Table 1.

NCQA Standards and Elements for PCMH Certification

NCQA PCMH Standards	Elements
Enhance Access and Continuity	Access during office hours and after hours, electronic access*, continuity, medical home responsibilities, culturally and linguistically appropriate services, the practice team*
Identify and Manage Patient Populations	Use data for population management*, collect patient information and clinical data, perform a comprehensive health assessment
Plan and Manage Care	Implement evidence-based guidelines, identify high-risk patients*, provide care management*, medication management*, and electronic prescribing
Provide Self-Care Support and Community Resources	Support self-care process*, provide referrals to community resources*
Track and Coordinate Care	Test tracking and follow-up, referral tracking and follow-up, coordinate with facilities/care transitions*
Measure and Improve Performance	Measure performance and patient/family experience, implement quality improvement report performance and data, use certified EHR technology*

^*Elements with evidence of effectiveness, detailed in Table 2.