2018 MIPS Improvement Activity IA_PM_13: Chronic Care and Preventative Care Management for Empaneled Patient

Activity Description

Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:

• •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 condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma, and heart failure) with evidence-based protocols to guide treatment to target; such as a CDC- recognized diabetes prevention program;
• •Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;
• •Use panel support tools (registry functionality) to identify services due;
• •Use predictive analytical models to predict risk, onset and progression of chronic diseases; 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