2022 Improvement Activities for
Mental and Behavioral Health

Activity IdActivity NameActivity WeightingActivity Description
IA_EPA_1Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical RecordHighIncrease patient access to eligible clinicians who work in an outpatient setting with the goal of reducing unnecessary emergency room visits.View
IA_EPA_2Use of telehealth services that expand practice accessMediumImprove health outcomes by expanding patient access to telehealth services that are delivered through standardized processes.View
IA_EPA_3Collection and use of patient experience and satisfaction data on accessMediumDevelop an improvement plan informed by patient experience and satisfaction data, including any differences across demographic groups, so that eligible clinicians can use data-driven approaches to improve patient access and quality of care.View
IA_EPA_4Additional improvements in access as a result of QIN/QIO TAMediumUse learnings from engagement with Quality Innovation Network-Quality Improvement Organization (QIN-QIO) technical assistance to design, plan, and initiate implementation of new activities, ultimately improving access to services or care coordination.View
IA_EPA_5Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)MediumHelp CMS improve the content provided on the Quality Payment Program (QPP) website.View
IA_PM_2Anticoagulant management improvementsHighImprove patient understanding and adherence while reducing the risk of medication errors and adverse drug events.View
IA_PM_3RHC, IHS or FQHC quality improvement activitiesHighImprove 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).View
IA_PM_4Glycemic management servicesHighImprove diabetes care by defining and documenting individualize glycemic control goals.View
IA_PM_5Engagement of community for health status improvementMediumImprove specific chronic condition health outcomes for community populations served by an eligible clinician or practice by implementing evidence-based practices and partnership with a Quality Improvement Organization (QIO).View
IA_PM_6Use of toolsets or other resources to close healthcare disparities across communitiesMediumDecrease healthcare inequities and improve health status in underserved communities.View
IA_PM_7Use of QCDR for feedback reports that incorporate population healthHighIncrease knowledge of practice patterns and treatment outcomes to better serve patients, including vulnerable populations.View
IA_PM_11Regular review practices in place on targeted patient population needsMediumImprove understanding of targeted populations’ unique needs to tailor clinical treatments, address structural inequities, and better utilize community resources.View
IA_PM_12Population empanelmentMediumStrengthen patient-clinician relationships, making it possible to provide comprehensive, patient-centered primary care.View
IA_PM_13Chronic care and preventative care management for empaneled patientsMediumImprove effectiveness, efficiency, and patient-centeredness of preventive and chronic care provided to empaneled patients.View
IA_PM_14Implementation of methodologies for improvements in longitudinal care management for high risk patientsMediumImprove health outcomes and patient-centeredness of care for patients at high-risk for adverse health outcomes or harm.View
IA_PM_15Implementation of episodic care management practice improvementsMediumUse episodic care management to improve quality of care and communication across referrals and transitions of care.View
IA_PM_16Implementation of medication management practice improvementsMediumMaximize the efficiency, effectiveness, and safety of care across settings by strengthening medication management.View
IA_PM_17Participation in Population Health ResearchMediumContribute to the development of evidence-based interventions, tools, or processes for improving health outcomes.View
IA_PM_18Provide Clinical-Community LinkagesMediumHelp patients and families access the right community resources for improving/maintaining health, education, and self-sufficiency with support from community health workers.View
IA_PM_19Glycemic Screening ServicesMediumScreen more patients at risk for diabetes.View
IA_PM_20Glycemic Referring ServicesMediumRefer more patients with pre-diabetes to a recognized preventive program to help prevent or slow disease progression.View
IA_PM_21Advance Care PlanningMediumIncrease the frequency and quality of advanced care planning and documentation.View
IA_CC_1Implementation of use of specialist reports back to referring clinician or group to close referral loopMediumImprove clinician-to-clinician communication to prevent delayed and/or inappropriate treatment while increasing patient satisfaction and adherence to treatment.View
IA_CC_2Implementation of improvements that contribute to more timely communication of test resultsMediumReduce risk of patient harm that occurs when abnormal test results are not delivered in a timely way.View
IA_CC_7Regular training in care coordinationMediumUtilize preferred practice patterns within your practice to improve care coordination.View
IA_CC_8Implementation of documentation improvements for practice/process improvementsMediumDevelop and utilize processes that improve care coordination outcomes.View
IA_CC_9Implementation of practices/processes for developing regular individual care plansMediumDevelop, maintain, and share personalized care plans with at-risk patients to promote patient-centered care and improve patient experience.View
IA_CC_10Care transition documentation practice improvementsMediumDefine and implement a standardized process for transitions of care that are relevant to the eligible clinician’s patient population.View
IA_CC_11Care transition standard operational improvementsMediumEnhance communication during care transitions to improve patient outcomes by establishing standard operations, or preferred practice patterns, for transition communications.View
IA_CC_12Care coordination agreements that promote improvements in patient tracking across settingsMediumImprove processes for care coordination and active referral management, thus making care more effective and efficient, preventing risky delays and under-treatment, and increasing patient satisfaction and adherence to treatment.View
IA_CC_13Practice improvements for bilateral exchange of patient informationMediumUtilize a program or process that provides an open exchange of necessary patient information between care teams and patients to guide patient care.View
IA_CC_14Practice improvements that engage community resources to support patient health goalsHighImprove the health and well-being of patients with health-related social needs (HRSN) by connecting them with appropriate community resources.View
IA_CC_15PSH Care CoordinationHighParticipate in a Perioperative Surgical Home (PSH) model to improve coordination of patient care through the acute-care episode, recovery, and post-acute care.View
IA_CC_16Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared PatientsMediumImprove whole-person care by establishing bidirectional communication between eligible primary care clinicians and behavioral health practices for shared patients.View
IA_CC_17Patient Navigator ProgramHighReduce avoidable hospital readmissions and make hospital stays less stressful and recovery periods more supportive for patients.View
IA_CC_18Relationship-Centered CommunicationMediumImprove quality of patient-clinician communication and interaction by attending training on relationship-centered care and communication techniques.View
IA_CC_19Tracking of clinician's relationship to and responsibility for a patient by reporting MACRA patient relationship codes.HighIncrease the utilization of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) patient relationship codes (PRC) using the applicable Healthcare Common Procedure Coding System (HCPCS) modifiers on Medicare claims. Using PRC ensure that appropriate attribution is assigned to the appropriate eligible clinician. For example, it would be inappropriate to attribute the cost of an aortic aneurysm repair to the ophthalmologist who performed a cataract surgery in the same calendar year.View
IA_BE_1Use of certified EHR to capture patient reported outcomesMediumImprove patient engagement through patient/clinician review of patient collected information or through assessment of a patient’s understanding, confidence, and ability to perform self-care.View
IA_BE_3Engagement with QIN-QIO to implement self-management training programsMediumBecome more equipped to help patients self-manage their chronic conditions.View
IA_BE_4Engagement of patients through implementation of improvements in patient portalMediumIncrease patient engagement, adherence to treatment plans, and self-management of chronic conditions through the availability of a patient portal within the electronic health record (EHR).View
IA_BE_5Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilitiesMediumEnsure eligible clinicians' website content and tools more accessible to people with disabilities.View
IA_BE_6Regularly Assess Patient Experience of Care and Follow Up on FindingsHighImprove patients' experience of and satisfaction with care by gathering and applying learnings from relevant data to make care more patient-centered.View
