FAQs: About Transformation

Each transforming health center is assigned an evaluator—an expert on the PCMH transformation process. The evaluator leads your virtual check-ins and is available for your questions and concerns throughout the process.

To get answers to some common questions about transformation and virtual reviews, we conducted Q&A with three NCQA PCMH evaluators.

Q: How can health centers prepare for virtual reviews and submission deadlines?

A: Health centers have three virtual reviews with the evaluator. To get the most out of these reviews, develop a timeline before the first meeting that focuses on all reviews. In the timeline, aim to complete all requirements for transformation by the second virtual review. This will give the evaluator time to provide feedback that can be discussed in the final review.

Setback scheduling can help you develop an effective timeline for the transformation process. Begin by noting the deadline for requirements (the date of the second virtual review) and develop a workplan that goes back in time, to make sure you stay on schedule. Include specific deadlines for achieving certain requirements; look at tasks that can be completed in parallel and those that will have to be done in sequence.

Here are some additional tips for preparing for virtual reviews and deadlines:

  • Check for and resolve technical issues before the virtual review (e.g., will you need Skype or another platform, and is it working?).
  • Shortly before your virtual review, read the comments your evaluator left in your Q-PASS account. Look at all criteria: Are any marked unmet? Revisit the Standards and Guidelines to understand gaps in your requirements.
  • Prepare all patient data that will be shared virtually.
  • If possible, have all relevant staff who can speak to specific workflows and processes join the review. This can reduce confusion and time needed to address specific issues.

Q: How can health centers manage the transformation process for multiple sites?

A: If you want additional sites to earn Recognition, you can streamline the transformation process and reduce the time commitment.

Set up all sites under the same organization in Q-PASS. This means that your health center keeps the same evaluator and automatically shares credits among sites. You can add sites to the profile. You can request permission to combine very small sites with a larger health center site. Make sure you check in all sites you add!

You may submit a single report for requirements that covers all sites. Although many requirements let you submit aggregated organization data, make sure you are aware of site-specific data requirements (for example, QI 08–QI 11). Each site may have different goals; you will need to show baseline data for each site and demonstrate improvement across criteria (subsequent data need to be above the baseline).

Q: How can health centers prepare and organize the transformation process in case of PCMH staff turnover?

A: Health centers tend to have a high staff turnover rate. While this can sometimes make the transformation process challenging, there are some things you can do to ensure that staff transitions don’t cause setbacks.

Work with a Certified Content Expert (CCE) to maintain continuity in the transformation process. If this isn’t possible because of cost issues, have at least two staff attend NCQA transformation classes. Alternatively, many state Primary Care Associations have practice coaches and other resources for centers that utilize PCMH CCEs at no additional cost. And stay organized: Maintain team minutes and a clearly structured, shared file system so you know exactly where documents are stored.

PCMH transformation is a team effort!

Q: What do successfully transformed health centers have in common?

A: Successfully transformed health centers typically have a consultant CCE and/or someone on staff with updated PCMH training. CCEs have experience with the PCMH process and are aware of transformation’s expectations. You probably have CCEs in your area! But if you don’t have the resources to consult with a CCE, NCQA offers webinars and in-person trainings.

You can also perform a gap assessment before registering in Q-PASS. This gives you the chance to understand the changes required to become a PCMH and maximizes the time for achieving transformation (12 months from the registration date). To save time, you can also delay enrollment until you are prepared for your first virtual review.

Other steps can make the transformation process go smoothly: Ensure team buy-in before beginning the PCMH process; target “low-hanging fruit” in the early phases of transformation; make the journey a team effort. For resources and tips to avoiding a stall in your transformation, read our PCMH Toolkit for Health Centers.

Q: What are health centers’ most common questions or concerns?

