FAQ Directory: Patient-Centered Medical Home (PCMH)

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8.25.2023 CM 04 What is the difference between expected outcome/prognosis and treatment goal for the care plan?

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

8.25.2023 Change to AR 2023 Criteria - AR TC 1 and AR CC 1 What changes have been made to Annual Reporting 2023?

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

6.23.2023 July 2023 PCMH Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 9?

TopicUpdate Highlights
Front Matter (Audit Section)Added “Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.”
Front MatterAdded a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04Added: “Note: After-visit summaries may only be used if they contain plain language and show patient involvement in the plan’s creation.

Also added, “The care plan is written at a health literacy level accessible to the patient (i.e., does not contain medical jargon, abbreviations/acronyms or billing codes).”

KM 09Removed “pronouns” and “language” in the guidance section as an example of “other aspects of health”.
KM 09Added a clarification about evidence, “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc."
AC 01Added to the guidance: The key to this criterion is patient preference. Some examples of questions asked may include, but are not limited to:
• Our practice is considering extended hours to 7PM. What day of the week would you most prefer?
• Our practice offers same day appointments at 9AM each day. Does this time work for your same day needs? Yes/No with a follow-up question: If not, please identify a time that you prefer.
• If scheduled telehealth visits were offered, would you use them instead of an in-person office visit? (Y/N or Likert Scale). Can follow-up with options.
CM 11New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up
QI 01 and 02Clarified that beginning in 2024, standardized measures must be used and reporting through the Measures Reporting Tile in Q-PASS.

PCMH 2017

1.09.2023 January 2023 Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 8.1?

TopicUpdate Highlights
Front MatterAdded definitions of “electronic health record (EHR)” and “certified electronic health record technology (CEHRT).”
TC 05Added a note that beginning in 2024, practices will be required to have an EHR.
KM 09Added a note that gender identify and sexual orientation requirements apply to all patients 18 years of age and older.
CM 10Replaced “person-driven outcomes approach” with “person-centered outcomes approach.”
QI 08 & QI 09PCMH QI 08 and QI 09: Added notes stating that if the measures reported in QI 01 or QI 02 do not leave room for improvement, practices may choose different measures within the categories to focus improvement efforts on. 

PCMH 2017

12.27.2022 Annual Reporting Why are evaluators asking for the practice to provide an explanation for performance rates? What should the explanation consist of?

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

7.05.2022 KM 09 For which patients does a PCMH need to collect sexual orientation and gender identity data?

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

6.30.2022 July 2022 Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 8?

TopicUpdate Highlights
Policies and ProceduresSection restructured
Policies and ProceduresAddition of language regarding Corrective Action Plans
KM 09Addition of Sexual Orientation and Gender Identity as required topics of data collection. Added requirement that data be direct collection
KM 10Added requirement that data be direct collection
CM 10New elective criterion regarding person-driven outcomes
Appendix 2 – GlossaryAdded “Age as a Vulnerability”

PCMH 2017

6.13.2022 For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”? For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”? (PCMH AR 2022)

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

6.13.2022 AR CC 4 For AR CC 4: Referral Tracking (aligns with PCMH CC 11), must practices meet a percentage threshold to meet criteria? (PCMH AR 2022)

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

4.01.2022 When do I need to add additional information about the measure performance?

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

4.01.2022 Is there a minimum threshold requirement when reporting a rate for Annual Reporting?

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

4.01.2022 Is a minimum reporting period required for measures?

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