IA_BE_7Participation in a QCDR, that promotes use of patient engagement tools.MediumIncrease patient engagement though use of qualified clinical data registry (QCDR)’s tools for promoting positive patient behavior such as consistent exercise.View
IA_BE_8Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.MediumIncrease involvement of interactive collaborative learning networks with support of qualified clinical data registry (QCDR) promotion and feedback reports.View
IA_BE_12Use evidence-based decision aids to support shared decision-making.MediumIncrease use of evidence-based decision aids to encourage shared decision-making with beneficiaries.View
IA_BE_14Engage patients and families to guide improvement in the system of care.HighUse active devices and platforms to allow the patient and the clinical care team to share information on a patient's status, adherence, comprehension, and indicators of clinical concern in a timely manner.View
IA_BE_15Engagement of patients, family and caregivers in developing a plan of careMediumIncrease engagement with patients, family, and caregivers and ensure care provided aligns with their priorities and needs.View
IA_BE_16Promote Self-management in Usual CareMediumImprove health outcomes by helping patients improve self-management.View
IA_BE_19Use group visits for common chronic conditions (e.g., diabetes).MediumGive patients with common chronic conditions opportunities to learn about self-management topics and discuss shared concerns while improving efficiency in the delivery of quality care.View
IA_BE_22Improved practices that engage patients pre-visitMediumIncrease the efficiency and effectiveness of visit time with patients, and promote patient engagement and satisfaction with care.View
IA_BE_23Integration of patient coaching practices between visitsMediumProvide additional direct support to patients in achieving their goals, thus improving patient satisfaction, adherence to plans, and health outcomes.View
IA_BE_24Financial Navigation ProgramMediumHelp patients navigate the stress and risks associated with paying for healthcare, and, when relevant, help them explore alternative options that address their holistic needs.View
IA_BE_25Drug Cost TransparencyHighHelp patients navigate the stress and risks associated with paying for healthcare by providing information on the patients’ share of the costs for medications in the drug formulary; help patients explore alternative options that address their holistic needs.View
IA_PSPA_1Participation in an AHRQ-listed patient safety organization.MediumAdopt and implement Patient Safety Organization (PSO) methodologies through data collection, analysis, reporting, and education to promote the quantifiable reduction of avoidable medical errors and deficiencies identified in the quality of care provided.View
IA_PSPA_2Participation in MOC Part IVMediumMaintain certifications with a Maintenance of Certification (MOC)-approved specialty board to increase/update knowledge and apply it to practice and safety improvements.View
IA_PSPA_3Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity.MediumObtain a Maintenance of Certification (MOC)-approved specialty board certification or other similar program to increase/update knowledge and apply it to practice and safety improvements.View
IA_PSPA_4Administration of the AHRQ Survey of Patient Safety CultureMediumCreate the opportunity to i) Raise staff awareness about patient safety; ii) Elucidate and assess the current status of patient safety culture; iii) Identify strengths and areas for patient safety culture improvement; iv) Evaluate trends in patient safety culture change over time; and v) Evaluate the cultural impact of patient safety initiatives and interventions (from www.ahrq.gov).View
IA_PSPA_6Consultation of the Prescription Drug Monitoring programHighUse patients' past prescription history to inform decisions about issuing new controlled substance schedule II opioid prescriptions, thus identifying and protecting patients who are at risk of opioid addition and/or overdose.View
IA_PSPA_7Use of QCDR data for ongoing practice assessment and improvementsMediumUse qualified clinical data registry (QCDR) data for practice assessment and improvement with primary goal of addressing patient safety for targeted populations.View
IA_PSPA_8Use of patient safety toolsMediumImprove the number of patients tracked and the precision of measurement for patient safety measures, thus allowing specialists to make evidence-based decisions about improving safety for their patients.View
IA_PSPA_9Completion of the AMA STEPS Forward programMedium

Gain the knowledge to "improve practice efficiency and ultimately enhance patient care, physician satisfaction and practice sustainability" (from edhub.ama-assn.org).

