New York State Patient-Centered Medical Home (NYS PCMH) Recognition Program

NCQA, the creator of the nation’s leading patient-centered medical home (PCMH) program, collaborated with the New York State Department of Health (NYSDOH) to develop a customized PCMH recognition program. NYS PCMH supports the state’s initiative to improve primary care through the medical home model. It also promotes the Triple Aim: better health, lower costs and better patient experience.

What Is PCMH?

PCMH is a care delivery model where the primary care team, along with the patient (and family, when appropriate), are responsible for managing the full spectrum of health care needs. The team also coordinates with clinicians in other settings when care cannot be provided in the primary care setting.

Why NYS PCMH?

The PCMH model focuses on care coordination, population health, evidence-based guidelines and effective use of HIT to meet patients’ needs. NYS PCMH recognition helps practices put the structure, systems and processes in place to be effective medical homes.

The NYS PCMH model helps practices:

  • Improve patient-centered access and patient experience.
  • Perform comprehensive health assessments to identify patient needs.
  • Deliver better preventive care such as immunizations and cancer screenings.
  • Prioritize comprehensive care management to keep chronic conditions under control.
  • Coordinate with other clinicians involved in patient care and close referral loops to improve continuity and avoid gaps.
  • Identify patients who require recommended interventions and patients who need medication monitoring.

Additional Benefits for Practices

To support the efforts required in transforming New York practices to this new, exclusive model of patient care, NYSDOH provides the following resources:

  • Recognition at no cost to practices. NYSDOH covers the first year NYS PCMH Recognition fee or the first NYS PCMH Annual Reporting fee. The practice is responsible for paying their Annual Reporting fee each year after earning NYS PCMH Recognition.
  • Transformation assistance. New York state contracted with 15 organizations that specialize in NYS PCMH transformation and are available at no cost to participating practices. These entities provide step-by-step assistance in managing the transformation process and support the efforts of improving the patient experience. For more information, or to find a Transformation Assistance Contractor, visit ncqa.org/ta.
  • Enhanced reimbursement opportunities. Practices that participate in NYS PCMH transformation may be eligible to receive supplemental payments through State programs such as the Medicaid PCMH Incentive Program. In addition, NYSDOH is engaged regionally with commercial payers to implement voluntary, multi-payer value-based payment (VBP) arrangements to support practices that have not had these opportunities through previous transformation efforts. Many of these models and eligibility to participate will depend on practices achieving NYS PCMH recognition.

This all leads to lower health care costs, improved patient experience and better health outcomes.

NYS PCMH Program Overview

The NYS PCMH recognition program features 6 concepts that make up a medical home. Criteria are the basis for these concepts. They are the activities for which a practice must demonstrate satisfactory performance to earn NYS PCMH Recognition. Criteria were developed from evidence-based guidelines and best practices.

To earn NYS PCMH Recognition, a practice must meet all 40 core criteria and 12 NYS-required criteria (with elective credit). Practices must earn a total of 25 credits in elective criteria across 5 of 6 concepts (16–19 credits are earned by meeting required NYS criteria, which cross all 6 concepts). Practices decide which of the remaining 6-9 credits of elective criteria to complete.

The NYS PCMH Standards and Guidelines document details program requirements.

How to Enroll in NYS PCMH

A practice downloads the Standards and Guidelines document, which contains the requirements for the program, and works with a Transformation Assistance Contractor to begin applying the standards to the practice. The entire recognition process is managed through Quality Performance Assessment Support System (Q-PASS), a user-friendly, online platform that allows for the upload of documentation, tracking of progress and management of practice sites and clinicians.
Paths to enroll for practices:

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