FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.07.2019 QI 08 & AR QI 03 Would increasing survey response rate qualify as a measure for improving patient experience ( QI 11, AR QI 03)?

No, increasing survey response rate is important in obtaining more representative patient feedback, but would not meet the intent of QI 08 or AR QI 03. The response rate is part of the platform for obtaining the feedback, while the measure for these criteria should be improving the feedback itself.

PCMH 2017

5.07.2019 QI 02 What are some examples that would qualify as resource stewardship?

For care coordination, the intent of QI 02A is to evaluate the communication/coordination that occurs between providers or providers and patients, so it's generally looking at closing the loop on care coordination tasks/processes. Some examples for care coordination may include but are not limited to:
– Reduced % of patients seeing multiple providers (3 or more)
– Medication reconciliation after care transition (MU)
– Follow up with patients or providers to ensure ordered lab or imaging tests were completed
– Follow up with patients following receipt of abnormal test results
– Outreach to patients not recently seen that result in an appointment
– Follow-up phone calls to check on the patient after an ER visit (or hospitalization)
– # patient calls received after hours by the call center were reconciled in the patient record and addressed by the care team the next business day
– Following up on pediatric visits to after-hours care
– Number of referrals sent
– % of patients who had a positive TB screen who had a FU Chest x-ray
– % of patients who had a positive GC/Chlamydia who were treated with antibiotics
The intent of QI 02B is for practices to use measures to help them understand how efficiently they're providing care and judiciously using resources. Examples of measures affecting health care costs may include but are not limited to:
– Total cost per patient
– Medical cost per medical visit
– # of medications prescribed
– Use of high cost medications
– Use of imaging for low back pain
– Redundant imaging or lab tests
– Emergency department utilization
– Hospital readmission rates
– Use of generic versus brand name medication
– # of Specialist referrals
– # of patients who went to urgent care during open office hours
– # of referrals/ED visits for needs that could be addressed in the office
– Appropriate testing for children with pharyngitis
– Appropriate treatment for children with URI

PCMH 2017

5.07.2019 CM 09 Would sending the care plan to outside points of care via a secure, electronic fax meet the intent of CM 09?

No, neither secure, electronic fax noR secure email would meet the intent of CM 09. For CM 09, the practice must demonstrate its capability to make their patient's care plans available securely to other care settings, such as hospitals, specialists, or other care facilities that could be managing patient care. This availability should be at the time the patient is seen, including after hours, and as such should not involve reaching out to the practice for the information to be sent. The way in which this care plan is shared may vary and NCQA is not prescriptive, but examples include sharing care plans via shared medical records, HIEs or other shared systems that enable staff from different care settings to view the patient's care plan for continuity and optimal care coordination while the patient receives care from multiple settings.

PCMH 2017

3.12.2019 PCMH Criteria and HIEs Can utilization of a Health Information Exchange (HIE) meet PCMH criteria?

Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:

PCMH Criteria 

Required Criteria 

AC 12(2 Credits) 

Continuity of Medical Record Information 


CM 09(1 Credit) 

Care Plan Integration 


CC 15(Core) 

Sharing Clinical information  


CC 17(1 Credit) 

Acute Care After-Hours Communication 


CC 18(1 Credit) 

Information Exchange During Hospitalization 


CC 19(1 Credit) 

Patient Discharge Summaries 


CC 21(Maximum 3 Credits) 

External Electronic Exchange of Information 

(A is required) 

PCMH 2017

1.24.2019 KM 02G Resource

10.12.2018 CC 06 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.)?

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.  



PCMH 2017

10.12.2018 Evidence 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.

PCMH 2017

10.12.2018 AC 10 & 11 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?

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.

PCMH 2017

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

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. 

PCMH 2017

10.12.2018 AR-TC 2 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.

PCMH 2017

10.12.2018 AR-PH-1 (2018 Version) AR-KM 01 (2019 Version) 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?

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.

PCMH 2017

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

PCMH 2017