IA_PSPA_10Completion of training and receipt of approved waiver for provision of opioid medication-assisted treatmentsMediumBecome better equipped to help patients overcome their opioid use disorders and, with certification, become a trusted source of care for patients with opioid disorders.View
IA_PSPA_12Participation in private payer CPIAMediumImprove the quality of care provided, and health outcomes for patients, by participating in improvement activities designated by private payers.View
IA_PSPA_13Participation in Joint Commission Evaluation InitiativeMediumImplement the Joint Commission’s Ongoing Professional Practice Evaluation with goal of identifying negative practice trends earlier.View
IA_PSPA_15Implementation of an ASPMediumReduce inappropriate use of antimicrobials, thus playing a critical role in reducing microbial resistance and the incidence of antimicrobial-caused adverse drug reactions, all of which will help improve patient outcomes and the efficiency of spending.View
IA_PSPA_16Use of decision support and standardized treatment protocolsMediumHelp eligible clinicians align diagnoses and treatment plans with up-to-date, evidence-based standards and guidelines as part of routine care, thus improving the appropriateness of the care they provide and the health outcomes of their patients.View
IA_PSPA_17Implementation of analytic capabilities to manage total cost of care for practice populationMediumCreate opportunities to assess total cost of care and identify ways to reduce unnecessary costs.View
IA_PSPA_18Measurement and improvement at the practice and panel levelMediumEnhance the measurement of the quality of care, making quality data relevant at practice and panel levels, and use those data to implement effective quality improvement activities.View
IA_PSPA_19Implementation of formal quality improvement methods, practice changes or other practice improvement processesMediumExpand and formalize quality improvement (QI) activities across the practice, ultimately leading to improvements in the quality of care and fostering a culture of participation among staff.View
IA_PSPA_20Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changesMediumInstitutionalize quality improvement within the practice by making it an explicit component of leadership’s roles and responsibilities, thus strengthening the commitment to care quality across the practice.View
IA_PSPA_21Implementation of fall screening and assessment programsMediumImprove identification of patients who are at risk of falling; then reduce their risk and improve their health outcome, independence, and satisfaction with care.View
IA_PSPA_22CDC Training on CDC's Guideline for Prescribing Opioids for Chronic PainHighBecome better equipped to improve prescription practices and thus help reduce patients' risks of addiction and overdose.View
IA_PSPA_23Completion of CDC Training on Antibiotic StewardshipHighReduce inappropriate use of antimicrobials to help reduce microbial resistance and the incidence of antimicrobial-caused adverse drug reactions, all of which will help improve patient outcomes and the efficiency of spending.View
IA_PSPA_25Cost Display for Laboratory and Radiographic OrdersMediumHelp eligible ordering clinicians easily obtain information on the cost of laboratory and radiography orders, allowing them to manage their costs strategically.View
lA_PSPA_26Communication of Unscheduled Visit for Adverse Drug Event and Nature of EventMediumAllow primary care doctors to immediately tailor plans of care for patients to prevent further medication errors and achieve better outcomes in the future.View
IA_PSPA_27Invasive Procedure or Surgery Anticoagulation Medication ManagementMediumFormalize and document a standardized process for management of patients on anti-coagulant medication before, during, and after invasive procedures, thus reducing risk of complications.View
IA_PSPA_28Completion of an Accredited Safety or Quality Improvement ProgramMediumComplete an accredited performance improvement continuing medical education (CME) program, ultimately applying program content to address a specific quality or safety gap.View
IA_PSPA_29Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic ImagingHighConsult Appropriate Use Criteria (AUC) through a clinical decision support (CDS) mechanism for imaging services to reduce unnecessary and potentially harmful over-imaging.View
IA_PSPA_30PCI Bleeding CampaignHighParticipate in the percutaneous coronary intervention (PCI) Bleed Campaign to reduce avoidable bleeding associated with patients who receive a PCI.View
IA_PSPA_31Patient Medication Risk EducationHighEducate patients regarding the risks of concurrent opioid and benzodiazepine use, thus reducing their risk of overdose.View
IA_PSPA_32Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision SupportHighMake Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain via clinical decision support (CDS) part of eligible clinicians' workflow, thus improving prescription practices, protecting patients at risk for addition and/or overdose, and helping to address the opioid epidemic.View
IA_PSPA_33Application of CDC’s Training for Healthcare Providers on Lyme DiseaseMediumImprove health outcomes for patients with Lyme disease by leveraging clinical decision support (CDS) and training tools.View
IA_AHE_1Enhance Engagement of Medicaid and Other Underserved PopulationsHighEnsure timely treatment of patients from underserved populations, to help them achieve improved health outcomes.View
