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PCMH Eligibility

The Patient Centered Medical Home (PCMH) program is for practices that provide first contact, continuous, comprehensive, whole person care for patients across the practice. PCMH has at its foundation the Joint Principles developed by the primary care medical societies (American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, American Osteopathic Association):

  • whole-person care;
  • personal clinician provides first contact, continuous, comprehensive care;
  • care is coordinated or integrated across the health care system;
  • team-based care.

Whole person care includes provision of comprehensive care and self management support and emphasizes the spectrum of care needs, such as routine and urgent care; mental health; advice, assistance and support for making changes in health habits and making health care decisions. Preventive care is also a key component of the expectation for clinician focus. Primary care physicians represent most of the recognized practices – including family practitioners, general practitioners, internists and pediatricians.

As the PCMH program has grown, different physician specialists and other clinicians have become interested in participating. Originally limited to physician-led practices, in 2010, NCQA decided to open the program up to nurse-led practices in states that allow these clinicians to provide the full range of primary care and practice independently. Advanced Practice Registered Nurses (APRNs) are also eligible to be listed as part of a recognized practice if they manage their own panel of patients.

NCQA has had many inquiries from specialty/subspecialty practices, such as OB-GYN, oncology, cardiology, endocrinology and mental health clinics. These practices often state that they are Patient-Centered Medical Homes -- but to a subset of their patients -- temporarily or permanently.

If a practice can demonstrate that it provides whole person care and meets the other elements of the joint principles for most of its patients (at least 75 percent), it can be eligible for PCMH recognition by NCQA even if it is not a traditional primary care practice.

As an example of how NCQA has applied this requirement, we have recognized clinics that specialize in care for patients with HIV/AIDS as they have demonstrated to us that they serve as the center of care for their patients. By contrast, most Oncology clinics only serve as the principle source of care for a subset of their patients but do not provide whole-person, comprehensive care for most. The clinicians that are identified with the PCMH Recognized practice must include all eligible clinicians at the practice site that can be selected by a patient as a personal clinician.

Clinicians that are not eligible to participate in the PCMH program may be eligible for NCQA’s Patient-Centered Specialty Practice (PCSP) Recognition Program. PCSP extends the medical home concepts to specialists. Now, specialty practices committed to access, communication and care coordination can earn accolades as the “neighbors” that surround and inform the medical home and colleagues in primary care. Practices that become recognized will demonstrate patient-centered care and clinical quality through: streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused care management and continuous clinical quality improvement.

Questions?

For more information, submit a PCS question using my.ncqa.org. In the portal, click “My Questions”, select “Ask a Question,” then select “Policy/Program Clarification Support.”