FAQ Directory: Patient-Centered Medical Home (PCMH)

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1.08.2019 Are there any outside resources that may help me in the PCMH transformation process?

Additional Resources

Content AreaCriteriaResource LinkDescription
TC02http://www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspxResource on how to optimize staff responsibilities
 02https://www.integration.samhsa.gov/operations-administration/OATI_Tool3_ART.pdfToolkit on how to optimize administrative staff responsibilities to benefit clinical practice
 02http://www.improvingprimarycare.org/team/pcpResource on how to optimize staff responsibilities
 04https://www.stepsforward.org/modules/pfacModule teaching how to create a patient advisory council
 07http://www.nachc.org/research-and-data/prapare/toolkit/Toolkit to better understand social determinants of health
 08https://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcademyGuidebook.pdfInformation on behavioral healthcare integration in primary practice
KM02 Ghttps://healthleadsusa.org/wp-content/uploads/2016/07/Health-Leads-Screening-Toolkit-July-2016.pdfSocial needs screening toolkit
 12https://www.cdc.gov/media/releases/2012/p0614_preventive_health.htmlDiscussion on benefits of preventative care
 14https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdfGuide to medication reconciliation at transitions
 16http://www.teachbacktraining.org/Information on teach back training
 17http://www.improvingprimarycare.org/work/medication-managementGuide to medication management
 24https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.htmlToolkit for shared decision making
 24http://msdmc.org/3-assess/Toolkit for shared decision making
 24https://shareddecisions.mayoclinic.org/Informative website about shared decision making
 13http://www.jabfm.org/content/28/2/170.full.pdf  "Patient Empanelment: The Importance of Understanding Who Is at Home in a Medical Home"
AC13http://www.annfammed.org/content/10/5/396.full "Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation"
  http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdfArticle discussing benefits and strategies to care management
CM03https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubricRisk stratification rubric available to members of the AAFP
 03http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdfRisk stratification rubric from California Quality Collaborative
 03http://www.millimanriskadjustment.com/MARA  – The Milliman Advanced Risk Adjuster is a model of risk stratification in which risk scores are normalized to a given population.
 04http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt1.pdfCare Plan template from AAFP, not exclusive to members
 06http://www.dartmouthatlas.org/downloads/reports/preference_sensitive.pdfResource on how to incorporate patient preference into care management
 08http://www.ihi.org/resources/pages/tools/selfmanagementtoolkitforclinicians.aspxToolkit to aid clinicians in promoting self-management
 08https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/index.htmlResources on self management
 08http://champsonline.org/tools-products/clinical-resources/patient-education-tools/patient-self-management-toolsCondition specific self management tools
 08https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/Article discussing proper communication between primary and specialist clinicians
CC14http://nihcr.org/analysis/improving-care-delivery/prevention-improving-health/ed-coordination/Information on improving communication between emergency and primary physicians
 16https://share.kaiserpermanente.org/article/kaiser-permanente-study-finds-tailored-post-hospital-visits-lower-risk-readmission-medicare-advantage-patients/Article discussing advantages of post hospital primary care visits
QI https://www.ahrq.gov/sites/default/files/publications/files/pcmhqi2.pdfResource for building quality improvement in primary care
 03http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspxInformation on how to utlize third next available appointment measurement
 08https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod4.htmlBenefits of PDSA cycle

10.12.2018 Do documented processes need to be 90 days old to be submitted?


No, the redesigned PCMH process enables practices to enroll and transform into a PCMH over the course of a 12 month period. If the documented process has been implemented for a sufficient amount of time for the practice to demonstrate the needed evidence to meet criteria, the practice may submit it for review.

10.12.2018 Does a single clinician practice need to provide a documented process and report for AC 10 and AC 11 as all patients would be on the same panel and always see their selected clinician by default?

AC 10 & 11

No, a single clinician practice may simply attest to having a single clinician. This can be done using the text box option of Q-PASS to receive credit for these criteria.

10.12.2018 What is the difference between BH 15 & BH 16 in the Behavioral Health Distinction program?

BH 15 & 16

In BH 15 (Core), the practice monitors either a mental health condition OR a substance use disorder. BH 16 is elective because it raises the bar by evaluating whether practices monitor both a mental health condition AND a substance use disorder. 

10.12.2018 Can my practice use comments received in a social media format (i.e., Yelp, Facebook, etc.) as qualitative feedback for QI 04B?

QI 04B

Yes, collection of qualitative data through reviews on Google, Yelp, Facebook, Health Grades, etc. may be used as data for QI 04B if the practice actively notifies patients of the availability of those sites to submit patient experience information. If the sites are not actively advertised and not all patients are aware and represented, it would not meet the intent of the criteria.

10.12.2018 For CC 06, is the practice required to include specialists' names on their list of commonly used specialists or is a list of just the commonly used specialty types acceptable (E.g., a list that says cardiology, ortho, endocrinology, etc.)?

CC 06

The list should include the specialist office names or specialist's names in addition to their specialty types. The intent of CC 06 is for the practice to monitor its referral patterns and identify areas where it might improve care coordination (e.g., identifying clinicians most commonly referred to and ensuring that communication expectations are established for the relationship with those providers, like for CC 08). This criterion requires that the practice demonstrate how it monitors referral patterns, which could be a report showing referral trends.  



10.12.2018 Is there a minimum threshold a practice must meet for these criteria?

CM 04 - CM 08

The expectation is that these facets of the care plan should be happening routinely. NCQA has not set a specific threshold, however if the practice is reporting less than 75% the evaluator may question whether the practice has truly implemented the criteria as part of their care plan routine.

10.12.2018 If a practice offers to print a care plan for the patient but the patient declines, would this count as a 'Yes' or 'No' in the numerator.

CM 05

If the practice offers to print the care plan and the patient declines, the practice may count the patient as a 'Yes'.

10.12.2018 How would a practice fulfill this criteria if they are already fully integrated?

BH 06

A practice with integrated behavioral health may provide its documented process and evidence of implementation. For evidence of implementation, the practice might demonstrate the practice's internal process for entering patient treatment notes, referral guidance and medication management within its system and how the integrated BH provider updates the PCP about the patient's progress. The documented process may also include how the practice facilitates transition to BH, such as through warm handoffs.

10.12.2018 For KM 07, should the required report outline what percentage of patients have a social determinant of health noted in the chart, or should the report include what the social determinants are and what percentage of patients fall under each?

KM 07

Elective criterion KM 07 goes beyond providing the percentage of patients with social determinants of health documented in the medical record; the report should include the breakdown by social determinant(s) so the practice understands which social determinants impact their patients to better implement appropriate care interventions. The intent of elective criterion is for the practice to show how it monitors social determinants of health at the population level for its patient population and also how it uses that data to address and assist in overcoming those social determinants of health. Reports may be generated from data collected in KM 02 G.

10.12.2018 Is it necessary to provide evidence in addition to affirming that we send out proactive reminders for all the necessary categories and noting the frequency?

AR-PH-1 (2018 Version) AR-KM 01 (2019 Version)

No additional evidence is needed beyond answering the questions. Since all practices completing Annual Reporting have already shown detailed evidence previously during the transformation phase, Annual Reporting has reduced the administrative burden of maintaining recognition by reducing the amount of evidence that must be submitted.

10.12.2018 Where is the PCMH 2017 criteria about employee experience feedback to match AR-TC-2?


AR-TC 2 (Employee Experience Feedback) does not align to a PCMH criteria. AR-TC 2 was included as an option for practices to demonstrate whether they evaluate concepts related to team-based care in their employee surveys. It is not a required requirement in Annual Reporting.