of practices/processes for developing regular individual care plans | Medium | Develop, maintain, and share personalized care plans with at-risk patients to promote patient-centered care and improve patient experience. | Details |
| IA_CC_10 | Care transition documentation practice improvements | Medium | Define and implement a standardized process for transitions of care that are relevant to the eligible clinician’s patient population. | Details |
| IA_CC_11 | Care transition standard operational improvements | Medium | Enhance communication during care transitions to improve patient outcomes by establishing standard operations, or preferred practice patterns, for transition communications. | Details |
| IA_CC_12 | Care coordination agreements that promote improvements in patient tracking across settings | Medium | Improve processes for care coordination and active referral management, thus making care more effective and efficient, preventing risky delays and under-treatment, and increasing patient satisfaction and adherence to treatment. | Details |
| IA_CC_13 | Practice improvements for bilateral exchange of patient information | Medium | Utilize a program or process that provides an open exchange of necessary patient information between care teams and patients to guide patient care. | Details |
| IA_CC_14 | Practice improvements that engage community resources to support patient health goals | High | Improve the health and well-being of patients with health-related social needs (HRSN) by connecting them with appropriate community resources. | Details |
| IA_CC_15 | PSH Care Coordination | High | Participate in a Perioperative Surgical Home (PSH) model to improve coordination of patient care through the acute-care episode, recovery, and post-acute care. | Details |
| IA_CC_16 | Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of
Information for Shared Patients | Medium | Improve whole-person care by establishing bidirectional communication between eligible primary care clinicians and behavioral health practices for shared patients. | Details |
| IA_CC_17 | Patient Navigator Program | High | Reduce avoidable hospital readmissions and make hospital stays less stressful and recovery periods more supportive for patients. | Details |
| IA_CC_18 | Relationship-Centered Communication | Medium | Improve quality of patient-clinician communication and interaction by attending training on relationship-centered care and communication techniques. | Details |
| IA_CC_19 | Tracking of clinician's relationship to and responsibility for a patient by reporting MACRA patient relationship codes. | High | Increase the utilization of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) patient relationship codes (PRC) using the applicable Healthcare Common Procedure Coding System (HCPCS) modifiers on Medicare claims. Using PRC ensure that appropriate attribution is assigned to the appropriate eligible clinician. For example, it would be inappropriate to attribute the cost of an aortic aneurysm repair to the ophthalmologist who performed a cataract surgery in the same calendar year. | Details |
| IA_BE_1 | Use of certified EHR to capture patient reported outcomes | Medium | Improve patient engagement through patient/clinician review of patient collected information or through assessment of a patient’s understanding, confidence, and ability to perform self-care. | Details |
| IA_BE_3 | Engagement with QIN-QIO to implement self-management training programs | Medium | Become more equipped to help patients self-manage their chronic conditions. | Details |
| IA_BE_4 | Engagement of patients through implementation of improvements in patient portal | Medium | Increase patient engagement, adherence to treatment plans, and self-management of chronic conditions through the availability of a patient portal within the electronic health record (EHR). | Details |
| IA_BE_5 | Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities | Medium | Ensure eligible clinicians' website content and tools more accessible to people with disabilities. | Details |
| IA_BE_6 | Regularly Assess Patient Experience of Care and Follow Up on Findings | High | Improve patients' experience of and satisfaction with care by gathering and applying learnings from relevant data to make care more patient-centered. | Details |
| IA_BE_7 | Participation in a QCDR, that promotes use of patient engagement tools. | Medium | Increase patient engagement though use of qualified clinical data registry (QCDR)’s tools for promoting positive patient behavior such as consistent exercise. | Details |
| IA_BE_8 | Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. | Medium | Increase involvement of interactive collaborative learning networks with support of qualified clinical data registry (QCDR) promotion and feedback reports. | Details |
| IA_BE_12 | Use evidence-based decision aids to support shared decision-making. | Medium | Increase use of evidence-based decision aids to encourage shared decision-making with beneficiaries. | Details |
| IA_BE_14 | Engage patients and families to guide improvement in the system of care. | High | Use active devices and platforms to allow the patient and the clinical care team to share information on a patient's status, adherence, comprehension, and indicators of clinical concern in a timely manner. | Details |
