FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.22.2018 AC 11 Urgent care visits or visits during extended hours may not be available with a patient’s primary care clinician. Does NCQA require a particular percentage of visits must be with a selected primary care clinician?

No. NCQA does not prescribe a percentage, nor does it expect patients to be seen by their selected primary care clinician for a specific percentage of visits.

PCMH 2017

5.22.2018 AC 07 Does a link to the practice’s Web page showing available practice activities meet the requirements for AC 07?

Documentation may be a screen shot demonstrating system capability. This could be multiple screenshots (one of the Web portal page and screenshots for each item) or one screenshot showing evidence of multiple capabilities required (requesting medication refills, appointments and requesting a referral or test) on an active website. Practices are also encouraged to demonstrate these capabilities with their evaluator during their virtual check-in.

PCMH 2017

5.22.2018 AC 02 May practices block nurse practitioners’ schedules for same-day appointments?

Yes. Practices may use nonphysician members of the clinical care team, such as nurse practitioners or physician assistants (PA) who have their own panel of patients, for same-day appointments. There is no requirement for all clinicians to have same-day appointment slots available every day.

PCMH 2017

5.21.2018 TC 04 May patient/family/caregiver members of a practice’s advisory council participate in meetings by telephone?

Yes. This method of participation must be included in the practice’s documented process for involving patients/families/caregivers on QI teams or practice advisory councils.

PCMH 2017

5.21.2018 TC 01 Does the clinician lead and staff managing the medical home transformation need to be an MD?

The clinician lead of the medical home must be a clinician as defined in the PCMH Policies and Procedures, which includes clinicians with an unrestricted license as an MD, DO, APRN or PA; however, NCQA is not prescriptive regarding the staff member who can be designated as the PCMH manager. Both can serve multiple sites and both roles can be assumed by the same person.

PCMH 2017

5.21.2018 TC 06 Are practices required to have daily, structured meetings with the entire care team? Is the clinician required to attend?

TC 06 requires practices to engage in regular communication to discuss care for patients scheduled each day, but this requirement can be satisfied by demonstration of either scheduled team meetings or scheduled electronic team communication, depending on the practice’s process for communication. Please note this communication is focused on patient care needs and is not to discuss practice transformation activities or staffing schedules.
All members of the practice care team, including clinicians, must participate in the communication; however, it is not required that the clinician be present if the team meets in-person, as long as there is a process in place to communicate the information from the meeting to the clinician.

PCMH 2017

5.21.2018 TC 06 Our clinical staff teams are on different schedules, so they often meet in separate teams to discuss patients. Does this meet the requirement?

The requirement is met if teams share questions or concerns about shared patients via regular, structured communication (such as the EHR). The intent of the criterion is for all members of the care team to be involved in communication about patient care, but care teams can meet separately for each clinician’s scheduled patients.

PCMH 2017

5.21.2018 TC 09 Is a practice brochure sufficient evidence for this criterion?

This criterion requires both a documented process ensuring information is distributed to patients and demonstration of patient materials with the minimum information described in the guidance. However, if the practice's documented process is described in the patient brochure, that brochure could be sufficient evidence for TC 09.

PCMH 2017

5.21.2018 TC 09 How can practices demonstrate that they provide access to evidence-based care?

Information about care can be provided to patients through materials such as brochures, flyers or information posted on the practice’s website. When describing the services provided by the practice, attention should be drawn to defining evidence-based guidelines for preventive and clinical care.

PCMH 2017

5.21.2018 TC 08 What credentials are required for the care manager?

NCQA is not prescriptive regarding which clinical staff it is (clinician, nurse, social worker or other provider) and the practice may determine the training and skills needed to address and manage the behavioral health care needs of their patient population.

PCMH 2017

11.09.2017 Additional Resources Are there any outside resources that may help me in the PCMH transformation process?

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/resources/the-health-leads-screening-toolkit/Social 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

PCMH 2017