NCQA PCMH Recognition Program

Case Study: Sheridan Health Services, Sheridan, CO


Sheridan Health Services is a federally qualified health center (FQHC) that includes a school-based health center and community clinic. The University of Colorado School of Nursing operates both clinics. Sheridan began the process of obtaining NCQA PCMH recognition for the sites in 2013. They selected NCQA because it seemed to be the most common choice among other FQHCs. In addition, Colorado Community Health Network, the state organization for community health centers, was providing no-cost technical assistance to support the recognition process.

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Sheridan recently put the recognition process on hold because of the roll out of a new electronic health record, which is requiring tremendous energy and effort. They plan to resume their efforts for NCQA PCMH recognition soon. Their greatest challenges have been making the necessary changes to the electronic health record to meet the NCQA standards and finding adequate staff time to complete the process.

Impact/Lessons Learned

Sheridan Health Services’ staff members value the transformative process that has resulted from the process. Dr. Erica Sherer, CEO, explained that in her opinion, however, the NCQA PCMH model is not an ideal fit for SBHCs. “The benefit would be greater,” Sherer said, “if the focus was on youth engagement, better alignment with the school, and behavioral health.” She feels quality medical care is not their challenge. “The NCQA model is better suited for practices associated with large organizations looking at systems change,” she concluded (Erica Sherer, DNP, personal communication, February 18, 2016).

Case Study: Washington, DC


Unity Health Care, Inc. is a federally qualified health center in Washington, DC. They operate a number of community health centers, including four school-based health centers. Three of their SBHCs have achieved Level 3 NCQA PCMH recognition. (The fourth was opened recently and has not yet gone through the recognition process.)

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Reason for Pursuing NCQA PCMH Recognition

The Health Resources and Services Administration encouraged FQHCs to adopt the patient-centered medical home model of primary care and supported the application process financially.  NCQA collaborated with HRSA in this work.

The Approach Taken

According to Francina Boykin, SBHC Director, Unity Health Care, and Charlissa Quick, BSN, RN, MSA, School Health Division Chief at the Department of Health, (personal communication, June 1, 2016),

Unity Health Care, Inc. has a quality improvement team that includes clinical providers. The team was responsible for completing the NCQA PCMH application process for all of their clinics, including the SBHCs, in collaboration with clinic staff. They spent three years preparing.


Ms. Boykin and Ms. Quick shared that NCQA staff had many questions about the SBHC model and whether it met the standards of PCMH. For example, NCQA staff needed clarification regarding the distinction between SBHCs and the school nurse program, particularly since school nurses are co-located at the SBHCs. They also had questions about whether the SBHCs continue to operate during school holidays like winter, spring and summer breaks when the schools are closed. In the case of Unity Health Care, the SBHCs do stay open during these periods.

Impact/Lessons Learned

Ms. Boykin encourages other SBHCs to pursue PCMH recognition. She says that SBHCs are already doing the work, so they might as well pursue recognition.

Case Study: Harris County, TX


Harris Health System is a large network of hospitals and community health centers (CHCs) in Harris County, Texas. They operate multiple CHCs, including five school-based health centers in the greater Houston area. The SBHCs function as community clinics and can be accessed by all children in the community, not just students. All of the SBHCs are currently recognized as NCQA Level 3 patient-centered medical homes (PCMH).

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Reason for Pursuing NCQA PCMH Recognition

According to Dr. Richard Lyn-Cook, SBHC Medical Director, (personal communication, June 1, 2016), Harris Health System administration chose to pursue PCMH recognition as a way to continually improve the quality of care provided to their patients. They also wanted to have a competitive edge in the crowded Houston health care market and be well-positioned for payment reform under the Affordable Care Act. The NCQA PCMH recognition process was selected as they considered it to be the most robust and well-respected.

The Approach Taken

They first underwent the process in 2010. The medical director of the SBHCs at the time was tasked with spearheading the effort for all their clinics, including the SBHCs. The medical director became the in-house NCQA expert. She and her team combed through the NCQA manuals assessing what changes to data collection, workflow, and other processes were needed. They reached out to NCQA with questions. The medical director was co-located with the Information Technology (IT) department. This was helpful because the IT department was critical to the implementation of needed system changes and electronic health record modifications. They prepared for the process for six months and all their sites initially achieved either Level 1 or 2 recognition. Since that time, they’ve built on that foundation and now allow more time (9-12 months) to prepare for recognition renewal. All their clinics have currently achieved Level 3 recognition.


Dr. Lyn-Cook shared that getting provider buy-in was one of their biggest challenges. The process required significant change on the part of the providers who were also implementing a new version of the electronic health record at the time. The other challenge was managing the additional work load put on staff. NCQA recommends that additional staff be hired to manage the transformation process but that in their case, that wasn’t possible. Instead, existing staff took on additional roles and responsibilities.

Impact/Lessons Learned

Since initially undergoing the process, Dr. Lyn-Cook reports that they have seen improvements in patient outcomes as measured by HEDIS indices, both for the adult and the pediatric population.  He said that the recognition has “upped their game.” They think a lot more about improving the quality of care and regularly track their performance using data.

Dr. Lyn-Cook’s advice to other SBHCs is to recognize that the process requires a significant amount of work and that each SBHC needs to determine for themselves if the effort is worth the time and expense. He believes they were successful because they are affiliated with a large organization, had a dedicated person to lead the effort, and had sufficient IT infrastructure. He says that for smaller SBHCs, without an affiliation to a larger organization, it might be very difficult to achieve recognition. He recommends that those SBHCs implement quality improvement initiatives based on existing NCQA recommendations prior to formally applying. He added that he personally cannot imagine pursuing PCMH without the organizational support that Harris Health afforded him.

Click here to see the six standards, 27 elements, and 162 factors for the NCQA PCMH recognition program.

Table 2: NCQA PCMH Recognition Program Standards
StandardElement (example)Factors (example)
Enhance access
and continuity
Patient-centered appointment access.
The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance
  • Documented process, definition of appointment types
  • Team-based careThe practice team.
    The practice uses a team to provide a range of patient care services by… holding scheduled patient care team meetings or a structured communication process focused on individual patient care.
  • Staff position descriptions or responsibilities

  • Description of staff communication processes including frequency of communication and 3 examples showing that practice follows its process.

  • Population health managementUse data for population management.
    At least annually practice proactively identifies populations of patients and reminds them, or their families/ caregivers, of needed care based on patient information, clinical data, health assessments and evidenced -based guidelines
  • Reports or lists of patients needing services generated within the past 12 months

  • Materials showing how patients were notified for each service (e.g., template letter, phone call script, screen shot of e-notice).

  • Plan and manage careCare planning and self-care support.
    Care team and patient/family/ caregiver collaborate to develop and update an individual care plan
  • Report from electronic system or submission of Record Review Workbook

  • Example of how each factor is met

  • Track and coordinate careReferral tracking and follow up.
    The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations.
  • Examples of types of info the practice has on specialist performance

  • Materials explaining how BH is integrated with physical health

  • Measure and improve performanceImplement continuous quality improvement.
    Practice uses ongoing quality improvement process; sets goals and analyze at least three clinical quality measures
  • Completed PCMH Quality Measurement and Improvement Worksheet
  • AAAHC Recognition Program