Alternative PCMH Models

Four alternatives to patient-centered medical home (PCMH) recognition exist for non-traditional primary care practices: the NCQA Patient-Centered Connected Care (PCCC) Recognition, the New York School-Based Health Alliance Patient-Centered School Based Health Care (PC-SBHC), the University of Michigan Adolescent Health Initiative’s Adolescent Champion Model, and the Boston Children Hospital’s Care Coordination Measurement Tool (CCMT).

NCQA PCCC Recognition

For health care “neighbors that surround and inform the medical home and colleagues in primary care,” NCQA developed the Patient-Centered Connected Care (PCCC) Program. The PCMH alternative for specialty practices focuses on access, communication, and care coordination. Its intended targets are retail clinics, urgent care centers, physical therapy, podiatry, optometry, chiropractic sites, and SBHCs that do not serve as the medical home.

Read More

Like its PCMH cousin, PCCC recognition is based on five standards, each with several components. It is not yet clear how these standards or the providers who achieve recognition will be rewarded by health care payers.

TABLE 8: NCQA PCCC Standards and Elements

StandardKey Elements
Connecting with Primary Care
  • Connecting Patients with Primary Care (Must-Pass)
  • Sharing Information with Primary Care
  • Demonstrating Information Sharing (Must-Pass)
  • Working with Primary Care
  • Coordination with Primary Care
  • Identifying Patient Needs
  • Informing Patients about Services Offered (Must-Pass)
  • Triaging Patients
  • Connecting Patients with Other Providers

  • Patient Care and Support
  • Implement Evidence-Based Decision Support (Must-Pass)
  • Medication Management
  • Test Tracking and Follow-Up
  • Collaborating With the Patient
  • Culturally and Linguistically Appropriate Services (CLAS)

  • System Capabilities
  • Patient Information
  • Clinical Data
  • Use of Electronic Prescribing

  • Measure and Improve Performance
  • Measure Clinical Quality Performance
  • Measure Resource Use and Care Coordination
  • Measure Patient/Family Experience
  • Set Goals and Analyze Results
  • Take Action to Improve (Must-Pass)
  • Reduce Disparities
  • Demonstrate Continuous Quality Improvement
  • Report Performance

  • Case Study: Health Delivery, Inc. Saginaw, MI

    Health Delivery, Inc. is a federally qualified health center located in Saginaw, Michigan, that operates multiple community health clinics and two SBHCs, both of which are included under the scope of services for the FQHC. Six of their CHCs currently have Level 3 NCQA PCMH recognition, and plans to get recognition for four more of their CHCs are in the works.

    In Michigan, several Medicaid qualified health plans pay a per-member/per-month (PMPM) incentive to practices that are NCQA PCMH recognized. The PMPM is pro-rated based on the level of recognition achieved. Michigan Medicaid also requires PCMH designation for participation in the MI Care Team Project, a coordinated, team-based approach to caring for Medicaid beneficiaries. Lastly, Health Delivery, Inc. receives an additional federal stipend from HRSA based on the number of sites that have PCMH recognition.

    Reason for Pursuing NCQA PCCC Recognition

    One goal of the organization is for all sites to receive recognition from one of NCQA’s three programs: PCMH, Patient-Centered Specialty Practice (PCSP), or PCCC. “Because our SBHCs don’t serve as the primary medical home, we opted to go with the PCCC recognition,” said Angelia Williams-Welch, MSN, BSN, RN, Director of Special Projects at Health Delivery, Inc. (personal communication, November 18, 2015 & March 23, 2016). Ms. Williams-Welch explained that it’s unclear if PCCC recognition will satisfy the PCMH recognition requirements of Michigan payers. Though HRSA does not support the PCCC recognition process, the Michigan Department of Health and Human Services (MDHHS) is covering the cost of the PCCC application for the SBHCs as part of a pilot project.

    The Approach Taken

    Health Delivery, Inc. started working on the PCCC recognition process in the summer of 2015 and they anticipate it will take one year to complete. The team they formed to do the work is composed of Ms. Williams-Welch, SBHC providers, the QI coordinator for the organization, IT staff, and consultants for the Child and Adolescent Health Center Program at MDHHS.


    Williams-Welch identified the following challenges in the process:

    • Time: It has been difficult finding sufficient time for the team to meet.
    • Staff Turnover: The recent loss of an SBHC primary care provider has delayed the process.
    • Lack of Expertise in PCCC Process: No one on the team was familiar with the PCCC recognition process.
    • Documentation of Standards: As with other recognition programs, one challenge is documenting existing processes. Most of the processes outlined in the standards are in place but documenting it in a way that can be demonstrated to NCQA is challenging. For example, Health Delivery, Inc. had to revise and create new policies and procedures that align with the standards and elements.
    Impact/Lessons Learned

    Ms. Williams-Welch said that although the process has been painstaking at times, overall she feels it has been valuable, was a great learning experience, and gave them the opportunity to improve care. They have enhanced cultural competency and improved communication with external providers, among many other advancements. “The standards reflect what should be practiced in SBHCs,” said Williams-Welch, adding that having the recognition will be advantageous when seeking future grant opportunities. Her recommendations for other SBHCs wishing to pursue PCCC recognition are to:

    • Include an IT person on the team to assist with pulling reports and data
    • Engage a knowledgeable consultant to facilitate the process

    New York School-Based Health Alliance PC-SBHC

    After completing a thorough comparison of several PCMH programs, collaborators from the New York State School-Based Health Alliance, the Montefiore Medical Center’s School Health Program, and the Primary Care Development Corporation concluded that the national recognition programs didn’t fit the work of SBHCs and, more importantly, lacked relevancy for SBHCs. And thus, the PC-SBHC 2014 Project was born. With funds from the Altman Foundation, their primary aim was to develop and pilot SBHC-specific PCMH standards. Using the NCQA PCMH standards, elements, and factors as a model, the group mapped a set of PCMH standards unique to SBHCs.