| IA_BE_15 | Engagement of patients, family and caregivers in developing a plan of care | Medium | Increase engagement with patients, family, and caregivers and ensure care provided aligns with their priorities and needs. | Details |
| IA_BE_16 | Promote Self-management in Usual Care | Medium | Improve health outcomes by helping patients improve self-management. | Details |
| IA_BE_19 | Use group visits for common chronic conditions (e.g., diabetes). | Medium | Give patients with common chronic conditions opportunities to learn about self-management topics and discuss shared concerns while improving efficiency in the delivery of quality care. | Details |
| IA_BE_22 | Improved practices that engage patients pre-visit | Medium | Increase the efficiency and effectiveness of visit time with patients, and promote patient engagement and satisfaction with care. | Details |
| IA_BE_23 | Integration of patient coaching practices between visits | Medium | Provide additional direct support to patients in achieving their goals, thus improving patient satisfaction, adherence to plans, and health outcomes. | Details |
| IA_BE_24 | Financial Navigation Program | Medium | Help patients navigate the stress and risks associated with paying for healthcare, and, when relevant, help them explore alternative options that address their holistic needs. | Details |
| IA_BE_25 | Drug Cost Transparency | High | Help patients navigate the stress and risks associated with paying for healthcare by providing information on the patients’ share of the costs for medications in the drug formulary; help patients explore alternative options that address their holistic needs. | Details |
| IA_PSPA_1 | Participation in an AHRQ-listed patient safety organization. | Medium | Adopt and implement Patient Safety Organization (PSO) methodologies through data collection, analysis, reporting, and education to promote the quantifiable reduction of avoidable medical errors and deficiencies identified in the quality of care provided. | Details |
| IA_PSPA_2 | Participation in MOC Part IV | Medium | Maintain certifications with a Maintenance of Certification (MOC)-approved specialty board to increase/update knowledge and apply it to practice and safety improvements. | Details |
| IA_PSPA_3 | Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity. | Medium | Obtain a Maintenance of Certification (MOC)-approved specialty board certification or other similar program to increase/update knowledge and apply it to practice and safety improvements. | Details |
| IA_PSPA_4 | Administration of the AHRQ Survey of Patient Safety Culture | Medium | Create the opportunity to i) Raise staff awareness about patient safety; ii) Elucidate and assess the current status of patient safety culture; iii) Identify strengths and areas for patient safety culture improvement; iv) Evaluate trends in patient safety culture change over time; and v) Evaluate the cultural impact of patient safety initiatives and interventions (from www.ahrq.gov). | Details |
| IA_PSPA_6 | Consultation of the Prescription Drug Monitoring program | High | Use patients' past prescription history to inform decisions about issuing new controlled substance schedule II opioid prescriptions, thus identifying and protecting patients who are at risk of opioid addition and/or overdose. | Details |
| IA_PSPA_7 | Use of QCDR data for ongoing practice assessment and improvements | Medium | Use qualified clinical data registry (QCDR) data for practice assessment and improvement with primary goal of addressing patient safety for targeted populations. | Details |
| IA_PSPA_8 | Use of patient safety tools | Medium | Improve the number of patients tracked and the precision of measurement for patient safety measures, thus allowing specialists to make evidence-based decisions about improving safety for their patients. | Details |
| IA_PSPA_9 | Completion of the AMA STEPS Forward program | Medium | Gain the knowledge to "improve practice efficiency and ultimately enhance patient care, physician satisfaction and practice sustainability" (from edhub.ama-assn.org). | Details |
| IA_PSPA_10 | Completion of training and receipt of approved waiver for provision of opioid medication-assisted treatments | Medium | Become better equipped to help patients overcome their opioid use disorders and, with certification, become a trusted source of care for patients with opioid disorders. | Details |
| IA_PSPA_12 | Participation in private payer CPIA | Medium | Improve the quality of care provided, and health outcomes for patients, by participating in improvement activities designated by private payers. | Details |
| IA_PSPA_13 | Participation in Joint Commission Evaluation Initiative | Medium | Implement the Joint Commission’s Ongoing Professional Practice Evaluation with goal of identifying negative practice trends earlier. | Details |
| IA_PSPA_15 | Implementation of an ASP | Medium | Reduce inappropriate use of antimicrobials, thus playing a critical role in reducing microbial resistance and the incidence of antimicrobial-caused adverse drug reactions, all of which will help improve patient outcomes and the efficiency of spending. | Details |
