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PCMH 2014 Renewal and Multi-Site Requirements

Multi-Site Requirements

As many as 18 elements are eligible for organizations to identify for review in the Corporate Survey Tool. All multi-site organizations must be able to respond to at least 12 elements in their Corporate Survey Tool; the remaining elements must be responded to at the practice-site level.

After determining which Elements to select for your Corporate Survey Tool, you will need to select them in the "Organization Background" section of your Corporate Survey Tool and in doing so the organization attests to the following:

Attestation

  • "By selecting these elements our organization attests that all of the practice sites applying for Recognition share the same policy, procedure, process or system."

Organizations seeking Renewal MUST have a current PCMH Recognition.

Reduced Documentation With Renewal

To acknowledge that practices with Level 2 or Level 3 Recognition have taken steps toward practice redesign and have systems in place that support their recognition level, NCQA offers a streamlined process for renewal through reduced documentation requirements. Practices that satisfactorily demonstrated basic medical home transformation can focus on more advanced aspects of redesign for their renewal applications. Renewal for Level 1 requires a full survey.

Multi-site organizations with practices that have achieved Level 2 or Level 3 Recognition are eligible to renew by completing the entire survey but it is only necessary to attach documentation for a limited number of specific elements.

The elements that do not require documentation are listed in the table below.

Although some elements do not require submission of documentation, organizations/practice sites must be able to provide documentation if they are selected for audit.

Attestations

Organizations/practice sites with Level 2 or Level 3 Recognition must indicate, in the "Organization Background" section of the Corporate Survey Tool and site specific survey tools, which Renewal Elements they have selected to affirmatively answer the statement below for all factors of the element indicated. 

Attestation for Sites/Organizations with Level 2 or 3 Recognition

Example
"Our practice achieved Level 2 or Level 3 Recognition as a patient-centered medical home and attests that the responses to the factors of this element reflect the current operation of the organization/practice sites. Documentation to support these responses can be provided upon request."

Exceptions

Renewing multi-site organizations that have practice sites with a combination of Level 1, Level 2 or Level 3 Recognition or that want to add practice sites not currently recognized, are eligible to use the reduced documentation in their Corporate Survey Tool. 

 

However, any Level 1 or non-recognized practice must include responses and documentation for all site-specific elements in the Survey Tool.

 

Points

PCMH 2014
Standards and Elements

Corporate-Eligible or Site-Specific Elements?

Documentation or Attestation?

10

PCMH 1: Patient-Centered Access

 

 

4.5

PCMH 1A: Patient-Centered Appointment Access
MUST-PASS

Site-Specific Element

Documentation

3.5

PCMH 1B: 24/7 Access to Clinical Advice

Corporate-Eligible Element

Attestation

2

PCMH 1C: Electronic Access

Corporate-Eligible Element

Attestation

12

PCMH 2: Team-Based Care

 

 

3

PCMH 2A: Continuity

Site-Specific Element

Attestation

2.5

PCMH 2B: Medical Home Responsibilities

Corporate-Eligible Element

Attestation

2.5

PCMH 2C: Culturally and Linguistically Appropriate Services (CLAS)

Corporate-Eligible Element

Attestation

4

PCMH 2D: The Practice Team
MUST-PASS

Site-Specific Element

Documentation

20

PCMH 3: Population Health Management

 

 

3

PCMH 3A: Patient Information

Corporate-Eligible Element

Attestation

4

PCMH 3B: Clinical Data

Corporate-Eligible Element

Attestation

4

PCMH 3C: Comprehensive Health Assessment

Site-Specific Element

Documentation

5

PCMH 3D: Use Data for Population Management
MUST-PASS

Corporate-Eligible Element

Documentation

4

PCMH 3E: Implement Evidence-Based Decision-Support

Corporate-Eligible Element

Attestation

20

PCMH 4: Care Management and Support

 

4

PCMH 4A: Identify Patients for Care Management

Site-Specific Element

Documentation

4

PCMH 4B: Care Planning and Self-Care Support
MUST-PASS

Site-Specific Element

Documentation

4

PCMH 4C: Medication Management

Site-Specific Element

Documentation

3

PCMH 4D: Use Electronic Prescribing

Corporate-Eligible Element

Attestation

5

4E: Support Self-Care and Shared Decision-Making

Corporate-Eligible Element

Attestation

18

PCMH 5: Care Coordination and Care Transitions

 

 

6

5A: Test Tracking and Follow-Up

Corporate-Eligible Element

Attestation

6

5B: Referral Tracking and Follow-Up
MUST-PASS

Corporate-Eligible Element

Documentation

6

5C: Coordinate Care Transitions

Corporate-Eligible Element

Attestation

20

PCMH 6: Performance Measurement and Quality Improvement

 

 

3

6A: Measure Clinical Quality Performance

Corporate-Eligible Element

Attestation

3

6B: Measure Resource Use and Care Coordination

Corporate-Eligible Element

Documentation

4

6C: Measure Patient/Family Experience

Corporate-Eligible Element

Attestation

4

6D: Implement Continuous Quality Improvement
MUST-PASS

Site-Specific Element

Documentation

3

6E: Demonstrate Continuous Quality Improvement

Site-Specific Element

Documentation

3

6F: Report Performance

Corporate-Eligible Element

Attestation

0

6G: Use Certified EHR Technology

Corporate-Eligible Element

N/A

 

 

Corporate -- 18
Site -- 9

Attestation -- 15 Elements
Documentation -- 11 Elements
N/A -- 1 Element

Prepare for PCMH 2014 renewal

  • Multi-site survey process is followed for multi-site renewals.
  • You need to: 1) obtain an online PCMH 2014 application, 2) purchase a survey license, and 3) respond to all the questions in the survey.
  • If you are a multi-site, do not purchase your survey tools until you have been approved for this process through the online application (even if you were approved for your previous Recognition). The last day to purchase PCMH 2014 survey tools is March 31, 2017.
  • Reduced documentation for multi-site groups with Level 2 or 3 recognized practices.
  • Review the table above "Requirements for Renewals." Prepare/link documentation for any of the 11 elements for which the practice responds "Yes".
  • For the 15 elements listed in the table above identified as "Attestation", the practice must attest that it is eligible and, if asked, can provide documentation for the indicated factors. 
  • Practice must complete the entire survey.
  • Full survey Pricing.
  • All multi-site practice recognitions share the first recognized site’s 3-year end date. For example, if the first site has a recognition date of 12/16/2015-12/16/2018, all sites submitted within the 3-year period or by 9/30/17, the last date to submit PCMH 2014 tools, will also have an end date of 12/16/2018. Each site’s start date may vary based on when the site’s review is completed (which may not be a full 3-year period).
  • Organizations must submit and achieve recognition for the first eligible practice site survey within 12 months of receipt of corporate survey results. After at least one site is recognized, organizations may submit eligible practice site surveys using the corporate survey results within the 3-year recognition period of the first recognized site or by 9/30/17, the last date to submit PCMH 2014 tools. (Please note, PCMH 2014 applicants that receive corporate results after 9/30/16 will not have 12 months to submit and achieve recognition for the first eligible practice site).
  • Practice site surveys will not be accepted in the last three months of the three-year recognition period or after 9/30/17 (whichever date is first).