Standards and Guidelines forNCQA’s Patient-Centered Medical Home(PCMH) 2014

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AcknowledgmentsThe PCMH Advisory CommitteeNCQA began planning for the next version of the PCMH standards shortly after the 2011 standards werereleased. From the 2011 release date, we solicited, received and catalogued suggestions for futuremodifications. Early in 2013, we assembled the PCMH Advisory Committee, a diverse, 21-membercommittee composed of representatives from practices, medical associations, physician groups, healthplans and consumer and employer groups. The committee met throughout 2013 to discuss and analyzedraft standards, PCMH data analysis and public comment results.The committee shaped updates to accomplish the following in PCMH 2014:1. Emphasize team-based care.2. Focus care management on high-need populations.3. Set the bar higher and align quality improvement activities with the Triple Aim.14. Align with Meaningful Use Stage 2 (MU2).5. Further integration of behavioral healthcare.The importance of this committee cannot be overstated. Its members gave their time, energy, enthusiasmand a willingness to hear and compromise on opposing perspectives. The PCMH 2014 standards are areflection of their hard work and collaboration.Randy Curnow, MD, MBA, FACP ChairVice President for Medical Affairs, Mercy HealthPhysiciansDaniel Miller, MDHudson River HealthCare Inc.Bruce Bagley, MDAmerican Academy of Family PhysiciansMarci Nielsen, PhD, MPHThe Patient-Centered Primary CareCollaborativeMichael Barr, MD, MBA, FACPAmerican College of PhysiciansLee PartridgeNational Partnership for Women and FamiliesSusan Edgeman-Levitan, PAStoeckle Center for Primary Care Innovation,Massachusetts General HospitalJacob Reider, MDOffice of the National Coordinator for HealthInformation TechnologyFoster Gesten, MDNew York State Department of HealthKaitlyn RoeFuse Health Strategies, LLCRalph Gonzales, MD, MSPHNew York State Department of HealthJulie Schilz, BSN, MBAWellPointMarjie Harbrecht, MDHealthTeam WorksXavier Sevilla, MD, FAAPAmerican Academy of PediatricsKathleen Jaeger, JDNational Association of Chain Drug StoresLisa Dulsky Watkins, MDVermont Blueprint for HealthRegina Julian, MHA, MBA, FACHEOffice of the Assistant Secretary of Defense for HealthAffairs/TRICARE Management ActivityAudrey Whetsell, CPHIT, MAResource PartnersDonald Liss, MDIndependence Blue CrossKimberly Williams, LMSWMental Health Association of New York CitySean Lyon, MSN, APRN, FNP-BCLife Long Care, im/Pages/default.aspxJuly 28, 2014NCQA’s Patient-Centered Medical Home (PCMH) 2014

Table of ContentsTable of ContentsNCQA’s Patient-Centered Medical Home 2014—Overview . 1Goals for PCMH and Beyond . 2NCQA PCMH Evolution . 3PCMH 2014 . 4Development . 4The Consumer Perspective . 5Public Comment . 5The Standards . 5The Must-Pass Elements . 5Recognition Levels and Point Requirements . 6Initial Recognition vs. Renewal . 6Optional Recognition for Use of Standardized Patient Experience Survey . 6Resources . 7Policies and ProceduresSection 1: Eligibility and the Application ProcessDefinitions . 11Eligibility . 11Fee Schedule Information . 12Recognition Program Partners in Quality. 12Start-to-Finish Pathway . 13The PCMH 2014 Online Application Process . 13Application Components . 13The PCMH 2014 Multi-Site Application. 14Determine Multi-Site Eligibility . 14Multi-Site Corporate and Site-Specific Survey Tool Submission . 15Practice Readiness Evaluation . 15Complete the Application . 15Prepare and Submit the ISS Survey Tool . 16Section 2: The Recognition ProcessNCQA Survey Tool Review . 18The Review . 18The Audit . 18PCMH 2014 Standards . 19A Standard’s Structure . 19Scoring Guidelines . 20Final Decision and Recognition Levels . 21Section 3: Additional InformationAdd-On Survey. 22Renewing Recognition . 22Reconsideration . 22Applicant Obligations . 23Complaint Review Process . 23Discretionary Survey . 24Suspension of Recognition . 24Revoking Decisions . 24Mergers, Acquisitions and Consolidations . 25Revisions to Policies and Procedures . 25Disclaimer . 25NCQA’s Patient-Centered Medical Home (PCMH) 2014July 28, 2014