A: Health centers are often confused about prevalidation, corporate attestation and accelerated renewal attestation in Q-PASS. These processes can save a lot of time, so it’s important to complete them correctly. Here are some tips for navigating these processes:

  • Prevalidation lets centers receive credits for EHRs by entering the relevant documentation in Q-PASS. Pay close attention to the requirements that data fulfill. Attestations let centers receive credits for previously completed Recognition programs. The PCMH Standards and Guidelines is a good place to gain in-depth understanding of differences in requirements. Here’s clarification for the most commonly misunderstood attestation criteria:
    • AC 01(Access and Continuity): Asking patients if your health center hours are adequate does not meet this requirement. Instead, obtain comprehensive patient feedback on current hours and types of appointments as well as by asking how well your center’s hours fill community needs.
    • CC 14–CC 16 (Care Coordination and Care Transitions): You need a process for communicating information about admissions and ED visits with local hospital systems and EDs. How do you let EDs know you are transferring a patient? How do you follow up with patients individually? Demonstrating follow-up communication can help ensure that patients do not return to the hospital; you can fulfill this requirement by showing that you communicate via phone to prevent patient relapse.

Remember, virtual reviews or trainings are a great place to raise questions!

Q: What are some typical roadblocks to transformation, and how can they be avoided?

A: PCMH transformation requires patience and a commitment of resources. It can be tempting to try to save time by cutting corners—but that can make the journey more difficult in the long term. Here are some tips for avoiding roadblocks:

  • Dedicate time to looking through NCQA PCMH resources. Browse the Education and Training webpage—it includes a list of upcoming trainings, webinars and on-demand tutorials. If you can’t find what you are looking for, contact your PCMH Representative via the “Ask a Question” function in Q-PASS. If you haven’t been assigned an evaluator, call NCQA Customer Service.
  • Attend NCQA trainings early in they transformation process; they will help you develop a thoughtful strategy for becoming a PCMH. Trainings also include exercises that contain practical advice for building workflows and getting your team to practice at the top of their licenses.
  • Try out the navigation and other functions in Q-PASS. Many health centers are not familiar with the system, so it may take time to adjust. Q-PASS contains helpful resources and tutorials, as well.
  • Read the Standards and Guidelines carefully and in depth. Pay attention to how requirements are worded so you complete the process accurately. Provide only what is necessary to fulfill requirements.
  • Become familiar with your health center’s EHR system and make sure you are using all of its capabilities. (Tip: Sometimes you need to turn on specific features in the settings.) Many EHR systems can generate reports, making data submission less time consuming, but manual submission is acceptable if your system does not have this capability.


Q: When will the slides/presentation be available?

A: Recording or slides will be posted on our website within 2 weeks of the training or Office Hour.

Q: Can Office Hours be used to obtain CCE Credit?

A: No. Because office hours are relatively informal and are not official Education programs, they do not convey continuing education credit for CCEs.

Tips to Maintain PCMH Recognition

Resources for maintaining NCQA PCMH Recognition

As part of the Annual Reporting process, your health center will demonstrate that its ongoing activities are consistent with the patient-centered medical home model of care. Many of the metrics required are already tracked by the center for other aspects of quality reporting required by HRSA. This overlap makes for a manageable process that promotes active quality improvement.

Tips to manage annual reporting:

  • Embrace PCMH and quality improvement. After you earn Recognition, continue to embrace and improve the PCMH model and activities—it will help when you submit for Annual Reporting next year.
  • Upload in stages. You can upload Annual Reporting requirements any time during the year—even before your NOI is approved by HRSA—allowing you to integrate reporting into existing processes. Note, however, that you may only submit requirements once, and only after HRSA approves your NOI.
  • Reviewing and adapting relevant measures. When measuring for quality improvement, make sure the measure you review is important to your health center’s population.
  • Get team buy-in. Talk through the goal with your entire team to confirm that it is possible and to get feedback about how to achieve it. Make sure staff understand that the value of quality improvement lies in improving patient care.
  • Involve your team. Work through the steps of Annual Reporting with your team—you want them invested in the goal and in the health center. Being involved in decisions about patients is part of why they chose to be health care professionals.

Learn more about Annual Reporting for PCMH Recognition.

Click here for step-by-step guides on navigating Q-PASS.

Still have a question? Ask an expert during a live Q-PASS Q&A session.

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