Category: Improvement Activities

To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.

Use group visits for common chronic conditions (e.g., diabetes).

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.

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

In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.

Provide counseling to patients and/or their caregivers regarding: costs of medications using a real time benefit tool (RTBT) which provides to the prescriber real-time patient-specific formulary and benefit information for drugs, including cost-sharing for a beneficiary.

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.

To receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by any one or more of the following:
• providing literature,
• facilitating a conversation about this topic using resources such as the “Think About Your Eyes” campaign,
• referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology’s EyeCare America and the American Optometric Association’s VISION USA, or
• promoting access to vision rehabilitation services as appropriate for individuals with chronic vision impairment.This activity is intended for:
• Non-ophthalmologists / optometrists who refer patients to an ophthalmologist/optometrist;
• Ophthalmologists/optometrists caring for underserved patients at no cost; or
• Any clinician providing literature and/or resources on this topic.This activity must be targeted at underserved and/or high-risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams or vision rehabilitation services.

MIPS eligible clinicians must implement at least one process improvement during treatment of patients taking anti-psychotic medication related to one or more component(s) of appropriate antipsychotic medication assessment and monitoring. Components include:
• Personal and family history of obesity, diabetes, dyslipidemia, hypertension, or cardiovascular disease;
• Body Mass Index (BMI);
• Waist circumference;
• Blood pressure;
• Fasting plasma glucose;
• Fasting lipid profile;
• Clinical assessment of abnormal movements, such as through the Abnormal Involuntary Movement Scale (AIMS).

Process improvements must include at least one of the following types of activities:
• Establishing and disseminating educational materials (for example, online or in-person training sessions) to educate clinical teams about physical health monitoring and protocols for monitoring (for example, AIMS assessment for medication-induced movement disorders);
• Creating and implementing monitoring templates and protocols (for example, EHR-integrated flags), to standardize collection and documentation of one or more components of physical health monitoring; or
• Establishing collaborative service agreements with an enhanced monitoring service, (for example, pharmacist-led monitoring clinic) to monitor for antipsychotic associated physical health condition and either adjust medications (for example, diabetes medications) based on laboratory results or refer patients for further
assessments (for example, AIMS).”

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.