FAQ Directory: Patient-Centered Medical Home (PCMH)

An example of expected outcome/prognosis is typically clinically based. Expected outcome/prognosis is what the expected outcome of complying with the care plan would be. You can think about it as if a patient follows all instructions of the care plan what you are expecting to happen (e.g., their A1C/BMI/stroke risk etc. will decrease). Generally, we see practices differentiate treatment outcome/prognosis as a more clinical metric, for instance lowering A1C by 2 points etc.  

Treatment goals are more lifestyle choices or outcomes for the patient, such as eating more vegetables or getting enough exercise to be able to walk around the block etc.  

All of these elements are incorporated into the care plan: a problem list, expected outcome/prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed.  

PCMH 2017

There has been an update to the PCMH 2023 annual reporting requirements. AR TC 1 ( Staff Involvement in Quality Improvement) and AR CC 1 ( Hospital and ED Coordination) will now require additional documentation to demonstrate practices are meeting requirements. NCQA is requesting a documented process and evidence of implementation in addition to attestation for this criteria. All practices will have the ability to upload necessary documentation in Q-PASS by the end August. Until then, your RP manager may reach out to request additional documents.
 

PCMH 2017

PCMH 2017

PCMH 2017

Evaluators may ask practices to provide an explanation, or context and reasoning, for the data submitted. If a reported performance rate seems too low (or too high), the evaluator may ask the practice to enter an explanation of the performance in the Notes section of QPASS.  

Practices are expected to provide a clear and succinct response as to why their performance rate is low, or unusually high. Because practices are expected to have fully implemented PMCH workflows and processes, the Review Oversight Committee (ROC) members would like to understand the reasoning behind the reported performance rates.  

PCMH 2017

Starting in 2023 for Transforming practices and in 2024 for currently recognized practices, direct collection of data on sexual orientation and gender identity of patients is required for KM 09. This requirement applies to all patients aged 18+, though practices are encouraged to also ask adolescent patients if they have a system for doing so.

PCMH 2017

PCMH 2017

Yes. AR-KM 1 confirms that practices meet PCMH KM 15, in which more than 80% compliance is required for medication lists. A rate less than or equal to 80% does not meet criteria.

PCMH 2017

No. There is no percentage threshold for referral tracking measures. The expectation is that practices track important referrals routinely; if performance is lower than expected, the practice should enter the rationale for their low percentage in the Notes from the Organization section in QPASS.

For example, if data show a 30% return rate, that means 70% of the practice’s referred patients never had a report returned to their PCP. 

PCMH 2017

Practices should submit an explanation when their performance falls below 80% for the following AR criteria: 
•    AR-AC 1: Timely Clinical Advice by Telephone
•    AR-AC 2:  Patient Visits with Clinician/Team
•    AR-CC 3 (Option): Lab and Imaging Test Tracking (2 rates)
•    AR-QI 1: Depression Screening and Follow-Up (if selected)
Practices should submit an explanation when their performance falls below 30% for the following AR criteria: 
•    AR-CC 4: Referral Tracking. 
If the practice does not submit an explanation, NCQA will contact the practice. 

PCMH 2017

It depends. If the AR requirement aligns with a PCMH criteria that specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then a threshold of 80% or more is expected to ensure consistent application of the process. Please note that there may be some cases where it’s acceptable for the rate to fall below 80%. 
An explanation is required for practices that report a rate less than 80% for the following criteria: AR-AC 1, AR-AC 2, AR-CC 3 [Tracking Imaging Results], and AR-CC 3 [Tracking Lab Results]. 
Additionally, this threshold requirement of 80% would also apply if a practice chooses to submit a depression screening measure for AR-QI 1.

PCMH 2017

NCQA recommends using the previous calendar year (January 1–December 31) when possible. If there is not a calendar year of data, the practice may submit the reporting period it uses to regularly monitor performance.  

PCMH 2017