Practice Spotlight: Community Health Centers of Burlington, Inc.

Since achieving PCMH Recognition in 2012, Community Health Centers of Burlington, Inc. in Vermont has built a strong and consistent foundation for delivering high-quality, patient-centered care. They currently have eight PCMH-Recognized practices—Champlain Islands, Essex, Good Health, Pearl Street, Riverside, Safe Harbor, South End and Winooski—serving more than 28,000 unique patients each year. With PCMH Recognition in place, care teams use data to monitor performance, identify gaps and drive meaningful improvements tailored to their community’s needs.

“As a large multi-practice Federally Qualified Health Center, having all of our sites recognized as patient-centered medical homes has provided a solid foundation for data-driven decision making,” says Kerry Goulette, PA-C, MHP, Medical Director of Quality, Risk and Compliance at Community Health Centers of Burlington. “Using data, we are able to implement, monitor and improve care delivery to meet the unique needs of our patients at every site. We have a better understanding of health disparities and barriers that allow us to focus our efforts to achieve improved outcomes.”

PCMH Recognition helps organizations build reliable processes, use data effectively and deliver high-quality, patient-centered care. Ready to strengthen your care model? Learn more about NCQA’s PCMH Recognition.

Announcing the Return and Expansion of PCMH Office Hours

NCQA has expanded PCMH Office Hours, a series of complimentary, hour-long Q&A sessions designed to support NCQA customers. Facilitated by NCQA staff, each session includes a brief program overview and time to answer product-specific questions from the audience. Upcoming topics include:

• Behavioral Health Integration.
• Certified Community Behavioral Health Clinics.
• Diabetes Recognition Program.
• Patient-Centered Specialty Practices.
• Virtual Care Delivery.

Stay tuned for more details about product-specific office hours, including upcoming dates, times and joining instructions.

Important Update: Late Fees for Annual Reporting Submissions Effective January 1

Effective January 1, NCQA began charging late fees for annual reporting submissions received after the reporting deadline. This change will help to ensure timely and consistent reporting across all programs.

To avoid late fees, please submit all required documentation by your organization’s designated reporting deadline. If you anticipate submission delays, please notify your assigned Recognition Programs Representative in advance. Visit NCQA’s PCMH webpage to learn more.

PCMH Public Comment: Open Through April 17

NCQA is seeking feedback on proposed revisions to the PCMH Care Management concept for 2027. The public comment period ends at 11:59 p.m. ET on April 17. Visit the NCQA website for details.

The post What’s New with PCMH: Practice Spotlight, Expanded Office Hours and Annual Reporting Changes appeared first on NCQA.

Join us for a webinar on March 18 at 2:00 p.m. (ET) to learn more about the proposed changes.

About NCQA’s Public Comment

NCQA releases program updates for public comment to generate thoughtful feedback and suggestions from interested parties. Many comments result in updates to our standards and policies, helping to strengthen them for all stakeholders. NCQA asks respondents to evaluate whether the proposed requirements are feasible as written and clearly articulated, and to identify areas that may need clarification.

Summary of Proposed Changes

Below is a summary of the proposed changes to NCQA’s programs and standards. You can review the full details on NCQA’s website.

New Accreditation Program for Wellness and Condition Management

NCQA is launching a new Accreditation program— Wellness and Condition Management— using our Wellness and Health Promotion Accreditation program as the foundation. The new program will assess vendors’ ability to empower members to manage their own health across the risk continuum, accounting for risk factors and condition-specific needs. It will create a common quality framework for purchasers and vendors.

The program’s content was informed by robust customer and market engagement—which continues through our new learning collaborative—and reflects the increasing use of digital vendors by health plans, health systems and employers. It shifts from prescriptive requirements toward more flexible and transparent expectations, while still holding organizations accountable for quality, equity and measurable impact.

The new program will include core standards and two modules: Health Assessment and Digitally Enabled Engagement. Organizations may participate in one or both modules. The updated standards will be released in July 2026, with an effective survey date on or after January 2027.

Patient-Centered Medical Home (PCMH) Recognition Updates

Proposed updates to the PCMH Recognition program aim to align standards with the changing market landscape, stakeholder needs and regulatory requirements, and to assist organizations in their pursuit of high-quality care.

