Table 1

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

PCMH Standard	Content Summary
1. Enhance access/continuity	Patients 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 populations	The 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 care	The 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 resources	The 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 care	The practice tracks, follows-up on, and coordinates tests, referrals, and care at other facilities (eg, hospitals)
5. Track/coordinate care	The practice manages care transitions
6. Measure/improve performance	The 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