Table of ContentsPCMH 2014 StandardsPCMH 1: Patient-Centered Access . 29PCMH 2: Team-Based Care. 37PCMH 3: Population Health Management . 46PCMH 4: Care Management and Support . 60PCMH 5: Care Coordination and Care Transitions . 71PCMH 6: Performance Measurement and Quality Improvement . 79AppendicesAppendix 1: PCMH 2014 ScoringAppendix 2: NCQA PCMH 2014 and CMS Stage 2 Meaningful Use RequirementsAppendix 3: PCMH 2014 GlossaryAppendix 4: PCMH 2011–PCMH 2014 CrosswalkAppendix 5: PCSP-PCMH 2014 CrosswalkJuly 28, 2014NCQA’s Patient-Centered Medical Home (PCMH) 2014

NCQA’s Patient-Centered Medical Home (PCMH) 2014July 28, 2014


NCQA’s Patient-Centered Medical Home (PCMH) 2014July 28, 2014

Overview1NCQA’s Patient-Centered Medical Home 2014Patient-centered medical homes (PCMH) are transforming primary care practices into what patients want:a focus on patients themselves and their health care needs. Medical homes are the foundation for ahealth care system that gives more value by achieving the “Triple Aim” of better quality, experience andcost. This is the overview to our vision for achieving that goal; it chronicles the PCMH evolution to date,the challenges that lie ahead and potential solutions to those challenges—some already underway, someyet to be developed.As of February 2014, 7,066 practices were recognized as PCMHs by NCQA, which has the nation’slargest PCMH program. To earn NCQA Recognition, practices must meet rigorous standards foraddressing patient needs; for example, offering access after office hours and online so patients get careand advice, where and when they need it. PCMHs get to know patients in long-term partnerships, ratherthan through hurried, sporadic visits. They make treatment decisions with their patients, based on patientpreference. They help patients become engaged in their own healthy behaviors and health care.Everyone in the practice—from clinicians to front desk staff—works as a team to coordinate care fromother providers and community resources. This maximizes efficiency by ensuring that highly trainedclinicians are not performing tasks that can be accomplished by other staff, and helps avoid costly andpreventable complications and emergencies through a focus on prevention and managing chronicconditions.A growing body of evidence documents the many benefits of medical homes, including better quality,patient experience, continuity, prevention and disease management. Studies show lower costs fromreduced emergency department (ED) visits and hospital admissions, reduced income-based disparities incare and lower rates of provider burnout.PCMHs’ power to improve the quality, cost and experience of primary care, however, only begins thebroad change our health care system needs. Other providers and facilities must build on PCMHfoundations to establish patient-centered care throughout health care. This is beginning in the patientcentered specialty practices (PCSP), which help specialists become part of medical neighborhoods toimprove quality and access.Adoption of patient-centered strategies is also underway in many emerging accountable careorganizations (ACO). ACOs build on a solid PCMH foundation to coordinate doctors, hospitals,pharmacies, other providers and community resources and make sure people get all the care they need.They share savings from reduced waste and inefficiency if they also improve quality.July 28, 2014NCQA’s Patient-Centered Medical Home (PCMH) 2014

2OverviewGoals for PCMH and Beyond Primary care clinicians will deliver safe, effective and efficient care that is well coordinated acrossthe medical neighborhood and optimizes the patient experience. Primary care will be the foundation of a high-value health care system that provides whole-personcare at the first contact. Everyone in primary care practices—from physicians and advancedpractice nurses to medical assistants and frontline staff—should practice to the highest level oftheir training and license in teams, to support better access, self-care and care coordination. PCMHs will show the entire health care system what patient-centered care looks lik