For surveys beginning January 1, 2027, NCQA proposes updates to three core criteria within the Care Management concept:

• CM 01: Identifying Patients for Care Management
• CM 02: Monitoring Patients for Care Management
• CM 04: Person-Centered Care Plans

We also propose the retirement of one elective criterion, which will be incorporated into CM 04:

• CM 07: Patient Barriers to Goals

Proposed updates address challenges some practices experience when applying current criteria across diverse clinical contexts (e.g., health conditions, populations, case mix). They are designed to better clarify the purpose and expected outcomes of the Care Management concept’s activities and to support individualized, meaningful care plans that reflect the varied needs of patient populations.

How to Participate in Public Comment

Visit My NCQA to submit comments through our new and improved public comment process. We’ve completely redesigned the experience by reducing clicks and organizing topics more logically. These updates enable NCQA to ask more meaningful questions and make it simpler for you to share feedback.

The public comment period ends at 11:59 p.m. (ET) on Friday, April 17. For details on proposed changes, visit the NCQA website.

Join our webinar, Updates to PCMH Recognition and the New Wellness and Condition Management Program, on March 18 at 2:00 p.m. (ET) to learn more.

The post NCQA Seeks Public Comment on a New Accreditation for Wellness and Condition Management and Updates to PCMH Recognition appeared first on NCQA.

NCQA’s Advanced Primary Care Pilot Program is defining the next generation of primary care. Building on what we’ve learned from our Patient-Centered Medical Home (PCMH) Recognition program, the pilot will accelerate innovation, test scalable models and help healthcare organizations meet the needs of diverse communities.

“Primary care is the foundation of a high-quality health system and one of the strongest levers to improve population health and affordability. The organizations participating in this pilot are doing more than testing approaches—they’re helping the entire industry learn and shaping the future of primary care,” said Vivek Garg, MD, MBA, President and Chief Executive Officer at NCQA. “We’re grateful to our primary care partners for leaning in as pilot participants and helping advance this work for primary care and patients alike.”

Which Organizations Are Participating in the Pilot Program?

NCQA selected four organizations through a competitive process based on their readiness and ability to lead change in primary care and their dedication to innovation and excellence. We’re pleased to announce our primary care partners:

Aledade

Bluegrass Community Health Center

Jefferson Health

NYC Health + Hospitals

Hear directly from some of the participating organizations about why they chose to join the pilot program and how it will improve care for patients.

“True systemic change in healthcare starts and ends with primary care. Every day, we see how primary care practices transform lives when they are empowered with the right data and a true value-based model. Through this effort we are proud to bring our decade of experience to help shape a quality standard that emphasizes what actually matters for primary care: preventing illness, serving communities, and delivering better care at a lower cost for everyone.”

Farzad Mostashari, MD, Co-Founder and CEO, Aledade

“Bluegrass Community Health Center appreciates the opportunity to collaborate with NCQA on the Advanced Primary Care pilot. As an FQHC, we are committed to models that recognize the depth of our work while remaining practical and sustainable. This pilot is an exciting opportunity to help shape a meaningful, usable program that supports primary care without adding unnecessary burden.”

Brandy Coyle, MBA, BS, RN, Chief Compliance Officer, Bluegrass Community Health Center

“As a large academic health system, Jefferson Health deeply values primary care as foundational to individual, family, community and public health across the many communities we serve. Quality measures shape the daily efforts of our clinical teams, and they articulate the value of primary care’s complex work to stakeholders within and beyond healthcare. We appreciate NCQA’s leadership in bringing on-the-ground voices from diverse organizations to help redefine the nation’s approach to primary care quality metrics.”

Anna Flattau, MD, MS, System Chief for Primary Care and Chair of Family and Community Medicine, Jefferson Health

What’s Involved in the Advanced Primary Care Pilot Program?

The PCMH model demonstrated that primary care practices can mature and deliver better outcomes at lower costs, but they must consistently invest in care delivery, data infrastructure and workforce to keep pace with evolving payment and performance expectations. The Advanced Primary Care Pilot Program will build the next step of primary care’s evolution.

“Today, there is no common definition of what ‘advanced’ primary care truly means, and expectations vary across the industry,” says Jeff Sitko, AVP, Product Management at NCQA. “As primary care takes on growing clinical and financial accountability, clearer shared expectations between plans and practices are essential. Through this pilot, we’re testing these concepts in real-world settings and defining a shared roadmap for how primary care capabilities mature, supporting more integrated, data-driven models that strengthen collaboration, advance behavioral health integration and deliver measurable improvements in outcomes.”

