FAQ Directory: Patient-Centered Medical Home (PCMH)

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6.25.2020 July 2020 PCMH Summary of Changes What changes were made to the PCMH Standards and Guidelines?

PCMH (Version 6) Summary of Changes
TopicUpdate Highlights
Standards and Guidelines / Appendix 7The New York State PCMH program was integrated into the PCMH Standards and Guidelines and is no longer a separate publication. The ‘NYS’ icon was added to all 12 required criteria for NYS PCMH. The new Appendix 7,  NYS PCMH Recognition Program, outlines the specifics of the NYS program.
Standards and GuidelinesAdded the ‘Site-Specific’ and ‘Cross-Program Shared Credit Option’ symbols to all relevant criteria.
Standards and Guidelines/ Appendix 6The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03Updated language describing an appropriate external PCMH collaborative and clarified than participation in an HIE will not meet the requirement.
TC 08Highlighted the behavioral healthcare manager may conduct their duties through telehealth.
TC 09Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
KM 04Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 05Clarified that asking patients for the date of their last dental exam or providing a list of local dentists does not meet the intent of the criterion.
KM 09Specified that age and gender are not acceptable as a third aspect of diversity.
KM 11ASpecified that the identification of a disparity in care/service for a vulnerable group should be driven by the practice’s data and compared to the general practice population. Actions taken to reduce the disparity should be specific to that vulnerable group.
KM 13Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01Specified that AC 01 focuses on assessing patient access needs and preferences specific to appointments. Also clarified that this differs from more general patient experience assessment of access in QI 04.
AC 02-AC 03Highlighted that same-day appointments and after-hours appointments may be conducted through telehealth.
AC 03Clarified that an ED cannot be used to provide appointments outside business hours.
AC 04 and AC 08Clarified that the report includes calls or messages received both during and after office hours.
AC 05Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 06Clarified that disease specific appointments, home visits and group visits do not meet the intent of the criterion.
AC 12Stated that continuity of the medical record is inclusive of telehealth appointments.
CM 02Specified that small sites and satellite sites may share a care management population with NCQA approval.
CM 03Specified that comprehensive risk stratification must include at least 3 of the categories outlined in CM 01.
CM 04 – CM 08Specified that care plans must be established for at least 75% of patients identified for care management.
CC 09Clarified that the agreement may be with a contracted behavioral telehealth provider.
CC 10Clarified that behavioral health integration may be done through behavioral telehealth.
CC 13

Clarified and updated the expectations for engagement regarding cost implications of treatments options. Practices should not only engage with patients regarding cost implications of treatment options, but also provide information about current coverage and make connections to financial resources as needed.

CC 16Highlighted that follow-up visits may be conducted through telehealth.
CC 21Clarified that electronically exchanging information should include data both sent and received.
QI 04BClarified that the report provided should summarize collected feedback.
QI 05Updated the vulnerable patient population definition.
QI 01 and QI 02Clarified that measures include activities conducted during telehealth visits.
QI 03Specified that major appointments may be conducted in person or via telehealth.
QI 04Clarified that the access category may include questions regarding telehealth.
Policies and ProceduresAdded a description of telehealth in NCQA recognition programs.
Policies and ProceduresUpdated the reconsideration process.
Policies and ProceduresThe “Discretionary Audit” is now called the “Discretionary Review”.


PCMH 2017