| IA_PSPA_16 | Use of decision support and standardized treatment protocols | Medium | Help eligible clinicians align diagnoses and treatment plans with up-to-date, evidence-based standards and guidelines as part of routine care, thus improving the appropriateness of the care they provide and the health outcomes of their patients. | Details |
| IA_PSPA_17 | Implementation of analytic capabilities to manage total cost of care for practice population | Medium | Create opportunities to assess total cost of care and identify ways to reduce unnecessary costs. | Details |
| IA_PSPA_18 | Measurement and improvement at the practice and panel level | Medium | Enhance the measurement of the quality of care, making quality data relevant at practice and panel levels, and use those data to implement effective quality improvement activities. | Details |
| IA_PSPA_19 | Implementation of formal quality improvement methods, practice changes or other practice improvement processes | Medium | Expand and formalize quality improvement (QI) activities across the practice, ultimately leading to improvements in the quality of care and fostering a culture of participation among staff. | Details |
| IA_PSPA_20 | Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes | Medium | Institutionalize quality improvement within the practice by making it an explicit component of leadership’s roles and responsibilities, thus strengthening the commitment to care quality across the practice. | Details |
| IA_PSPA_21 | Implementation of fall screening and assessment programs | Medium | Improve identification of patients who are at risk of falling; then reduce their risk and improve their health outcome, independence, and satisfaction with care. | Details |
| IA_PSPA_22 | CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain | High | Become better equipped to improve prescription practices and thus help reduce patients' risks of addiction and overdose. | Details |
| IA_PSPA_23 | Completion of CDC Training on Antibiotic Stewardship | High | Reduce inappropriate use of antimicrobials to help reduce microbial resistance and the incidence of antimicrobial-caused adverse drug reactions, all of which will help improve patient outcomes and the efficiency of spending. | Details |
| IA_PSPA_25 | Cost Display for Laboratory and Radiographic Orders | Medium | Help eligible ordering clinicians easily obtain information on the cost of laboratory and radiography orders, allowing them to manage their costs strategically. | Details |
| lA_PSPA_26 | Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event | Medium | Allow primary care doctors to immediately tailor plans of care for patients to prevent further medication errors and achieve better outcomes in the future. | Details |
| IA_PSPA_27 | Invasive Procedure or Surgery Anticoagulation Medication Management | Medium | Formalize and document a standardized process for management of patients on anti-coagulant medication before, during, and after invasive procedures, thus reducing risk of complications. | Details |
| IA_PSPA_28 | Completion of an Accredited Safety or Quality Improvement Program | Medium | Complete an accredited performance improvement continuing medical education (CME) program, ultimately applying program content to address a specific quality or safety gap. | Details |
| IA_PSPA_29 | Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging | High | Consult Appropriate Use Criteria (AUC) through a clinical decision support (CDS) mechanism for imaging services to reduce unnecessary and potentially harmful over-imaging. | Details |
| IA_PSPA_30 | PCI Bleeding Campaign | High | Participate in the percutaneous coronary intervention (PCI) Bleed Campaign to reduce avoidable bleeding associated with patients who receive a PCI. | Details |
| IA_PSPA_31 | Patient Medication Risk Education | High | Educate patients regarding the risks of concurrent opioid and benzodiazepine use, thus reducing their risk of overdose. | Details |
| IA_PSPA_32 | Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support | High | Make Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain via clinical decision support (CDS) part of eligible clinicians' workflow, thus improving prescription practices, protecting patients at risk for addition and/or overdose, and helping to address the opioid epidemic. | Details |
| IA_PSPA_33 | Application of CDC’s Training for Healthcare Providers on Lyme Disease | Medium | Improve health outcomes for patients with Lyme disease by leveraging clinical decision support (CDS) and training tools. | Details |
| IA_AHE_1 | Enhance Engagement of Medicaid and Other Underserved Populations | High | Ensure timely treatment of patients from underserved populations, to help them achieve improved health outcomes. | Details |
| IA_AHE_3 | Promote use of Patient-Reported Outcome Tools | High | Make it possible to use Patient Reported Outcomes (PRO) data as part of routine care, thus increasing patient engagement and health outcomes for all populations. | Details |