NCQA has developed a preliminary set of standards for primary care organizations. Pilot participants will implement and test these standards within their organizations and help identify what is both valuable and realistic. They will also report on a standardized set of electronic clinical quality measures appropriate for their populations and assess the feasibility of reporting digital quality measures.

At the end of the pilot, the four organizations will be rated on their overall results through a “mock survey” process, and they’ll make recommendations about how NCQA should adjust and evolve the standards and measures in the future.

“We’re excited to bring these organizations into the test kitchen with us to determine what actually matters to them,” says Sitko. “Let’s get rid of the ‘fluff’ so we’re not asking delivery systems to check boxes and perform activities procedurally that don’t actually bring value at the end of the day. And let’s make sure we’re anchored in those areas that positively impact clinical outcomes for patients.”

The ultimate goal is to create a clearer path to integrated, data-driven team-based care that enables primary care to thrive in advanced payment models and strengthens the relationship between payers and primary care.

What’s Next

We’ll share the results of the pilot program later this year, along with details about how NCQA plans to enable the next generation of primary care.

In the meantime, listen to our Quality Matters podcast, What’s New and What’s Next for Primary Care, featuring Jeff Sitko and Karen Johnson, Vice President, Practice Advancement for the American Academy of Family Physicians.

The post NCQA Launches Advanced Primary Care Pilot Program—Meet Our Primary Care Partners! appeared first on NCQA.

Here’s a sample of our most popular self-paced courses. Complete them online any time, at your convenience.

HEDIS 101: Introduction to the Healthcare Effectiveness Data and Information Set

HEDIS is the most widely used system for measuring health care quality in the U.S. In this online, self-paced course, you’ll learn what HEDIS is, why it matters and how you can leverage its insights to drive better outcomes. This course is for quality improvement professionals who are new to HEDIS or want to deepen their understanding.

Introduction to the Digital Quality Transition

This online, self-paced course will provide a foundation in digital quality measurement: why it’s important, and how your organization can make a successful transition. This course is designed for quality and data reporting professionals working in health plans, health systems and technology organizations.

Health Plan Accreditation Survey Year 2026 Updates

This course includes seven self-paced modules covering updates, changes and policy clarifications for the Health Plan Accreditation standards and guidelines. It’s a great resource to help health plans, consultants, policymakers and vendors stay up to date on the latest requirements.

Accreditation in Utilization Management

This course provides a comprehensive explanation of updates and changes to NCQA’s Utilization Management Accreditation, including quality improvement for utilization management, collaboration with delegates, timeliness of decisions and more. NCQA surveyors and staff guide learners through requirement updates and their implications.

NCQA Essentials for Case Management

This course is designed for clinicians and health care professionals who are responsible for case management operations. It covers the fundamentals of case management—from systematic evidence reviews through care transitions—and takes a deep dive into the practical applications of case management, including working with interdisciplinary teams and helping to ensure that patients receive timely and appropriate care.

Introduction to PCMH 2026

This introductory course focuses on the fundamentals of the PCMH Recognition program, including the core elements and how to gather evidence to show compliance. Participants will also learn about policies, processes and procedures that help a practice transform into a medical home.

Advanced PCMH 2026

This advanced course takes a deeper dive into each PCMH concept and explores the characteristics of a successful medical home and the assessment process. It also focuses on advanced topics such as behavioral health integration, electronic clinical quality measures and how to receive automatic credit for certain standards. To get the most from this course, participants should have a working knowledge of the PCMH Recognition program.

Note: Save $395 when you bundle the Introduction to PCMH and Advanced PCMH courses.

Virtual Care Accreditation Essentials for PCMH Practices

This course will help participants from PCMH Recognized practices understand the value of NCQA’s Virtual Primary Care Accreditation, the similarities and differences between PCMH and Virtual Care standards and how to get started. Participants will also hear from a practice that achieved Virtual Care Accreditation.

PCMH Recognition Annual Reporting 2026: Continued Success

Learn about the goals of Annual Reporting and how to prepare for annual submission under PCMH Recognition. This course is designed for individuals working in PCMH practices who have at least one year of experience collecting, reporting and acting on annual reporting data.

Learn More

View our library of NCQA education courses here. To schedule training for a team, please contact us.

The post NCQA Education Courses: Use Your Training Budget Before Year’s End! appeared first on NCQA.

We all know the United States has a primary care crisis. Practices struggle with resource challenges, new technologies and clinician and office staff burnout. Patients can’t access the care they need, when they need it.

If you ask a typical primary care clinician how things are going in their practice, they probably wouldn’t say they are living the dream—but there’s hope. NCQA’s Patient-Centered Medical Home (PCMH) Recognition program helps primary care practices deliver care more efficiently, which allows them to focus time and energy on what matters most: caring for their patients. The goal of the medical home model is to help clinicians practice at the top of their license and to create opportunities for practice staff to share their unique skills and talents.

What Is PCMH Recognition?

PCMH Recognition is the is the most widely adopted medical home evaluation program in the country. More than 10,000 practices and 50,000 clinicians are Recognized by NCQA. Recognition provides a blueprint for strong primary care infrastructure, drives actionable data use and enhances the patient experience.

Recognition program standards are organized in six key areas:

• Team-Based Care and Practice Organization.
• Knowing and Managing Your Patients.
• Patient-Centered Access and Continuity.
• Care Management and Support.
• Care Coordination and Care Transitions.
• Performance Measurement and Quality Improvement.

PCMH is not about checking boxes; it’s about process. If you buy a paintbrush at the hardware store and leave it on a shelf in your garage, it’s of no value to you—but as soon as you dip it in a can of paint, it becomes a tool. Similarly, primary care practices that use PCMH as a tool to restructure their day-to-day operations will realize the benefits.

What Are the Benefits of PCMH Recognition?

Every practice faces different challenges. PCMH provides a set of adaptable organizing principles that help primary care practices:

1. Create an efficient operating structure. PCMH standards help primary care practices organize their workflows to help them prepare for a patient visit ahead of time. It’s like a ‘choose your own adventure’ model where practices decide how they want to implement the standards, based on what works best for them.
2. Build a culture of improvement. PCMH creates a system of accountability that practices can use to improve quality: holding regular meetings, consistently evaluating quality measures and goals, identifying areas that need attention, developing tactics to make changes.
3. Improve patient care. By defining workflows and focusing on continuous improvement, practices have seen notable improvement in patient outcomes. PCMH practices have shown a 9% increase in cervical cancer screenings and a 7% increase in breast cancer and colorectal cancer screenings.
4. Lower costs. Implementing PCMH can help lower costs through better chronic care management, preventive medicine and coordination across care settings and transitions. PCMH practices have demonstrated $482.40 lower per capita spending¹ and $5 million annual savings for 100,000 patients.²
5. Align with value-based contracts. PCMH can make it easier to succeed in value-based care, and establish primary care practices as strong contracting partners for health plans and health systems.

What’s New in PCMH for 2026?

NCQA is investing in primary care by strengthening the PCMH program. We’ve added minimum frequency criteria to define how often practices should engage in key activities, clarified the requirements around measurement and heightened the focus on medication reconciliation and patient safety.

We’ve also added nine optional criteria that align with NCQA’s new Virtual Care Accreditation program: helping ensure that virtual care is appropriate for the patient’s needs, obtaining patient consent to treatment through virtual modalities, assessing the clinician and care team experience, setting goals and actions for improvement. PCMH provides a solid foundation for organizations that want to pursue Virtual Care Accreditation.

Looking to the Future: Advanced Primary Care

NCQA continues to evaluate the PCMH model’s relevance and usefulness for primary care practices, with the goal of focusing on outcomes associated with implementing the standards and sustaining practice transformation. That could mean fewer, more impactful standards that are consistent with a practice’s quality goals. We’re also exploring the role of networks in providing accountability, structure and crucial wraparound services for primary care practices, and how we can acknowledge their contributions.

Advanced Primary Care—the next stage in the life cycle of high-functioning primary care—builds on the vital PCMH foundation, and presents an opportunity to create better alignment between practices and health plans, reduce duplicate activities and clarify shared responsibilities. Care management is one area where health plans and primary care practices should have a shared care plan for high-risk patients—collaborating rather than duplicating efforts. If we can build trust and alignment among organizations, we can produce better outcomes and a more seamless patient experience.

Our customers and partners often express interest in a collaborative learning network where they can share best practices and ideas. This network may take time to build, but we know that the most valuable source of best practices is a primary care office doing the hard work to innovate and improve on the patient experience. We look forward to helping connect advanced primary care offices and creating a space to advance knowledge sharing.

Learn More

• View our webinar, PCMH Recognition: 2025 Updates and Beyond.
• Listen to our podcast, Why ‘Systemness’ Is the Key to Better Quality.
• Get the 2026 PCMH Standards and Guidelines in the NCQA Store.
• Register for our upcoming live course, PCMH Recognition Annual Reporting 2026: Continued Success.

New to PCMH? Contact us today to get started on your PCMH journey.

Fun Fact: The NCQA PCMH Recognition program, launched in 2008, was hailed as a practice model that could change everything: how doctors worked, how information flowed, how patients interacted with providers, how practices were compensated. Seventeen years later, PCMH is still evolving to meet the needs of modern primary care.

¹ Department of Vermont Health Access/Vermont Blueprint for Health.

² Rosenthal MB, et al. (2016). A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot.

The post “Living the Dream” With PCMH Recognition appeared first on NCQA.

WellSpan is an integrated health system with more than 23,000 team members across 13 counties in central Pennsylvania and northern Maryland, delivering high-quality, safe, reliable and equitable care in inpatient and ambulatory settings. Pursuing NCQA Health Outcomes Accreditation was a natural progression for WellSpan—57 of its medical practices have earned Patient-Centered Medical Home Recognition, and its Population Health services have earned Case Management and Utilization Management Accreditation.

“We have a long history of serving the needs of our community and improving access to care for all people,” says Dr. Mike Seim, Senior Vice President and Chief Quality Officer at WellSpan. “Pursuing Health Outcomes Accreditation gave us an opportunity to further refine our processes and identify areas where we had opportunities or could make improvements toward equitable care.”

Getting Leadership Buy-In

Sustained, impactful health equity work requires strong leadership and a willingness to prioritize health equity as a way of doing business, with specific objectives and dedicated resources. Health Outcomes Accreditation was a vehicle for Dr. Seim and WellSpan’s CEO, Dr. Roxanna Gapstur, to drive organizational changes and communicate health equity-focused goals to every part of the organization.

Performing a Gap Analysis

Although WellSpan had a long history with health equity and quality improvement, a gap analysis identified key areas for improvement.

• Data Collection. WellSpan collected data on race, ethnicity and language, but not on sexual orientation and gender identity.
• Process Improvement. WellSpan had experience providing culturally and linguistically appropriate services, but wanted to make its health equity practices more structured and sustainable.
• Patient Experience. WellSpan collected data on patient experience, but hadn’t reviewed the data through a health equity lens.

“The gap analysis was enlightening and really helped shape our equity initiatives moving forward,” says Ann Kunkel, VP Community Health, Home Care and Hospice. “The Accreditation process created a framework for us to align our processes with established standards and best practices.”

Navigating the Survey Process

Organizing the information and managing the survey process is a significant undertaking that requires a team approach. Although WellSpan does not have a dedicated “health equity team,” it was able to leverage multidisciplinary collaboration across departments, such as Quality, Community Health and Engagement and Diversity, Equity and Inclusion. Each leader identified individuals from their team to join the project.

“We were able to harness the passion and dedication of our employees to prepare for the survey,” says Holly Wolfe, Senior Director of Quality. “The team’s strong analytic capabilities and prior experience working with CMS and state regulators were essential for our success.”

WellSpan established a Health Equity Steering Committee that reports to the Board of Directors. Dr. Seim provided executive oversight, and the team leaned heavily on the expertise of key departments—Community Health and Engagement, Language Services and Quality Management. The presence of an effective project manager helped organize meetings and ensure the right participants were engaged.

Improving Organizational Performance

Accreditation provided a framework for WellSpan to refine existing processes and accelerate change in the organization.

• Create Alignment. The Accreditation standards helped demonstrate how each part of WellSpan’s operations contributes to its goals of improving patients’ health, access to care and overall experience.
• Encourage a Proactive Approach. The Health Outcomes Accreditation empowered WellSpan to be proactive and intentional about identifying and selecting its focus areas—a capability it’s using to tune in to the unique needs of diverse populations.
• Improve Employee Engagement. The Accreditation allowed WellSpan to increase employee engagement by cultivating a culture of equity where staff view themselves as allies to their patients and to each other.

