| KM 02: Comprehensive Health Assessment | Added a note, "All patients need all the components addressed in their medical record. Providing components from multiple patients does not meet the intent." |
| KM 03: Depression Screening | Added this clarification in the adolescent section, "Screening under age 12 may be conducted as clinically indicated." |
| KM 14: Medication Reconciliation and KM 15: Medication Lists | The thresholds have changed from more than 80% to more than 90%. |
| KM 26: Community Lists | Added, “The practice maintains a list of resources supported by the community and/or payers by selecting five topics or service areas of importance to the patient population.” |
| AC 01: Access Needs and Preferences | Added more detailed information, “The practice annually surveys patients to determine if existing access (e.g., days open, hours of operation, modalities, etc.) is meeting the needs of the patient population. The screening also collects input of the patient to understand their preferences.” |
| CM 04: Person-Centered Care Plans | Clarified that the required elements include the patient’s medication list and management as well as the patient’s comprehensive problem list. Also, provided more guidance on a care plan’s requirements. |
| CM 10: Person-Centered Outcomes Approach | Added, “If the organization chooses to use PROMs to track goals, NCQA recommends that the organization have at least 8–10 PROMs for clinicians to choose from, for use with patients.” |
| CC 04: Referral Management | Added, “The practice uses the patient's medical health history and clinical protocols to determine when a referral is necessary.” Also, “The organization confirms that referrals are local to the patient's community of residence, and whether the referral is in the patient's practitioner network.” Additionally, “The expectation is that the specialist/ancillary clinician return visit documentation so the loop can be closed” |
| CC 08: Specialist Referral Expectations And CC 09: Behavioral Health Referral Expectations | Added, “The organization communicates referral expectations to patients, including the contact information of the referring clinician and additional instructions or education, if applicable.” |
| CC 21: External Electronic Exchange of Information | Added D. Clinical data exchange with payers. This is worth 1 elective credit point. |
| QI 01: Clinical Quality Measures and QI 02: Resource Stewardship Measures | Added a documented process to the evidence. |
| Cadance Thresholds | Please see additional FAQ for cadence thresholds, added to 45 existing criteria. |
Criteria Retirement:
Eight criteria were identified as no longer serving a substantial purpose or adding meaningful value to primary care, leading to their retirement from the PCMH program.
| Criteria Identification and Title |
| TC 03: External PCMH Collaborations |
| TC 09: Medical Home Information |
| KM 08: Patient Materials |
| KM 18: Controlled Substance Review |
| KM 25: School/Intervention Agency Engagement |
| KM 28: Case Conferences |
| CC 12: Co-Management Arrangements |
| QI 18: Electronic Submission of Measures |
PCMH 2017