Become a Patient Centered Medical Home (PCMH)

Depending on the state you live in, pediatric practices using PCC software can receive payment incentives from payers by becoming a Patient Centered Medical Home.

By adopting the functions of PCMH, you help your patients and families gain access to care and you gain additional benefits for your practice.

What is a Patient Centered Medical Home?

PCMH encompasses a philosophy of patient care as well as a set of standards. It is an approach to care where “practices seek to improve the quality, effectiveness, and efficiency of the care they deliver while responding to each patient’s unique needs and preferences.” ( The core principles of a medical home are defined in the Joint Principles of the Patient-Centered Medical Home document, and endorsed by the AAP, AAFP, ACP, and AOA.

Summarized, the principles are:

  • Physician-led practice: Patients have access to a personal physician who leads the care team within a medical practice.

  • Whole-person orientation: The care team provides comprehensive care, including acute care, chronic care, preventive services, and end-of-life care, at all stages of life.

  • Integrated and coordinated care: Practices take steps to ensure that patients receive the care and services they need from the medical neighborhood, in a culturally and linguistically appropriate manner.

  • Focus on quality and safety: Practices use the quality improvement process and evidence-based medicine to continually improve patient outcomes.

  • Access: Practices commit to enhancing patients’ access to care. (

Various state and local organizations, insurance carriers, and other governing bodies have adopted the PCMH standard and created paid incentive programs for practices that implement these principles.

What is the Process of Achieving PCMH Recognition?

As of 2017, NCQA’s PCMH Recognition program includes six concepts that align with the principles of primary care. Within each concept are competencies which are meant to organize the criteria within each concept area. Criteria are the individual structures, functions and activities that indicate a practice is operating as a medical home.

The program includes ongoing, sustained recognition status with annual reporting.

To achieve PCMH recognition, practices must:

  • Meet all core criteria
  • Earn 25 credits in elective criteria across 5 of 6 concepts.

This ensures a minimum set of capabilities and gives practices the flexibility to focus on activities that not only mean the most to their patient population, but are feasible to accomplish with their resources and the resources of their community.

How Can My Practice Use PCC to Achieve PCMH Recognition?

PCC’s tools and services can help you meet the goals and requirements for PCMH recognition.

PCC has organized the 2017 PCMH Standards on our public wiki website, to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors.

The PCMH standards and guidelines ask practices to show that they meet PCMH principles through using a certified EHR, attestation, and providing report details on meeting Meaningful Use Measures, Clinical Quality Measures, and other standards. Many program requirements are similar to those defined by CMS in the Medicaid EHR Incentive Program (renamed Promoting Interoperability in 2018).

To learn more, read:

You can also get data for your PCMH application with PCC’s reports. For more information, read:

  • Meaningful Use Measures Report: The Meaningful Use Measures report in PCC EHR calculates your office’s performance on the Meaningful Use standards indicated in ARRA’s EHR Medicaid Incentive program and referenced in PCMH requirements.
  • Clinical Quality Measures Report: The Clinical Quality Measures report in PCC EHR calculates your clinicians’ performance on CQMs (Clinical Quality Measures).
  • PCC EHR Report Library: The PCC EHR Report Library contains several reports specifically designed to help you calculate numbers needed for your PCMH application, including “Care Plans By Date”.
  • Practice Vitals Dashboard: Your Practice Vitals Dashboard contains numerous measures that you can use for your PCMH application.

PCC Prevalidation: As of March 2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. If you are interested in learning more about using PCC EHR to achieve PCMH recognition, please contact your Client Advocate.

After Recognition, Are There Annual Requirements?

Once a practice has gone through PCMH for the first time, they are required to meet some annual reporting requirements. These requirements are comprised of a small subset of the 2017 PCMH requirements. Contact PCC support for assistance.

What Are Other PCC Practices Doing to Achieve PCMH Recognition?

PCC sponsors and maintains a public wiki where we share information gathered from PCC clients who have successfully achieved PCMH recognition.

The website includes screenshots and descriptions of how to use PCC’s software to complete your PCMH process. We welcome your input!

What PCMH Programs Are There in My Area?

PCMH programs vary from region to region. You can find out what’s available in your region at the Patient-Centered Primary Care Collaborative map.

PCMH Consultation with the Verden Group

PCC has partnered with the Verden Group to offer discounted consultation services to PCC clients looking to achieve PCMH recognition.

Get in touch with to learn more.

  • Last modified: April 5, 2024