ACHIEVING NCQA PCMH RECOGNITION
A TOOLKIT FOR PRACTICES SEEKING TO APPLY
CHIPRA QUALITY DEMONSTRATION GRANT
BACKGROUND
In February 2010 as part of the Children’s Health Insurance Program Reauthorization Act (CHIPRA), the Centers for Medicare
and Medicaid Services (CMS) awarded 10 quality demonstration grants, funding 18 states, to improve health care quality
and delivery systems for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). Under this grant
opportunity, Florida and Illinois have worked collaboratively on developing and implementing a variety of initiatives related
to medical home practice transformation for child-serving practices.
Ongoing medical home projects in both states demonstrated the value of and practice desire to achieve the National
Committee on Quality Assurance’s (NCQA’s) Patient-Centered Medical Home (PCMH) recognition, and also exposed the
difficulty in achieving this goal without additional assistance. This experience led Florida and Illinois to collaborate on an
additional medical home venture – to provide direct technical assistance to child-serving practices working to achieve
NCQA PCMH recognition, and to use this experience to develop an understanding of practice needs for transformation to
the PCMH model of care, including understanding the resources and effort necessary for practices to achieve PCMH
recognition and identifying transformation areas and processes that are the most challenging for individual practices.
Through this project, this toolkit of key resources was developed. The intention of this toolkit is to share more broadly with
practices considering applying for recognition the tools created through this work that the involved practices found most
useful, and to inform the medical community and federal and state policy makers of needed resources and the lessons
learned from this work.
This toolkit is not intended to be a comprehensive guide to achieving recognition. Rather, it is a compilation of the tools
that the practices involved in this project found useful and most helpful. There are many other resources available – many
of which, including trainings and other resources – are developed by NCQA directly. This toolkit is a supplement to other
available resources – filling in gaps that typically impede practices in their pursuit of recognition.
TOOLKIT CONTENTS
Considering
Recognition
Assessing
Status
Preparing for
Application
Strategic Plan
template
Determine need
for TA
Completing
Application
Factor overlap
crosswalk
Documentation
library
Assessment tool
Timeline template
Document
preparation tip
sheet
Build PCMH team
Tracking Tool
Internal
documentation
checklists
CONSIDERING RECOGNITION
NCQA PCMH Certified Content Experts
Becoming NCQA PCMH recognized is a complex, daunting process, for multi-site hospital-based practices and solo
provider practices alike. The process of transformation to the medical home, and the ability to document and display that
to NCQA, requires thoughtful and carefully planned action. Recognizing this, NCQA created a certification for PCMH
“experts” – called NCQA PCMH Certified Content Experts (CCEs) – a credential highlighting an individual’s knowledge of
the NCQA PCMH recognition program, including the requirements, application process, and documentation. CCEs are
available to provide technical assistance to practices to aide in the recognition application process. Our project
employed teams of two to three CCEs that provided direct technical assistance to the involved practices and developed
this toolkit and the resources it contains. NCQA’s list of CCEs can be accessed at http://cce.ncqa.org/pcmh/.
The Need for Technical Assistance
The intention of this toolkit is to provide resources for practices considering recognition; we strongly recommend practices
consider seeking technical assistance directly from an outside source. It is possible to achieve recognition on your own;
however, this project has shown the value in receiving technical assistance from knowledgeable certified experts. We
discovered that practices of varying sizes and structures all benefited from the level of expertise that an expert can provide.
There are many levels of consultation that can be useful to practices. Practices should assess their resources and need for a
consultant. Some practices engage consultants to be on-site and involved in every step of the transformation/recognition
process. Other practices consult with an expert on an “as needed” basis (by e-mail or phone) to obtain clarification on
standards/elements/factors or only for documentation review prior to submission. Technical assistance can be structured to
meet the needs of the practice and its resources. Practices with limited resources are encouraged to locate online
resources and/or engage another practice that has achieved recognition. Most recognized practices are willing to share
tips and documentation examples. A complete listing of recognized practices can be found on NCQA’s website, at
www.recognition.ncqa.org. Free consultation may be available from provider organizations or insurers/health plans with
whom practices contract.
Building a PCMH Team
Creating a solid group of individuals to navigate collaboratively through the transformation and recognition process is vital.
The process is long, complicated and time-consuming – and if possible, should not be attempted by one person. Four key
roles need to be filled, which we refer to here as the PCMH Champion, Communicator-in-Chief, Lead Administrator, and
Report Master. Though it is possible for one person to wear multiple hats, and/or one role to be shared among multiple team
members, establishing who is responsible for each task at the outset it critical to ensure accountability. First, you must
identify your “PCMH Champion”; who will help guide the practice through the quality transformation processes. A
“Communicator-in-Chief” will serve as the point person for all communication and interactions with staff and other support
individuals, as well as community and other organizations. The “Lead Administrator” is in charge of tracking the
transformation process, organizing the documents, and ultimately completes and submits the application. It is highly
encouraged the individual(s) have strong computer skills. Finally, a “Report Master” is needed, who is an individual with a
strong understanding of the EHR and the ability to pull various reports and billing information.
Once you have formed your team, key discussions must be made by the team to set realistic expectations and ensure buyin. Things to consider in these discussions include: Where will the manpower come from? A reduction in patient load?
Extended work hours? Working on weekends? Will this require a shift in duties and/or responsibilities? Where, when, and how
will the team meet? Other issues may arise and discussing them as early as possible is beneficial. Medical home
transformation is valuable to your patients and practice, but it is not a quick process. Creating a unified team is a major
asset.
Additional Resources/Toolkits
There are many facets of PCMH to consider, and a variety of toolkits and resources are available. While this toolkit contains
a compilation of the tools that the practices involved in this project found useful and most helpful in order to fill in gaps that
typically impede practices in their pursuit of recognition, additional resources should also be considered and explored.
Here are some additional resources you may find helpful.
PCMH Toolkit - Resources for Connecticut FQHCs: This resource was developed for Connecticut FQHCs and contains a variety of tools
that address the core components of a PCMH approach to primary care.
AHRQ Patient Centered Medical Home Resource Center: The Agency for Healthcare Research and Quality's (AHRQ) Patient Centered
Medical Home Resource Center includes tools and resources for practices, practice facilitators, researchers and policymakers.
Patient-Centered Primary Care Collaborative: PCPCC advances primary care and the patient-centered medical home among
policymakers, health care professionals, employers, researchers, and consumers through a variety of initiatives and special projects.
ASSESSING STATUS
Assessing Current Status
To put into context where a practice needs to be in order to achieve recognition, it is helpful to first understand where the
practice currently stands. To begin, we recommend assessing the current level of medical homeness according to NCQA’s
standards. This will help frame how near or far the practice is to recognition, and will highlight the areas that need
additional work. Practices should begin the recognition process by completing a baseline assessment to determine its
current status.
The Scoring Process
NCQA PCMH 2014 recognition is awarded based on whether a practice
achieves a certain amount of points toward recognition, and is divided into
three levels. This leveling system allows practices with varying degrees of
medical homeness to achieve recognition, while also recognizing practices
with greater medical home capabilities with a higher recognition level.
NCQA PCMH 2014 Recognition Levels
Six standards make up NCQA’s PCMH program, and each standard contains
several elements, each of which is made up of multiple factors. For each
present factor within a practice, a point is awarded. Some factors are
considered critical – all critical factors must be achieved in order to reach
any level of recognition. Some elements are “Must Pass” – scores of 50
percent or higher must be achieved on all of these elements to reach any
level of recognition. The percentage scored on a given element are based
on NCQA’s scoring mechanism, which differs for each element.1 Determining a practice’s score can be a daunting
process – and one easily prone to error if done by hand. NCQA’s scoring page can be accessed here.
When trying to determine the score of an element, note the scoring section in the Standards and Guidelines for each element. Every element has different
requirements to achieve 100% of the points. Some elements do not require completion of all factors to earn 100%. All “Must Pass” elements must achieve at least 50%
in scoring and all “Critical Factors” must be met to receive recognition.
1
The NCQA 2014 Medical Home Assessment Tool
The NCQA 2014 Medical Home Assessment Tool provides an efficient means of assessing baseline status.
Practices can follow through each tab (representing each standard) on this excel workbook, created by
the Primary Care Development Corporation, marking which factors are currently met by the practice. The
workbook will automatically calculate the score, based on the results entered. It also provides aggregate
statistics, including status on achieving the critical factors and “Must Pass” elements. Practices completing this tool will have
a solid understanding of where they stand in terms of currently meeting NCQA’s PCMH recognition standards. The NCQA
2014 Medical Home Assessment Tool can be accessed here.
A sample from the NCQA 2014 Medical Home Assessment Tool workbook showing PCMH Standard 1, Element A.
PCMH 1: PATIENT CENTERED ACCESS
Factor Present?
(Yes = 1, No=0)
Factor
Documentation
Required
ELEMENT A: PATIENT CENTERED APPOINTMENT ACCESS (MUST PASS)
The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance on:
1. Providing same-day appointments for routine and urgent care. (CRITICAL FACTOR)
P/R
2. Providing routine and urgent-care appointments outside regular business hours.
P/R
3. Providing alternative types of clinical encounters.
P/R
4. Availability of appointments.
P/R
5. Monitoring no-show rates.
P/R
6. Acting on identified opportunities to improve access.
P/R
Total Possible Points for PCMH 1A:
Total # of Factors with "Yes" for PCMH 1A:
4.5
0
% Points Received for PCMH 1A:
0%
Total # of Points Received for PCMH 1A:
0.00
MUST PASS Element - Passed at 50% Level?
NO
Additional Notes for
1A:
PREPARING FOR APPLICATION
Strategic Plan Template
While completion of the assessment tool will inform a practice of how close or far they are to achieving the
needed points for NCQA PCMH 2014 recognition, it will not inform them where to go next. It’s easy for
practices to get mired in the pursuit of achieving individual factors, and “missing the forest through the
trees” – the end goal is recognition after all, and every factor does not need to be met to achieve this. We
recommend practices create a strategic plan to determine how best to proceed with recognition. Essential elements to
include in the strategic plan are:






Current scores in comparison to recognition levels
Assessment of needs related to Critical Factors and “Must Pass” elements, including how many are still needed, and
how much is missing (e.g., are processes lacking, or just the documentation?)
Current scores in comparison to what the current score would be if all Critical Factors and “Must Pass” elements are
achieved (i.e., if these factors and elements are achieved, is it enough to achieve a level of recognition? Or is more
work needed?)
Of the needed elements/factors to achieve a level of recognition, what is the practice capable of doing on their
own? Where is outside technical assistance needed?
What is the feasibility of achieving a higher level of recognition (Level 2 or 3)? How many of the additional points
would come from areas that would be relatively simple for the practice to achieve, vs. those that are a “heavier lift”?
What would be the timetable to achieve the needed points for a higher level, and is this feasible?
What is the practice’s timeline for achieving recognition? Given this timeline, how can resources be best allocated –
achieving a lower level of recognition? Receiving technical assistance?
We created a Strategic Plan template to assist practices in organizing these analyses. The template can be accessed here.
Timeline Template
Determining the timeline for recognition application is a critical step. A number of issues must be
considered in determining an appropriate and realistic timeline. While some issues relate to the recognition
requirements, specific characteristics of the practice must also be considered. We recommend that the
practice works to establish a reasonable timeline, given both types of issues. We do not recommend that a practice begins
with PCMH Standard 1, and try to work through the process in a sequential order. A timeline should be established that
considers issues inherent to the recognition process, such as:




Some standards take longer to complete.
Certain factors must be in place for specific time period before a practice can apply for recognition. These need to
implemented accordingly.
Certain factors need to be achieved before another factor can be worked on. These need to begin early.
Some factors align with other factors. These should be worked on concurrently.
We have designed a generic timeline template that accounts for these issues, based on a 12-month timeline. This timeline is
a good starting point for practices, but practices must also consider and include practice-level characteristics and issues in
finalizing their own timeline. These include:



Is the practice applying for single or multi-site recognition?
How many factors are needed, and what is needed to achieve them (documentation, or processes?)
How many team members, consultants, etc. are available, and what is their availability to devote time to this
project?
The timeline can be adjusted based on the practices’ own time requirements. The timeline template can be accessed
here.
Tracking Tool
Accurate tracking of the application process is needed to ensure ownership, accountability, and that the
process progresses according to the timeline. Important elements to include in a tracking document
include the owner, due date, status, and whether the documentation has been uploaded to NCQA. In
designing a tracking tool for the practices, we determined it would have greater utility if it were embedded in their
assessment tool. This would limit the need to go back and forth between multiple documents, which could potentially
create a version control issue. We also flagged the Critical Factors and “Must Pass” elements. This tracking tool, which is
built on PCDC’s Medical Home Assessment Tool but includes the tracking fields that the Florida-Illinois CHIPRA team has
added, can be accessed here as an example. However, we recommend that these tracking fields are imported into the
Medical Home Assessment tool (described above) that the practice has already completed (if it has done so already) to
ensure version control.
