FAQ Directory: Patient-Centered Medical Home (PCMH)

Elective criterion KM 07 goes beyond providing the percentage of patients with social determinants of health documented in the medical record; the report should include the breakdown by social determinant(s) so the practice understands which social determinants impact their patients to better implement appropriate care interventions. The intent of elective criterion is for the practice to show how it monitors social determinants of health at the population level for its patient population and also how it uses that data to address and assist in overcoming those social determinants of health. Reports may be generated from data collected in KM 02 G.

This applies to the following Programs and Years:

No, a single clinician practice may simply attest to having a single clinician. This can be done using the text box option of Q-PASS to receive credit for these criteria.

This applies to the following Programs and Years:

In BH 15 (Core), the practice monitors either a mental health condition OR a substance use disorder. BH 16 is elective because it raises the bar by evaluating whether practices monitor both a mental health condition AND a substance use disorder. 

This applies to the following Programs and Years:

No, the redesigned PCMH process enables practices to enroll and transform into a PCMH over the course of a 12 month period. If the documented process has been implemented for a sufficient amount of time for the practice to demonstrate the needed evidence to meet criteria, the practice may submit it for review.

This applies to the following Programs and Years:

The expectation is that these facets of the care plan should be happening routinely. NCQA has not set a specific threshold, however if the practice is reporting less than 75% the evaluator may question whether the practice has truly implemented the criteria as part of their care plan routine.

This applies to the following Programs and Years:

No additional evidence is needed beyond answering the questions. Since all practices completing Annual Reporting have already shown detailed evidence previously during the transformation phase, Annual Reporting has reduced the administrative burden of maintaining recognition by reducing the amount of evidence that must be submitted.

This applies to the following Programs and Years:

For FQHCs that are part of a larger organization with multiple practices under the same umbrella, UDS reporting would not meet KM 13 because the data is at the organizational/corporate level. The data for KM 13 must be at the practice level because recognition is at the practice level. An exception to this is for standalone practices whose UDS data is specific to the practice site location.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

Care coordination resources, including a sample patient care plan can be found at: 
https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Care-Coordination.aspx 

National Center for Medical Home Implementation Building Your Medical Home Guide: 
https://medicalhomes.aap.org/Pages/Managing-Your-Patient-Population.aspx
https://medicalhomes.aap.org/Documents/PediatricCarePlan.pdf 

NICHQ Care Plan Template: https://www.nichq.org/resource/nichqs-care-plan-template 
 

This applies to the following Programs and Years:

Pediatric practices are not penalized for not sharing information with parents if the adolescent requests that information not be shared, but applicants must explain the exclusion of adolescent patients in the associated documentation. The system must include only legitimate requests for information based on state and federal confidentiality requirements
 

This applies to the following Programs and Years:

This applies to the following Programs and Years:

NCQA is not prescriptive regarding which depression screening tool is used as long as it’s a standardized tool. Some depression screening tool examples that would be appropriate for adolescents include but are not limited to PHQ2, PHQ9, PHQ-A, PSC, PSC-Y, RAAPS, or HEADSS. 

This applies to the following Programs and Years: