Patient Centered Medical Home

The Patient-Centered Medical Home is a model of care that puts patients at the forefront of care. PCMHs build better relationships between people and their clinical care teams. Research shows that they improve quality, the patient experience and staff satisfaction, while reducing health-care costs. Medical Practice Management by Amalgaworks offers introductory and specific training sessions on elements, criteria, standards and compliance via on-site training, webinars and the HIPAA Compliant TeamViewer Remote Meeting platform. We can also assist with an implementation plan moving you closer to the required criteria. 

Summary of NCQA PCMH 2017 Standards

Team-Based Care and Practice Organization (TC)

The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.

Knowing and Managing Your Patients (KM)

The practice uses information about the patients and community it serves to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.

Patient-Centered Access and Continuity (AC)

The practice provides 24/7 access to clinical advice and appropriate care facilitated by their designated clinician/care team, considers the needs and preferences of the patient population when modeling standards for access.

Care Management and Support (CM)

The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

Care Coordination and Care Transitions (CC) The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations.


Performance Measurement and Quality Improvement (QI)


The practice establishes a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/families/ caregivers in quality improvement activities.


CLICK HERE to download version 5 of the PCMH Standards and Guidelines.

Click here for our Oversight Checklist