FAQ Directory: Patient-Centered Medical Home (PCMH)

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

3.08.2024 Are providers required to sign-off on care plans?

The request for provider sign-off stems from the ability to verify work has been reviewed by the eligible clinician, and not solely managed by another role within the organization—or externally.

An eligible provider must be able to provide evidence of their involvement in Care Management efforts. They should not be submitting care management efforts they have not directly reviewed. That said, we suggest provider’s sign-off on care plans to indicate that they have reviewed the care plans they are counting towards their CM efforts. 

If there is a systematic limitation–meaning an electronic system does not allow the provider to electronically sign-off on the care plan–an acceptable workaround would be to provide a relevant office visit note(s), a telephone communication note(s), etc. where the provider has documented that the care plan was reviewed, discussed, updated, etc. with the patient. 

Evidence provided should exemplify that the eligible clinician has had direct oversight in care management efforts for the patient. Care planning efforts may be facilitated by other parties within the practice, but the eligible clinician must be an involved participant in the care management efforts included in their CM reporting.

PCMH 2017

2.21.2024 KM 09 Is there a minimum percent threshold for KM 09 (diversity) reporting?

The expectation is that diversity data is collected from all patients in the practice. An overwhelming majority of the practice’s population should have diversity data on file. If this is not the case, the practice should annotate an implementation plan in the notes section of Q-PASS. This plan should include an expected timeline for improved performance.

Please note that diversity data should be collected directly from the patient/family/caregiver. Please refer to the Standards and Guidelines for acceptable response options for each aspect of diversity.

PCMH 2017

2.21.2024 AR-CM 1 (AR 2024) What is considered “total population” for AR-CM 1 (AR 2024)?

For AR-CM 1 (AR 2024), “total population” is defined as unique patients seen by the practice in the prior 12 months. The intent of this attestation is to provide a point of reference for the ratio of care managed patients to your practice-site’s total patient population.

PCMH 2017

11.22.2023 CM 04 For CM 04, what does it mean that the care plan must show patient involvement in its creation?

The document should not simply be a hardcoded paper that auto-populates structured fields from the EHR into the document. It should contain language showing that the patient provided input and understands the plan. NCQA is not prescriptive on specific verbiage that must be in the care plan. 

The intent of CM 04 is to give the patient ownership and the power to improve their health outcomes. Engaging the patient in the development of their care plan can result in greater success and adherence to treatment goals.  

PCMH 2017

11.22.2023 CM 04 For CM 04, what does “the care plan is written at a health literacy level accessible to the patient” mean?

This means that the information is not all medical jargon. So instead of the care plan stating, “1 PO BID”, the practice may say “take one by mouth two times a day.” Instead of hardcoded complex diagnosis names and codes, write the diagnosis in common language. For example, instead of only providing the diagnosis of “dyspnea,” use “shortness of breath.”  

The intent is to ensure that the patient understands his/her condition(s), goals, and plans to follow to improve their health.  

PCMH 2017

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