FAQ Directory: Patient-Centered Medical Home (PCMH)

Yes. Practices must assess whether there are barriers to meeting goals and should address any identified barriers. Both components must be listed in the medical record in order to select “Yes” in the Record Review Workbook. If the practice assesses potential barriers and none are identified, the practice may answer “Yes.”
Note: Practices must provide an example of how they meet each criterion and complete the Record Review Workbook. Examples are not required if a practice provides a report as evidence.
 

This applies to the following Programs and Years:

NCQA does not specify a time period required for remeasurement, but it must be long enough for the practice to implement a performance improvement plan and to assess results.

This applies to the following Programs and Years:

No. The tracking system needs to include a record of both the order and receipt of results. A tickler system includes a copy of the order and is removed when results are received; it does not meet the requirement of the CC 04C because it does not maintain a record of receiving results.
 

This applies to the following Programs and Years:

This applies to the following Programs and Years:

There must be interconnectivity between the practice and facilities to exchange clinical information. The practice can demonstrate CC 21C via demonstration of the capability of the certified EHR to exchange clinical information.
 

This applies to the following Programs and Years:

Practices must provide a documented process for staff to follow to ensure that demographic and clinical data are available for the specialist, and either a report/log or an example showing that the process is followed (e.g., a screen shot of available information and how the information is made available to the specialist). If external referrals are made, the practice must specify the process for sharing information with those providers, as well. 

This applies to the following Programs and Years:

A practice may use health plan data to identify patients if it is provided at least weekly and if at least 75 percent of the patient population is represented by the health plan. The practice may use data from more than one health plan as long as the plans collectively represent at least 75 percent of the practice population.
 

This applies to the following Programs and Years:

Practices are not restricted to referring patients only to practices with whom they have established agreements. NCQA reviews at least one example of a formal or informal agreement with a subset of specialists, but does not expect practices to have agreements with all specialists to whom they refer patients. The goal is that expectations are outlined in the agreement, in addition to expectations of timeliness/content of response from specialists.
 

This applies to the following Programs and Years:

There is no minimum data requirement. To meet this core requirement, practices must meet all six items outlined in CC 01. Practices must consider how best to demonstrate their process for each item to meet the intent as described in the guidance section of this criterion. 

This applies to the following Programs and Years:

Yes. Practices must have an agreement or documented process outlining the responsibilities of the referring provider and the specialist, even in an integrated system. It is essential that each provider understands the expectations and responsibilities of the referral, including the frequency and methods of communication.
 

This applies to the following Programs and Years:

No. Practices may use any patient experience survey that includes questions related to three of the four categories specified in the standards (access; communication; coordination; whole-person care, self-management support and comprehensiveness).

This applies to the following Programs and Years:

No. Practices are not required to identify all patients admitted to the hospital or ED, but they must have a process for identifying patients admitted to facilities used most often by their population. In addition to a documented process, practices must also submit a log or report demonstrating that patients were identified.
 

This applies to the following Programs and Years: