Patient Centered Medical Home

The process of Patient Centered Medical Home (PCMH) recognition enables community health centers (CHCs) to work toward improving quality of care and outcomes for their populations, increasing access and providing care in a cost effective manner.

Beginning the Transition to NCQA PCMH 2017

In light of NCQA’s redesign for PCMH Recognition, those health centers already PCMH-Recognized can transition to the new NCQA PCMH 2017 criteria. Those not recognized and applying for the first time will only be recognized under the new NCQA PCMH 2017 design. The following steps outline where to begin with the new process to the PCMH redesign.

For all health centers (regardless of current PCMH status)

Step 1: Submit NOI to HRSA

According to HRSA, health centers must notify HRSA of intent by submitting a Notice of Intent (NOI) in the HRSA EHBs. In the EHBs, one must go to the Grant Folder and click on ‘HRSA Accreditation/PCMH Initiative’ link.[1]

  • For NCQA PCMH recognition, the total number of sites requesting recognition is needed
  • HRSA will review NOI for readiness and completeness and approve within 2-4 weeks.
  • HRSA will contact NCQA of the approved NOI and NCQA will contact health center directly to begin process

HRSA will also provide a code for health centers, which allows health centers to bypass payment during the enrollment process for NCQA PCMH 2017.  This code needs to be entered into the ‘Discount Code’ field under Payment in Q-PASS (see below).

Step 2: Enrollment in Q-PASS

  • Under PCMH 2017, NCQA has introduced a new interface known as Q-PASS ( Health centers may log in and access Q-PASS at any time, however, they would ‘Complete Enrollment’ when ready to begin submitting evidence and reporting to NCQA representative (6 months - 1 year before renewal date depending on level of recognition and readiness).

o   If already recognized, health center site information should be generated in Q-PASS by clicking on “Claim organization” to transfer your existing information.

  • NCQA outlines the enrollment process in Q-PASS as follows (There is also Blog/Youtube video detailing how to use Q-PASS available in the Blog section within Q-PASS):
    • Step 1: Add practice sites. 
    • Step 2: Add the recognition program for which you want to be recognized. 
    • Step 3: Set up clinicians. 
    • Step 4: Sign legal agreements. 
    • Step 5: Generate the invoice and pay. (At this point, health centers can apply the HRSA discount code so payment is not necessary.)
    • Step 6: Review your information and complete enrollment. 



New recognition (previously not recognized)

Step 1: Submit NOI (See above)

Step 2: Enrollment in Q-PASS (See above)

Step 3: Virtual Check-In’s

Once enrolled in Q-PASS, an NCQA representative will be assigned to your health center and will begin scheduling virtual check-in’s with health centers. The representative will schedule an initial call for introductions then develop a schedule of up to three check in’s over the course of the transformation.

Step 4: Assessment

Begin working within Q-PASS to gather evidence, prepare, and upload documentation. You may also demonstrate capabilities during live virtual reviews.   


o   Further information on this process is described by NCQA at:


Transition to 2017 (previously recognized health centers)

  • PCMH 2014 Level 3 Health Centers: If already recognized as PCMH 2014 Level 3, health centers can enroll into Q-PASS and go directly to the Annual Reporting phase of recognition. The Annual Reporting begins 30 days before expiration of current recognition cycle.


  • All other PCMH Recognized Health Centers: If already recognized in PCMH 2011 at Level 1, 2, or 3 or in PCMH 2014 at Level 1 or 2, health centers can undergo an accelerated process for PCMH 2017 recognition. This includes attesting to meeting certain criteria without having to provide all of the evidence as those seeking recognition for the first time.


o   NCQA provides detailed information on the accelerated renewal process for previously recognized health centers here:


Additional Resources

NCQA provides crosswalks for transitioning to 2017 to see which factors align with new criteria:

o   PCMH 2014 to 2017 Crosswalk:

o   PCMH 2011 to 2017 Crosswalk:

Frequently Asked Questions on Redesign Recognition:


[1] Health Resources & Services Administration. (n.d.). Notice of Intent Review and Approval. Retrieved from


PCMH Resources

Patient-Centered Medical Home

HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative

  • HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative

o   How To Apply

  1.       Select an Accreditation/PCMH Recognition Organization
  2.       Submit HRSA Notice of Intent
  3.       Prepare for a Survey depending on the selected accreditation/recognition organization

PCMH Organizations

PCMH Organizations

o   PCMH 2014 Opening Introduction

o   PCMH 1: Patient-Centered Access

o   PCMH 2: Team Based Care

o   PCMH 3: Population Health Management

o   PCMH 4: Care Management and Support

o   PCMH 5: Care Coordination and Care Transitions

o   PCMH 6: Performance Measurement and Quality Improvement

o   Single Site Online Application

o   Multi Site Online Application

o   Interactive Survey System (ISS) Part 1

o   Interactive Survey System (ISS) Part 2

o   Record Review Workbook

  • Upcoming trainings – NCQA PCMH 2014 Links to NCQA upcoming training calendars (GRIP and the regular)

o   NCQA Government Recognition Initiative Program Training & Technical Assistance Calendar – May-June 2016

o   NCQA PCMH 2014 topics – May –July 2016

o   PCMH 2014 Resources

o   PCDC links

o   Safety Net Medical Home Initiative Resources:

- Patient-Centered Medical Home Assessment (PCMH-A) tool– To assess the Medical Home status and identify areas for improvement in the context of Change Concept for Practice Transformation.

- Advancing Primary Care through the Patient-Centered Medical Home Model and Optimization of Health Information Technology: White Paper



  • NCQA Redesign (starting from March 2017):

o   NCQA PCMH Recognition Redesign Overview

o   Information for Practices Currently Recognized Under PCMH 2011 Standards

o   Information for Practices Currently Recognized Under PCMH 2014 Standards

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