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Are you ready for PCMH annual reporting 2023?

Doctor discussing care with patient who is sitting

Achieving Patient-Centered Medical Home recognition sets your practice apart from others as you focus on the quadruple aim: continual improvement of outcomes, decreased expenditures and increased patient and staff satisfaction.

PCMH adopts repeatable processes, policies, communication, documentation and reporting, which is ─ the backbone of value-based incentive programs and payer initiatives nationwide. Using a team approach to best understand patient populations and meet patients where they are leads to more equitable healthcare across all patient populations.

To keep the benefits of PCMH recognition, practices must keep their medical homes current and sustain the program from year to year. Sites must demonstrate in Q-PASS (the National Committee for Quality Assurance’s web-based evaluation tool) that their medical home workflows are in place by their stated reporting date.

NCQA updated the PCMH standards, guidelines and annual reporting requirements for 2023.

Standards and Guidelines Version 8:

  • Recognized practices should ensure their medical home core criteria are aligned with the most current version of the standards and guidelines. A practice can be audited at any time on any of the criteria associated with their PCMH. Standards and guidelines are available for download on NCQA’s website. Notable changes:
    • In 2024, all practices will be required to use electronic clinical quality measures or standardized measures and reporting periods for quality reporting. 2023 is a transition year where practices should start exploring their technology’s functionality and team’s abilities to prepare data in this manner.
    • Practices will be required to document and report on sexual orientation and gender identity as part of the diversity identification demographic intake.

Annual reporting requirements for 2023:

  • To prove PCMH has been sustained, the annual requirements are associated with core criteria from the standards and guidelines. Each July, the new requirements from the six concept areas for the following year are released and can be accessed on NCQA’s website.
  • The reporting requirements for 2023 are:
    • Quality improvement: In 2024, all practices are required to use eCQMs or standardized measures and reporting periods for annual reporting. Like 2022, 2023 is a transition year where custom measures and reporting periods can be used. Practices are encouraged, if possible, to use identified eCQMs as outlined by NCQA.
    • Access and continuity: Sites are asked to report on continuity of care with their primary care physician of record and their availability for after-hour appointments or what their process is for providing extended hours of care.
    • Team-based care: Practices must attest to the frequency in which they host team-centered quality improvement meetings.
    • Knowing and managing your patients: Reports for updated medication lists and the diversity breakdown of the patient panel must be shown.
    • Care coordination and transitions: Attestations regarding referral patterns and coordination efforts with emergency rooms and inpatient hospital facilities.
    • Care management and support: Practices report on their total patient population and perform a care plan audit on their identified panel of care management patients.
    • Practices must attest that ALL the core and selected elective criteria of the sites PCMH are still integrated into the daily practices of the organization.

How can DataGen help?

Regardless of where you are on your PCMH journey, DataGen is your trusted partner. For more than a decade, we’ve worked with practices nationwide to achieve, sustain and mature their PCMH. We collaborate with care teams to streamline and improve care delivery, team dynamics and reporting. We also assist practices in attaining Patient-Centered Specialty Care and other NCQA accreditations.

DataGen’s services include:

  • transformation guidance for prospective, new or recognized PCMHs;
  • education/understanding of the intent of the NCQA standards and guidelines/reporting requirements;
  • change/project management;
  • gap analysis of policy, processes and technologies;
  • web-based and/or in-person organizational retreats;
  • workflow redesign and technology exploration;
  • reporting, documentation and policy templates;
  • performance improvement strategies to create a culture of data analysis and application;
  • Q-PASS/NCQA relationship management; and
  • alignment with measures for the Health Plan Employer Data and Information Set (HEDIS), Merit-based Incentive Payment System (MIPS) and other value-based payment programs.

DataGen provides the guidance and tools to maximize investment in the medical home while reducing the administrative burden to allow your staff to be more present in patient care. Contact us to learn more.


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