Table 3.
Measures of the PCMH and Primary Care
| Domain | Current NCQA Measure Component (NCQA PPC®-PCMH)™ 160 | Missing Elements in Current Conceptualizations or Measures | Example Sources for Additional Measures | |
|---|---|---|---|---|
| PCMH Principlea | Primary Care Functionsb | |||
| Personal physician | Sustained partnership & relationship | 1. Access & Communication (Written standard for scheduling appointments with a personal clinician) | Relationships/partnerships with other members of the care team Patient-centered care 200 (RPAD201) | MHI 180 CPCI173–175 PCAS169 PCAT171,172 ACES170 CARE184 CAHPS176 |
| Physician-directed team practice | 3. Care Management | Team function Adaptive reserve & capacity for change (PCC202) | CCI202 OA203 ACIC177 | |
| Enabling relationships, leadership & communication (MHI 180 ACES170) | Integration of the team204 | |||
| Whole-person orientation | Accountability for addressing a large majority of personal health care needs | Personalization of care based on knowing the person’s medical and personal history & values | PCAS169 PCAT171,172 CPCI173–175 | |
| >85% of problems managed in practice | ||||
| Coordination / integration of care | Coordination / integration of care | 3. Care Management | Integration and prioritization of care across multiple co-morbid chronic illnesses, 45,205–210 acute and chronic illness, mental health, prevention & family care.38,211–213 | MHI 180 CPCI173–175 PCAS169 ACES170 PCAT171,172 ACIC177 |
| 7. Referral Tracking | ||||
| Quality & Safety | 2. Patient Tracking & Registry | Person-level quality of care: | Disease-specific quality & safety: | |
| 3. Care Management | Patient Enablement (PEI182,187,214) | ACQA Starter Set219 | ||
| 4. Self-Management Support | Protection from overtreatment215 | ACIC177 | ||
| 5. Electronic Prescribing | MHI 180 | |||
| 6. Test Tracking | Personalization of care | |||
| 7. Referral Tracking | Patient-centered care (Epstein200 RPAD201) | |||
| 8. Performance Reporting & Improvement | Cultural competency (ECHO216 CCA-PC217,218) | |||
| 9. Advanced Electronic Communications | Patient engagement in PCMH improvement | |||
| Enhanced access | Accessibility as 1st contact with the healthcare system | 1. Access & Communication | Defined population that represents community | PCAT171,172 ACES170 CAHPS176 |
| 9. Advanced Electronic Communications | ||||
| Payment for added value | (In some pilot, practices are paid more for being recognized at higher levels) | Recognition of the value of a primary care PCMH at other levels of the system | Blended payment91,92 for services, quality & enabling relationships | |
| Recognition of transition costs to PCMH93 | ||||
| (Neighborhood) | Family & community (& system) context | 8. Performance Reporting & Improvement | Family care212,220 | PCAT171,172 CPCI173–175 ECHO216 MHI 180 ACES170 PCC202 ACIC177 |
| Seamless transitions between places and levels of care | ||||