A sample of the tracking tool (embedded in the NCQA 2014 Medical Home Assessment Tool workbook).
PCMH 1: PATIENT CENTERED ACCESS
Factor
Present?
(Yes = 1, No=0)
Factor
TRACKING
Doc
Required
Owner
Due
Date
Status
ELEMENT A: PATIENT CENTERED APPOINTMENT ACCESS (MUST PASS)
The practice has a written process and defined standards for providing access to
appointments, and regularly assesses its performance on:
*MUST PASS*
1. Providing same-day appointments for routine and urgent care.
(CRITICAL FACTOR)
P/R
2. Providing routine and urgent-care appointments outside regular
business hours.
P/R
3. Providing alternative types of clinical encounters.
P/R
4. Availability of appointments.
P/R
5. Monitoring no-show rates.
P/R
6. Acting on identified opportunities to improve access.
P/R
Document
Uploaded
(Y/N)
Pricing and Application
The cost of applying for NCQA PCMH Recognition varies depending on practice characteristics, and pricing is provided
here.
To initiate the application process, you must first purchase an ISS Survey Tool, which includes all information needed to
prepare and submit materials for an NCQA survey. The Survey Tool must be completed and submitted to NCQA. The
survey tool allows for you to document your practice’s medical home features. The Survey Tool also contains the Record
Review Workbook and Quality Improvement Worksheet.
Before submitting your recognition application, you must pay your application fee based on the pricing found in the link
above. Practices must submit payment via the Recognition Program Payment Portal. The portal will generate a payment
application for the practice to submit payment via credit card or e-check prior to submitting their application. It also
includes instructions for mailing in a paper check.
NCQA reviews your application and notifies you in 1-5 business days that your application is linked to your Survey Tool.
COMPLETING APPLICATION
Factor Overlap Crosswalk
As we’ve noted, many factors and elements closely align with, or must be completed in conjunction with or
subsequent to another factor/element. As such, we do not recommend a practice attempts to achieve
each standard, element and factor in a sequential order. We created a crosswalk to show where factors
and elements overlap. This crosswalk is meant to assist practices in developing their timeline, and also in
determining their strategic plan for completion – aligned factors/elements should be worked on by the same owner, or
owners that consult with each other in order to prevent duplication of efforts or working at cross purposes. The Factor
Overlap Crosswalk can be accessed here.
Documentation Library
The Documentation Library contains examples of documentation that meets NCQA requirements for each
element/factor. The examples provided should not be considered the “final word”, as other types of
documentation may be acceptable. The examples were gathered from NCQA training materials and
practices that received recognition. The documentation library can be accessed here.
Document Preparation Resources
We learned through our work with practices that document preparation is extremely important. We
regularly encouraged practices to refer to NCQA’s resources on documentation preparation. The most
important point to keep in mind about documentation is that NCQA reviewers are not familiar with your
practice, its electronic health record or terminology/acronyms, nor are they clinicians so may not be able
to interpret the documentation you have provided. Clearly label everything to “tell the story” of what you are providing.
NCQA’s document preparation tips can be accessed here.
Internal Documentation Checklists
Whether utilizing the technical assistance of a certified consultant or not, it is helpful to have another team
member review a documentation example before it is submitted. This task serves two purposes: 1) it
promotes accountability and accuracy since more than one team member is aware of and understands
what has been submitted; and 2) it saves technical assistance resources, which can be costly, for tasks that
are harder for the PCMH team to complete on their own. By reviewing the documentation prepared by another PCMH
team member, the reviewer often develops a greater understanding of NCQA requirements and is better able to prepare
their own documentation that meets standards. Additionally, it ensures that documents developed by one team member
are not contradictory or redundant with documents developed by another team member. For this reason, we recommend
that at least two team members are responsible for the development and submission of documentation, and that they
each review each other’s documentation examples. We created checklists for each factor to assist in this review and
provide a standardized process. These checklists can also be used during the creation of documentation.
The internal documentation checklists can be accessed here.