WellSpan’s Health Outcomes Accreditation has also been a springboard for public speaking engagements and recognition of its commitment to quality and equity, including winning the American Hospital Association’s Quest for Quality Prize in 2024.

Reducing Health Disparities

Pursuing Health Outcomes Accreditation propelled WellSpan’s efforts to reduce disparities in care and embed health equity goals in all aspects of care delivery—for example, its project focused on closing the disparity gap in breast cancer screening and colorectal cancer screening. By creating new variables for race, population of color and language, WellSpan was able to identify disparities, implement culturally and linguistically appropriate outreach and address patients’ social drivers of health.

These efforts led to positive improvements in health outcomes and projected life expectancy for people of color.

• Breast cancer screening rates for people of color improved by 6.31% from MY 2022 to MY 2023, preventing an estimated 15 breast cancer deaths and adding 215 years of life.
• Colon cancer screening rates improved by 8.73% for people of color from MY 2022 to MY 2023, preventing an estimated 360 colorectal cancer deaths and adding 4,053 years of life.

“One of the benefits of NCQA’s Health Outcomes Accreditation is our ability to measure progress objectively,” says Dr. Seim. “We have the data to identify disparities in health outcomes and track our progress in closing the gaps—and that leads to more equitable care for all patients.”

Learn More

• Visit our website to learn more about NCQA’s Health Outcomes Accreditation.
• Take an online course: Multi-Cultural Resources and Tools to Engage Members and Communities.

The post Success Story: WellSpan’s Health Outcomes Accreditation Experience appeared first on NCQA.

The NCQA Education Department offers five webinars about antibiotics stewardship on-demand for free through December 2023.

Each course is approved for a maximum of 1.0 AMA PRA Category 1 Credit™, ANCC, and ACPE credits.

Each live course also grants 1 continuing education credit for PCMH Certified Content Experts.

About the Webinars

Antibiotic resistance caused by inappropriate use of antibiotics is a serious problem we discuss often.

Smart antibiotic stewardship improves how clinicians prescribe antibiotics and how patients use them.

Last summer, with support from the Pew Charitable Trusts, NCQA hosted five webinars to give health plans and practices new tools to fight antibiotic resistance.

Take Your Pick

Click the links below to register and take as many courses as you want.

Need help or have questions? Email our antibiotics education lead.

• Defining Antibiotic Stewardship and Reviewing Associated HEDIS^® Measures

Colleagues at NCQA discuss HEDIS measures that assess antibiotic prescribing for three conditions that drive inappropriate prescribing.

• What’s New in the World of Antibiotic Stewardship? Part One: Using Performance Measures in Practice to Drive Change

Learn about NCQA’s new HEDIS antibiotic measure. Then learn how a high performing organization monitors antibiotic utilization.

•  What’s New in the World of Antibiotic Stewardship? Part Two – Impacts of COVID and Use of Telehealth

CDC Medical Officer Sharon Tsay discusses current research on antibiotic stewardship. Learn how the pandemic and telehealth trends may impact antibiotic prescribing.

• Addressing the Social and Behavioral Drivers of Prescribing: Innovative Approaches to Antibiotic Stewardship 

Learn how social and behavioral factors affect antibiotic stewardship. Speakers highlight practical, evidence based strategies that address these factors.

• Panel Discussion: How Health Plans Approach Antibiotic Stewardship and HEDIS Antibiotic Measures

Hear a summary of health plans’ Measurement Year 2020 performance on HEDIS antibiotic measures. Then, high-performing health plans share best practices and lessons from the field.

The post Get Continuing Education Credits for FREE appeared first on NCQA.

The PCMH CCE Quality Awards recognizes outstanding Certified Content Expert, or CCEs, who have been nominated for their work supporting practices with transformation and maintenance of PCMH Recognition. Each year NCQA puts out a call for nominations asking Recognized practices and PCMH stakeholders to nominate CCEs who they feel are working at the top of the field.

Denean Anderson, PCMH CCE
Patient Advocate of Capital Area Health Network in Richmond, VA
“Denean wears multiple hats and is a key player in helping us achieve our goals and serve our community. Her willingness to take on difficult projects like the PCMH Committee has led our organization to successfully achieve and maintain our PCMH Recognition across our multi-sites!”

