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FAQ Directory: Patient-Centered Medical Home (PCMH)

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7.01.2025 What are the cadence thresholds that have been added to the PCMH Standards and Guidelines for Version 11?

Cadence Thresholds Added:
Cadence thresholds are applied to 45 criteria to ensure continuous improvement and to avoid stagnation in workflows (i.e. “at least annually").
 

Criteria Title
TC 06: Individual Patient Care Meetings/ Communication
TC 07: Staff Involvement in Quality Improvement
KM 02: Comprehensive Health Assessment
KM 03: Depression Screening
KM 04: Behavioral Health Screenings
KM 05: Oral Health Assessment
KM 06: Predominant Conditions
KM 07: Social Determinants of Health
KM 09: Diversity
KM 11: Population Needs
B. Educates practice staff on health literacy and
C. Educates practice staff in cultural competence.
KM 17: Medication Responses and Barriers
KM 21: Community Resource Needs
KM 23: Oral Health Education
KM 26: Community Resource List
KM 27: Community Resource Assessment
AC 01: Access Needs and Preferences
AC 09: Equity of Access
AC 11: Patient Visits with Clinician/Team
AC 13: Panel Size Review and Management
AC 14: External Panel Review and Reconciliation
CM 01: Identifying Patients for Care Management
CM 02: Monitoring Patients for Care Management
CM 03: Comprehensive Risk Stratification
CM 04: Person-Centered Care Plans
CM 05: Written Care Plans
CM 06: Patient Preferences and Goals
CM 07: Patient Barriers to Goals
CM 08: Self-Management Plan
CM 10: Person-Centered Outcomes Approach
CM 11: PCO: Monitoring and Follow-Up
CC 06: Commonly Used Specialists Identification
CC 07: Performance Information for Specialist Referrals
CC 14: Identifying Unplanned Hospital and ED Visits
QI 03: Appointment Availability Assessment
QI 04: Patient Experience Feedback
QI 05: Health Disparities Assessment
QI 07: Vulnerable Patient Feedback
QI 08: Goals and Actions to Improve Clinical Quality Measures
QI 09: Goals and Actions to Improve Resource Stewardship
QI 10: Goals and Actions to Improve Appointment Availability
QI 11: Goals and Actions to Improve Patient Experience
QI 13: Goals and Actions to Improve Disparities in Care/ Service
QI 15: Reporting Performance Within the Practice
QI 16: Reporting Performance Publicly or With Patients
QI 17: Patient/Family/ Caregiver Involvement in Quality Improvement

PCMH 2017