Table 1

Summary of NCQA Patient-Centered Medical Home (PCMH) 2011 Standards

PCMH StandardContent Summary
1. Enhance access/continuityPatients have access to culturally and linguistically appropriate routine/urgent care and clinical advice during and after office hours
The practice provides electronic access
Patients may select a physician
The focus is on team-based care with trained staff
2. Identify/manage patient populationsThe practice collects demographic and clinical data for population management
The practice assesses and documents patient risk factors
The practice identifies patients for proactive reminders
3. Plan/manage careThe practice identifies patients with specific conditions, including high-risk or complex care needs and conditions related to health behaviors, mental health, or substance abuse problems
Care management emphasizes:
Previsit planning
Assessing patient progress toward treatment goals
Addressing patient barriers to treatment goals
The practice reconciles patient medications at visits and after hospitalization
The practice uses e-prescribing
4. Provide self-care support/community resourcesThe practice assesses patient/family self-management abilities
The practice works with patient/family to develop a self-care plan and provide tools and resources, including community resources
Practice clinicians counsel patients on healthy behaviors
The practice assesses and provides or arranges for mental health/substance abuse treatment
5. Track/coordinate careThe practice tracks, follows-up on, and coordinates tests, referrals, and care at other facilities (eg, hospitals)
The practice manages care transitions
6. Measure/improve performanceThe practice uses performance and patient experience data to continuously improve
The practice tracks utilization measures, such as rates of hospitalizations and emergency department visits
The practice identifies vulnerable patient populations
The practice demonstrates improved performance
  • NCQA = National Committee for Quality Assurance.

  • Reprinted with permission from the NCQA.6