| IA_AHE_5 | MIPS Eligible Clinician Leadership in Clinical Trials or CBPR | Medium | Encourage clinicians to minimize disparities in healthcare access, care quality, affordability, or outcomes by contributing to new and improved tools, research, or processes, which may include addressing health-related social needs. | Details |
| IA_AHE_6 | Provide Education Opportunities for New Clinicians | High | Provide clinicians-in-training with diverse experiences, allowing them to gain deep understanding of the challenges facing eligible clinicians and patients in small practices or in underserved or rural areas. | Details |
| IA_AHE_7 | Comprehensive Eye Exams | Medium | Improve eye health of underserved and/or high-risk populations, and empower patients in these populations to become more educated consumers of eye care. | Details |
| IA_AHE_8 | Create and Implement an Anti-Racism Plan | High | Begin to address inequities in health outcomes by creating and implementing an anti-racism plan. | Details |
| IA_AHE_9 | Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols | Medium | Reduce food insecurity and improve nutritional outcomes for at-risk patients. | Details |
| IA_ERP_1 | Participation on Disaster Medical Assistance Team, registered for 6 months. | Medium | Provide sustained support to communities facing the impact of disasters, filling immediate needs, and contributing to a faster, better recovery. | Details |
| IA_ERP_2 | Participation in a 60-day or greater effort to support domestic or international humanitarian needs. | High | Provide sustained support to communities across the globe that need humanitarian volunteer support, thus helping to alleviate suffering, save lives, and maintain human dignity. | Details |
| IA_ERP_4 | Implementation of a Personal Protective Equipment (PPE) Plan | Medium | Ensure the safety of patients and staff by maintaining a sufficient supply of personally protective equipment (PPE) for all clinicians and other health workers. | Details |
| IA_ERP_5 | Implementation of a Laboratory Preparedness Plan | Medium | Ensure preparedness and safety of staff working in laboratories providing patient care during COVID-19 or another public health emergency. | Details |
| IA_BMH_1 | Diabetes screening | Medium | Improve rates of screening for patients with schizophrenia or bipolar disorder, who have higher risk or higher prevalence of diabetes relative to the general population, thus increasing eligible clinicians' ability to detect and respond early to positive diagnoses, potentially reducing the burden and complications of the disease. | Details |
| IA_BMH_2 | Tobacco use | Medium | Help patients at high risk for tobacco dependence and with behavioral or mental conditions to avoid or end addiction to tobacco. | Details |
| IA_BMH_4 | Depression screening | Medium | Improve the identification of depression among patients with behavioral or mental health conditions and sustain patient-centered support and treatment for those diagnosed with depression. | Details |
| IA_BMH_5 | MDD prevention and treatment interventions | Medium | Increase patient-centered support and treatment for patients with conditions of behavioral or mental health conditions to prevent severe depression and suicide. | Details |
| IA_BMH_6 | Implementation of co-location PCP and MH services | High | Integrate mental health and substance use disorder services with primary and/or non-primary clinical care through the co-location and co-promotion of these services. | Details |
| IA_BMH_7 | Implementation of Integrated Patient Centered Behavioral Health Model | High | Support patients with behavioral health needs and poorly controlled chronic illnesses though integrated behavioral health services and the use of evidence-based tools or other initiatives. | Details |
| IA_BMH_8 | Electronic Health Record Enhancements for BH data capture | Medium | Continually improve the care provided to behavioral health populations through evidence-based interventions and the use of electronic health record technology (EHR). | Details |
| IA_BMH_9 | Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients | High | Help patients better manage or overcome their alcohol and/or other substance abuse challenges through screenings and counseling. | Details |
| IA_BMH_10 | Completion of Collaborative Care Management Training Program | Medium | Develop strategies to improve integration of behavioral health into primary care practices, ultimately improving patient-centeredness of care and health outcomes for mental health patients. | Details |
| IA_BMH_11 | Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice | Medium | Ensure delivery of responsive care for patients and clinicians who have experienced physical or mental trauma. | Details |
| IA_BMH_12 | Promoting Clinician Well-Being | High | Improve the well-being of clinicians and the quality and safety of care they deliver. | Details |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation | | Obtaining Patient-Centered Medical Home™ certification drives significant and sustainable practice improvements including population care quality, efficiency, and improved patient satisfaction all directly linked to better health outcomes. | Details |
| IA_ERP_3 | COVID-19 Clinical Data Reporting with or without Clinical Trial | High | Contribute to the development of clinically proven treatments for COVID-19. | Details |
