PM 13 - Chronic Care and Preventative Care Management for Empaneled Patients

Activity Weighting: Medium
Subcategory Name: Population Management
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.

Supporting Documentation

1. Individualized Plan of Care - Annual opportunity for development and/or adjustment of an individualized plan of care appropriate to age and health status; or 
2. Condition-Specific Pathways - Use of condition-specific pathways for chronic conditions with evidence-based protocols, or 
3. Pre-visit Planning - Use of pre-visit planning to optimize preventive care and team management; or 
4. Panel Support Tools - Use of panel support tools to identify services that are due; or 
5. Reminders and Outreach - Use of reminders and outreach to alert and educate patients about services due; or 
6. Medication Reconciliation - Use of routine medication reconciliation.

Resources
2018 Improvement Activities Requirements
2019 Improvement Activities Requirements
2018 MIPS Improvement Activities Fact Sheet
Scores for Improvement Activities for MIPS APMs in the 2018 Performance Period Fact Sheet