    Read More

    The PC-SBHC model is composed of six standards, 27 elements, and multiple factors for each element. The six standards are nearly identical to the NCQA PCMH standards:

    1. Patient-centered access
    2. Interdisciplinary team-based care
    3. Population health management
    4. Care management and support
    5. Coordinate and track care
    6. Measure and improve performance

    While there are many similarities, several NCQA PCMH elements have been revised or added to reflect preventive care and the population management strengths of SBHCs. The focus on electronic health record standards was deemphasized. Its creators say PC-SBHC’s objective wasn’t to make the recognition process easier, but to assure relevancy for SBHCs.

    Case Study: PC-SBHC

    The PC-SBHC standards were piloted in five school-based health centers in New York and two SBHCs in Connecticut in 2015. Participating SBHCs were required to use an electronic health record and adhere to Meaningful Use Stage 1. Pilot sites underwent a baseline assessment and received an individualized practice-specific work plan. Participating SBHCs then formed QI teams and were provided bi-weekly coaching and guidance on gathering documentation. It took anywhere from 12 to 18 months to complete the process depending on (1) time allocated by SBHC staff (weekly meetings versus twice a month meetings), and (2) where the SBHC was at baseline in terms of integration of PCMH principles.

    • Many of the processes outlined in the standards were in place but not being documented in a way that could be demonstrated to others.
    • There was much variation in the QI efforts of the pilot sites. They all found benefit in formally implementing QI processes and having data to support their efforts.
    • The level of integration that an SBHC has with its sponsor has a strong effect on the SBHC’s ability to meet the standards.

    The pilot sites identified a number of challenges and barriers, several of which are not unique to PC-SBHC. Rather, these are challenges most SBHCs will face when pursuing PCMH recognition—irrespective of the particular program.

    • PCP-SBHC tension: There can be tension between the community primary care physician and the SBHC in terms of who is responsible for different aspects of a child’s care. There is often an assumption with PCMH that a single provider is responsible for patient care, but in reality, primary care responsibilities are shared.
    • Small teams: SBHCs are generally staffed with a small number of individuals; finding sufficient time can be a constraint.
    • Documenting standards: SBHCs had to design strategies to document many of the clinic processes that were already in place, but not captured, such as care coordination.
    • Electronic health record functionality: While SBHCs utilized many of the features of their electronic health record, they discovered additional features and reporting tools to document various functions of patient care.
    • Insufficient data support: PCMH recognition requires the ability to extract, analyze, and report data, but many SBHCs lack sufficient IT support to do this.
    • Measuring standard of care: It was hard to identify the standard for preventive care that is provided to the patient. Many SBHCs are doing sick care/urgent care but it is more difficult to get a sense of what preventive care is uniformly provided.
    • SBHCs made improvements in population management with the help of previously undiscovered electronic health record features.
    • SBHCs modified existing processes or created new ones to improve clinic operations.
    • SBHC staff improved communication through team huddles and other strategies.
    • Sponsor organizations became increasingly aware that SBHCs should be included in QI processes, meaningful use, etc., and began to include their SBHCs in these efforts.
     Lessons Learned
    • Clinicians should be included on the QI Team because they are the ones implementing changes.
    • A dedicated IT person who is familiar with how SBHCs operate is essential for PCMH transformation to help with data extraction and reporting, and to assist in implementing features of the electronic health record.
    • Data are not only needed for QI. They can be very powerful for telling an SBHC’s story.
    • SBHCs need to be empowered to ask for what they need from their sponsoring agency and be included in PCMH and QI processes.
    Next Steps

    The collaborators plan to pilot the standards in additional New York and Connecticut SBHCs in 2016. Their goal is to find a “home” for SBHC-PC Standards among one of the nationally-recognized accrediting bodies to create an option for SBHCs looking to become recognized as a PCMH.

    To learn more about PC-SBHC, contact the New York School-Based Health Alliance at or visit their website at

    University of Michigan Adolescent Health Initiative’s Adolescent Champion Model

    The Adolescent Champion Model drives health centers to become adolescent-centered medical homes. The Champion model is a multi-faceted intervention to address a health center’s environment, policies, and practices to ensure that all aspects of a visit to the health center are youth-centered. It includes: a facilitated clinic assessment that aligns with PCMH standards; HEDIS-based quality improvement initiatives; customized implementation plans; and recommendations and resources for improving clinical practice, including workflows, templates, trainings, and tools to measure impact across providers, health center staff, and adolescent patients. Additional information can be found here.

    Boston Children Hospital’s CCMT

    This free tool developed by Richard Antonelli, MD, at Boston Children’s Hospital measures care coordination activities, resources needed to implement care coordination, and resulting outcomes.  CCMT can be used by any personnel performing care coordination, including nurses, social workers, patient navigators, case managers, and primary and subspecialty care providers.  It has been adapted for pediatric health systems in both ambulatory and in-patient settings. CCMT has also been cited in the AHRQ Care Coordination Measures Atlas. More information can be found here.