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2023 MIPS Improvement Activity IA_PM_3: RHC, IHS or FQHC quality improvement activities

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Activity 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.

Activity ID Activity Weighting Sub-Category Name
IA_PM_3 High Population Management

Objective & Validation Documentation

Objective: 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).

Validation Documentation: Evidence of quality improvement activity participation as part of RHC, Indian Health Service (HIS), or FQHC participation. By vulnerable populations/patients, CMS is referring to racial and ethnic minorities, refugees, those who are elderly, financially disadvantaged, or without health insurance, and those who have a disability or medical condition which are associated with disparities in outcomes across populations. Include both of the following elements:
1) Name of RHC, IHS or FQHC – Identified name of RHC, IHS, or FQHC in which the eligible clinician participates in ongoing engagement activities; AND
2) Continuous quality improvement activities – Documented continuous quality improvement activities aimed at services provided to RHC, IHS, or FQHC patients. To the extent possible, these quality improvement activities should contribute to more formal quality reporting, and should include receiving quality data back for broader quality and benchmarking improvement (e.g., data reports or dashboards tied to quality improvement projects).