PCMH Practice Spotlight and Annual Reporting Updates

Get the latest updates on NCQA’s Patient-Centered Medical Home (PCMH) Recognition program and learn how one of our Recognized practices is delivering patient-centered care.

Practice Spotlight: ProHealth Physicians

What does patient-centered care look like in action? For ProHealth Physicians, it means helping patients feel supported at every step—with coordinated care, trusted relationships and resources that meet people where they are.

Since becoming a PCMH-Recognized organization, ProHealth Physicians has continued to strengthen how it supports whole-person care. The organization helps patients navigate their healthcare needs through coordinated services, strong patient relationships and connections to resources that support better outcomes.

Comprehensive Care Planning

That approach is especially clear in ProHealth Physicians’ comprehensive care planning. Care plans include problem lists, medication management, treatment goals, expected outcomes and scheduled reviews. The organization also recognizes that social and financial factors can affect a patient’s ability to manage their health. Care teams work with patients to address these barriers and, when additional support is needed, connect them with case managers and community resources.

“Providing a true medical home for our patients has always been part of ProHealth Physicians’ DNA. Our commitment to patient-centered care means helping patients navigate every stage of their healthcare journey through trusted relationships, coordinated support and a focus on quality outcomes,” says Heather Goodness, MBA, Associate Director of Clinical Quality at ProHealth Physicians, part of OptumCare.

Continuity of Care

This commitment comes through in the processes ProHealth Physicians has built to support patients across care settings. Using information from the electronic health record, care teams identify patients who have visited the emergency department or been admitted to the hospital, track their progress and follow up after discharge. The practice also maintains communication with hospitals during admissions, helping support continuity of care as patients move between settings.

Medication Management

The patient-focused approach also extends to medication management. Most of its practices achieved at least a 90% rate for documenting, reviewing and updating patient medications during visits. This consistent process helps care teams identify medication-related concerns and support patient safety.

Case Management

ProHealth Physicians also expanded case management and social services to connect patients with the support they need. “One of our most significant service enhancements has been the expansion of case management and social services, ensuring patients have access to the clinical, behavioral and community-based resources they need to achieve better health outcomes,” says Goodness.

Together, these efforts show how PCMH Recognition can support organizations in building practical processes that improve care coordination, address barriers to care and keep patient needs at the center of care delivery.

For ProHealth Physicians, the work reflects a continued commitment to making care easier to navigate and more responsive to patient needs. Its focus on coordinated care and patient support demonstrates how PCMH Recognition can help organizations turn strong processes into meaningful improvements in practice.

Simplifying Annual Reporting

NCQA is introducing two ways to make the Annual Reporting process easier for PCMH practices.

Tiered Sampling for Care Plans

NCQA has introduced an optional tier-based multi-site sampling approach for Care Management requirements in Annual Reporting. Designed for larger organizations, this approach reduces reporting burden by allowing eligible organizations to submit care plans from a subset of sites selected by NCQA.

Who Is Eligible?

• Organizations with nine or more sites.
• Sites must share the same reporting date.

 What This Means

• Eligible organizations may submit care plans from a subset of sites selected by NCQA.
• Sampling is based on organization size.
• Reduced documentation requirements can help streamline the Annual Reporting process and lessen administrative burden.

Organizations interested in using this option or confirming their eligibility should contact their NCQA Representative through My NCQA.

New Notebook Hints in Q-PASS

Notebook hints are now available in Q-PASS, providing quick access to evidence requirements directly within applicable Annual Reporting criteria. This in-platform guidance helps organizations better understand expectations, prepare documentation with confidence and streamline evidence collection.

Together, these enhancements create a more efficient and user-friendly Annual Reporting experience, allowing organizations to focus on demonstrating the high-quality, person-centered care they can provide.