IA_AHE_3Promote use of Patient-Reported Outcome ToolsHighMake it possible to use Patient Reported Outcomes (PRO) data as part of routine care, thus increasing patient engagement and health outcomes for all populations.View
IA_AHE_5MIPS Eligible Clinician Leadership in Clinical Trials or CBPRMediumEncourage clinicians to minimize disparities in healthcare access, care quality, affordability, or outcomes by contributing to new and improved tools, research, or processes, which may include addressing health-related social needs.View
IA_AHE_6Provide Education Opportunities for New CliniciansHighProvide clinicians-in-training with diverse experiences, allowing them to gain deep understanding of the challenges facing eligible clinicians and patients in small practices or in underserved or rural areas.View
IA_AHE_7Comprehensive Eye ExamsMediumImprove eye health of underserved and/or high-risk populations, and empower patients in these populations to become more educated consumers of eye care.View
IA_AHE_8Create and Implement an Anti-Racism PlanHighBegin to address inequities in health outcomes by creating and implementing an anti-racism plan.View
IA_AHE_9Implement Food Insecurity and Nutrition Risk Identification and Treatment ProtocolsMediumReduce food insecurity and improve nutritional outcomes for at-risk patients.View
IA_ERP_1Participation on Disaster Medical Assistance Team, registered for 6 months.MediumProvide sustained support to communities facing the impact of disasters, filling immediate needs, and contributing to a faster, better recovery.View
IA_ERP_2Participation in a 60-day or greater effort to support domestic or international humanitarian needs.HighProvide sustained support to communities across the globe that need humanitarian volunteer support, thus helping to alleviate suffering, save lives, and maintain human dignity.View
IA_ERP_4Implementation of a Personal Protective Equipment (PPE) PlanMediumEnsure the safety of patients and staff by maintaining a sufficient supply of personally protective equipment (PPE) for all clinicians and other health workers.View
IA_ERP_5Implementation of a Laboratory Preparedness PlanMediumEnsure preparedness and safety of staff working in laboratories providing patient care during COVID-19 or another public health emergency.View
IA_BMH_1Diabetes screeningMediumImprove rates of screening for patients with schizophrenia or bipolar disorder, who have higher risk or higher prevalence of diabetes relative to the general population, thus increasing eligible clinicians' ability to detect and respond early to positive diagnoses, potentially reducing the burden and complications of the disease.View
IA_BMH_2Tobacco useMediumHelp patients at high risk for tobacco dependence and with behavioral or mental conditions to avoid or end addiction to tobacco.View
IA_BMH_4Depression screeningMediumImprove the identification of depression among patients with behavioral or mental health conditions and sustain patient-centered support and treatment for those diagnosed with depression.View
IA_BMH_5MDD prevention and treatment interventionsMediumIncrease patient-centered support and treatment for patients with conditions of behavioral or mental health conditions to prevent severe depression and suicide.View
IA_BMH_6Implementation of co-location PCP and MH servicesHighIntegrate mental health and substance use disorder services with primary and/or non-primary clinical care through the co-location and co-promotion of these services.View
IA_BMH_7Implementation of Integrated Patient Centered Behavioral Health ModelHighSupport patients with behavioral health needs and poorly controlled chronic illnesses though integrated behavioral health services and the use of evidence-based tools or other initiatives.View
IA_BMH_8Electronic Health Record Enhancements for BH data captureMediumContinually improve the care provided to behavioral health populations through evidence-based interventions and the use of electronic health record technology (EHR).View
IA_BMH_9Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care PatientsHighHelp patients better manage or overcome their alcohol and/or other substance abuse challenges through screenings and counseling.View
IA_BMH_10Completion of Collaborative Care Management Training ProgramMediumDevelop strategies to improve integration of behavioral health into primary care practices, ultimately improving patient-centeredness of care and health outcomes for mental health patients.View
IA_BMH_11Implementation of a Trauma-Informed Care (TIC) Approach to Clinical PracticeMediumEnsure delivery of responsive care for patients and clinicians who have experienced physical or mental trauma.View
IA_BMH_12Promoting Clinician Well-BeingHighImprove the well-being of clinicians and the quality and safety of care they deliver.View
IA_PCMHElectronic submission of Patient Centered Medical Home accreditationObtaining Patient-Centered Medical Home™ certification drives significant and sustainable practice improvements including population care quality, efficiency, and improved patient satisfaction all directly linked to better health outcomes.View
IA_ERP_3COVID-19 Clinical Data Reporting with or without Clinical TrialHighContribute to the development of clinically proven treatments for COVID-19.View

Outcomes focused: Improving the quality 

and delivery of care