Patient Centered Medical Homes FAQs

What is the definition of a Patient Centered Medical Home (PCMH)?

The PCMH model of primary care emphasizes care coordination and communication to transform primary care into a more connected and interactive experience. Research confirms that medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ care experiences.  


What is the history of the PCMH?

  • The AAP introduced the medical home concept in 1967
  • 2003 – National Committee for Quality Assurance (NCQA) launched Physician Practice Connection, a precursor of PCMH
  • 2008 – NCQA launched the first PCMH Recognition Program
  • 2011 – Updates include Meaningful Use criteria, pediatric examples, CAHPS participation
  • 2014 – Integration of behavioral healthcare, emphasis on team care, alignment with Triple Aim
  • 2017 – Further integration of behavioral healthcare, parental/patient involvement, closing disparity gaps, risk stratification and care management

As of February 2016 there were 11,409 NCQA recognized PCMH practices.


How does SCCN contribute to the PCMH model?

  • Wellcentive - Population Health software that accesses each practice’s electronic medical record to perform like a patient registry and create reports on select measures indicative of performance to predefined goals
  • Policies and process documents – Library of universally applicable core set of policies and related processes
  • Peer group for collaboration and consultation
  • Choice of purchased services such as a care coordinator, high risk patient case manager, etc. (future)
  • Evidence-based protocol development and tactics for implementation that produce best practices and standardize medical management across the population
  • Total cost of care data for your practice (future)
  • Patient experience survey (future)
  • Step-wise financial incentive for initial and sustaining fees towards National Committee for Quality Assurance PCMH recognition (future)


What are the six PCMH standards and their key elements?

1.  Patient-centered access

  • Must Pass Element: Patient-centered appointment access
  • 2014 Standard: 3 elements (10 points)

– Patient-centered appointment access

–24/7 Access to clinical advice

–Electronic access


2.  Team-based care

  • Must Pass Element: The Practice Team
  • 2014 Standard: 4 elements (12 points)


–Medical Home Responsibilities

–Culturally & Linguistically Appropriate Services

–The Practice Team


3.  Population health management

  • Must Pass Element: Use data for population management
  • 2014 Standard: 5 elements (20 points)

–Patient Information

–Clinical Data

–Comprehensive Health Assessment

–Use data for population management

–Implement evidence-based decision support




4.  Care management and support

  • Must Pass Element: Care Planning and Self-care Support
  • 2014 Standard: 5 elements (20 points)

–Identify patients for care management

–Care planning and self-care support

–Medication management

–Use of electronic prescribing

–Support self-care and shared decision making


5.  Care coordination and care transitions

  • Must Pass Element: Referral Tracking and Follow-up
  • 2014 Standard: 3 elements (18 points)

–Test Tracking and Follow-up

–Referral Tracking and Follow-up

–Coordinate Care Transitions


6.  Performance measurement and quality improvement

  • Must Pass Element: Implement continuous quality improvement
  • 2014 Standard: 7 elements (20 points)

–Measure clinical quality performance

–Measure resource use and care coordination

–Measure patient/family experience

–Implement continuous quality improvement

–Demonstrate continuous quality improvement

–Report Performance

–Use Certified EHR Technology (not scored)