The Agency for Healthcare Research and Quality recognizes that revitalizing the Nation’s primary care system is foundational to achieving high-quality, accessible, efficient health care for all Americans. The primary care medical home, also referred to as the patient centered medical home (PCMH), advanced primary care, and the healthcare home, is a promising model for transforming the organization and delivery of primary care.

Practice Benefits

• Align with where health care is headed. Payers continue to move from the fee-for-service model towards rewarding integration and quality care. They are increasingly contracting with organizations that can show they have strong infrastructure and quality improvement initiatives. NCQA PCMH Recognition prepares you to succeed.
• Integrate services across your entire organization. If you are a health system or clinically integrated network with specialty practices, urgent care centers and other types of practice sites, NCQA’s Patient-Centered Specialty Practice (PCSP) and Patient-Centered Connected Care programs mean your whole organization can evolve into a high-functioning medical home neighborhood. These programs are built off of the PCMH model and complement NCQA PCMH Recognition.
• Support revenue growth. Many Federal, state and commercial payers offer incentive programs to practices that achieve NCQA PCMH or PCSP recognition.
• Improve your practice. Use NCQA PCMH Recognition to do gap analyses and implement processes and procedures that improve care for your patients and make your practice more efficient.
• Keep your staff happy. The PCMH model helps standardize procedures and streamline processes and practice staff to allow staff to work at the top of their knowledge, skills and ability. It has been shown to result in higher staff satisfaction.⁴
• Market your practice. NCQA publishes all recognized practices and clinicians in its recognition directory at www.ncqa.org/pcmhdirectory. You can also use the NCQA seal to market your accomplishment to patients and partners.

Clinician Benefits

• Earn higher reimbursement. More than 100 payers and other organizations offer either enhanced reimbursements for recognized clinicians or support for your practice to become recognized.
• Succeed in MACRA. The Centers for Medicare & Medicaid Services (CMS) acknowledges both NCQA’s PCMH and PCSP Recognition programs as ways to receive credit in Medicare Access and CHIP Reauthorization Act (MACRA). Clinicians in NCQA-Recognized PCMHs or PCSPs automatically get full credit in the MIPS Improvement Activities category. Clinicians in NCQA-Recognized PCMH and PCSP practices will likely do well in other MIPS categories. The PCSP Recognition Program is the only specialty-focused evaluation program in the country recognized by CMS in MACRA.
• Earn Maintenance of Certification (MOC) credits. The American Board of Internal Medicine (ABIM), American Board of Family Medicine (ABFM) and American Board of Pediatrics (ABP) allow clinicians in NCQA-recognized practices to receive maintenance of certification (MOC) credits, reducing the burden on clinicians to take on additional activities.
• Focus on patient care. One aspect of the PCMH model is to ensure each team member operates at the highest level of their knowledge, skills, abilities and license within their assigned roles and responsibilities.

Patient Benefits

• Stay healthy. Patients who are treated in PCMHs tend to receive preventative services and screenings at a higher rate than patients not in PCMHs, helping keep them healthy.
• Better communication. A core concept of the PCMH model is to communicate with patients and their families/caregivers. The model emphasizes enhanced access so patients can get clinical advice or medical records when needed.
• Better manage chronic conditions. PCMHs are especially helpful for patients with complex chronic conditions. Research shows that these conditions are managed better in a medical home.
• Have a better experience. When attributes of team-based care are described to people, they say it is the type of care they want to receive.

Practice

One or more clinicians (including all eligible primary care clinicians) who practice together and provide patient care at a single geographic location and must include all eligible primary care clinicians at the site. “Practicing together” means that all the clinicians in a practice:

• Follow the same procedures and protocols.
• Have access to (as appropriate) and share medical records (paper and
electronic) for all patients treated at the practice site.

Electronic and paper-based systems and procedures support clinical and
administrative functions (e.g., scheduling, treating patients, ordering services, prescribing, maintaining medical records and follow-up).

Multi-site group

Three or more primary care practice sites using the same systems and
processes, including an electronic medical record system.

Clinicians who qualify for PCMH

• Clinicians who hold a current, unrestricted license as a doctor of medicine (MD), doctor of osteopathy (DO), advanced practice registered nurse (APRN), or physician assistant (PA).
• Only clinicians who can be selected by a patient/family as a personal clinician are eligible to be listed, in addition to the practice Recognition, on NCQA’s Website.
– The practice can define a “personal clinician” as:

•  A residency group under a supervising clinician or faculty physician
  (residents are not identified individually for selection as personal
  clinicians).
• A combination physician and APRN or PA who share a panel of patients.

• Physicians, APRNs (including nurse practitioners, clinical nurse specialists)
and PAs who practice internal medicine, family medicine or pediatrics, with the intention of serving as the personal clinician for their patients.

These clinicians will be identified individually with the recognized practice.
• Physician-led practices applying with identified APRNs or PAs:
– Patients may choose the APRN or PA as their primary care clinician, or
– ARPNs or PAs share a panel of patients as a primary care team with the
physician.

Note: Clinicians who are part of the practice but are not considered personal
clinicians (e.g., behavioral healthcare clinicians, dentists, OB/GYNs) will not be identified individually, but their work on behalf of patients can be used to
demonstrate the practice meets PCMH criteria.

Clinicians who do not qualify

• Nonprimary care specialty clinicians and APRNs and PAs who do not have a panel of patients.

Special circumstances

• Practices that do not have a physician with a panel of patients at the site may achieve NCQA Recognition with the following considerations:
– It is allowed according to the scope of practice determined by state law.
– Practices are reviewed against the same requirements as physician-led
practices.

Note: Physicians providing oversight of a practice where required by state law do not need to be identified in the practice application unless they actively practice in the site and patients are able to choose them as their primary care clinician.

A growing body of evidence supports practice facilitation as an effective strategy to improve primary health care processes and outcomes, including the delivery of wellness and preventive services, through the creation of an ongoing, trusting relationship between an external facilitator and a primary care practice.

CMS Solutions’ PCMH Simplified Consulting is a supportive service provided to primary care and specialty providers by a trained individual or team of individuals. These individuals use a range of organizational development, project management, quality improvement (QI), and practice improvement approaches and methods to build the internal capacity of a practice to help it engage in improvement activities over time and support it in reaching incremental and transformative improvement goals. This support may be provided onsite, virtually (through phone conferences and Webinars), or through a combination of onsite and virtual visits.

What activities do practice facilitation programs support?

Practice facilitation may involve a wide range of activities, depending on the needs and goals of the practice. Taken together, these form a coherent set of activities for practice change and redesign. They include, but aren’t limited to, the following:

• Assessment of and feedback to practices regarding organizational, clinical, and business functions to drive change
• Use of practice-level data to drive change
• Training of staff in QI methods and specific transformation processes, such as team-based care
• Formation and facilitation of practice QI teams
• Executive coaching and leadership training
• Best practices in QI structures and methods
• Support, encouragement, reinforcement, and recognition of successes
• Project and change management
• Resource identification and procurement
• Capacity building in the use of health IT to support improved clinical care and office efficiency
• Cross-pollination of good ideas and best practices between primary care practices
• Capacity building for improved linkages to outside resources
• Technical assistance in implementing particular models of care, such as the chronic care model (CCM)

In addition to supporting general QI work and these specific activities, practice facilitators also can support activities more directly related to patient centered medical home (PCMH) transformation goals.

Practice One or more clinicians (including all eligible primary care clinicians) who practice together and provide patient care at a single geographic location and must include all eligible primary care clinicians at the site. “Practicing together” means that all the clinicians in a practice:
• Follow the same procedures and protocols.
• Have access to (as appropriate) and share medical records (paper and electronic) for all patients treated at the practice site.
Electronic and paper-based systems and procedures support clinical and
administrative functions (e.g., scheduling, treating patients, ordering services, prescribing, maintaining medical records and follow-up).
Multi-site group Three or more primary care practice sites using the same systems and processes, including an electronic medical record system.