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As part of the Merit-based Incentive Payment System (MIPS) program, practices must implement improvement activities. High-weighted activities address areas with the greatest impact on patient care, safety, health, and well-being, or require significant investment of time and resources, according cms.gov.
In fact, each improvement activity has a point value, high-weight activities are worth 20 points and medium-weight activities are worth 10 points. Each practice must earn 40 improvement activity points.
Small practices get a bonus of having the point values doubled for improvement activities, so for small practices high-weight activities are worth 40 points and medium-weight activities are worth 20 points. In this article we will provide information on high-weight activities that you can implement in your practice. Our next article will focus on medium-weight activities.
High-Weight Improvement Activities (Worth 20 points for large practices or 40 points for small practices):
- Centers for Disease Control and Prevention (CDC) training on their guidelines for prescribing opioids for chronic pain
- Completion of all the modules of the CDC course: “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every four years, to avoid duplicative information given that some of the modules may change on a year-by-year basis but over four years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.
- This free training can be found at : https://www.cdc.gov/opioids/providers/training/index.html
- Completion of CDC training on antibiotic stewardship
- Completion of all modules of the CDC’s antibiotic stewardship course. Note: This activity may be selected once every four years, to avoid duplicative information given that some of the modules may change on a year-by-year basis but over four years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score
- This free training can be found at: https://www.cdc.gov/antibiotic-use/training/continuing-education.html
- Create and implement an anti-racism plan
- Create and implement an anti-racism plan using the CMS Disparities Impact Statement or other anti-racism planning tools. The plan should include a clinic-wide review of existing tools and policies, such as value statements or clinical practice guidelines, to ensure that they include and are aligned with a commitment to anti-racism and an understanding of race as a political and social construct, not a physiological one. The plan should also identify ways in which issues and gaps identified in the review can be addressed and should include target goals and milestones for addressing prioritized issues and gaps. This may also include an assessment and drafting of an organization’s plan to prevent and address racism and/or improve language access and accessibility to ensure services are accessible and understandable for those seeking care. The MIPS eligible clinician or practice can also consider including in their plan ongoing training on anti-racism and/or other processes to support identifying explicit and implicit biases in patient care and addressing historic health inequities experienced by people of color.
- More information about elements of the CMS Disparities Impact Statement is detailed in the template and action plan document at: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Disparities-Impact-Statement-508-rev102018.pdf.
- Create and implement a plan to improve care for lesbian, gay, bisexual, transgender, and queer patients
- Create and implement a plan to improve care for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients by understanding and addressing health disparities for this population. The plan may include an analysis of sexual orientation and gender identity (SO/GI) data to identify disparities in care for LGBTQ+ patients. Actions to implement this activity may also include identifying focused goals for addressing disparities in care, collecting and using patients pronouns and chosen names, training clinicians and staff on SO/GI terminology (including as supported by certified health IT and the Office of the National Coordinator for Health Information Technology US Core Data for Interoperability [USCDI]), identifying risk factors or behaviors specific to LGBTQ+ individuals, communicating SO/GI data security and privacy practices with patients, and/or utilizing anatomical inventories when documenting patient health histories.
- Promoting clinician well-being
- Develop and implement programs to support clinician well-being and resilience—for example, through relationship-building opportunities, leadership development plans, or creation of a team within a practice to address clinician well-being—using one of the following approaches:
- Completion of clinician survey on clinician well-being with subsequent implementation of an improvement plan based on the results of the survey.
- Completion of training regarding clinician well-being with subsequent implementation of a plan for improvement.
- Provide 24/7 access to MIPS eligible clinicians or groups who have real-time access to patient’s medical record
- Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:
- Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);
- Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or
- Provision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.
To learn more about these improvement activities please reach out to Registry Clearinghouse at https://www.registryclearinghouse.com, by phone at (631) 996-9222 or by email [email protected]