Susanne Campbell, RN, MS, PCMH CCE
Senior Program Administrator of Care Transformation Collaborative of Rhode Island
“Susanne has led the statewide effort to transform adult and pediatric practices to the PCMH model of care and to assist practices in achieving their NCQA recognition. With 184 practices currently recognized as a patient-centered medical home, Rhode Island has one of the highest per capita rates of practices with NCQA recognition.”

The Criteria

Awardees met the following criteria:

1. Significant contributions toward practice transformation resulting in achieving NCQA PCMH Recognition.
2. In-depth knowledge, experience and performance with NCQA PCMH program standards, guidelines, documentation and the Recognition process.
3. Being an organized, goal-oriented, team player, coach and advocate with a positive attitude.

Nominate Your CCE

Nominate your PCMH CCE for the 2023–2024 awards today! Nominees must hold an active NCQA certification. Deadline for nominations is July 31.

Nominations require the following information:

• Your organization and contact information.
• The CCE’s contact information.
• A brief description of your organization or practice’s characteristics (e.g., single or multi-site, private, hospital based, population served, location).
• Number of practices and/or submissions the CCE has supported.
• A brief description of the CCE’s accomplishments and contributions and why you are nominating them; for example, initiatives, projects or systems the CCE implemented that had a significant impact on your patients or organization.

Learn More About PCMH CCE

The post 2022-2023 PCMH CCE Quality Award Winners! appeared first on NCQA.

Diabetes is prevalent in 10% of U.S. adults (34 million people) and is a leading cause of chronic kidney disease (CKD). African American, Hispanic and American Indian patients are disproportionately at high risk for kidney disease, in part due to higher rates of diabetes in these communities.

Even though chronic kidney disease leads to progressive loss of kidney function, people suffering from the condition often don’t feel symptoms until the late stages of the disease.  Nine of every 10 adults with CKD are unaware they have it. And it has repercussions beyond kidneys. CKD increases the risks of heart disease, stroke and early death, in addition to kidney failure.  Early diagnosis and treatment can prevent or at least slow chronic kidney disease. That’s why ongoing monitoring of kidney health is crucial for people with diabetes.

Clinical practice guidelines from the American Diabetes Association and the National Kidney Foundation (NKF) recommend screening patients with diabetes for kidney disease every year using estimated Glomerular Filtration Rate (eGFR) and urine Albumin-to-Creatinine Ratio (uACR).

Two Tests Assess Kidney Health

Kidney damage is assessed using uACR based on a spot urine sample, recommended by guidelines because it is unaffected by variation in urine concentration. Other tests for albumin, such as a dipstick, are not recommended because they are less

sensitive and do not detect lower uACR levels.

Kidney function is assessed using eGFR based on the patient’s serum creatinine level, age, sex and race, but clinicians are currently reevaluating the use of race in calculating kidney function. The NKF-ASN (American Society of Nephrology) Task Force on Reassessing the Use of Race in Diagnosing Kidney Disease is working toward a national solution to eGFR reporting (a final report is expected in 2021). ,

Together, these two tests provide key information regarding kidney health, including determining the stage of CKD and the risk of progression.  So,  laboratories collaborated to create a standardized Kidney Profile that bundles these components in one request. Elevated uACR is often the earliest sign of CKD. Rising uACR (≥30 mg/day) detection occurs about 10 years before a detectable decline in eGFR and thus is an early indicator of kidney disease in patients with diabetes.

Two Tests, One Lab Request, One Performance Measure

Evidence shows that contrary to clinical guidance, fewer than half of people with diabetes receive an annual kidney assessment that includes both eGFR and uACR. Kidney Health Evaluation for Patients With Diabetes (KED) addresses this gap. KED is a new HEDIS® measure in its first year of implementation, with public reporting of results expected in 2022. The Centers for Medicare & Medicaid Services will report KED on its display page for 2022 Star Ratings and will consider adding it to Star Ratings in the future.

Test results are used to diagnose and code a patients’ CKD stage and are often secondary to a code for the underlying cause, such as diabetes or hypertension. Test results can also be used to educate patients about kidney disease and the elevated risk for those with diabetes. Educational resources to support conversations, including videos addressing the risk of kidney disease and handouts explaining kidney test results, are available from the National Institute of Diabetes and Digestive and Kidney Diseases.

So, regular monitoring of kidney health is clearly an identified priority.

The Resource

Primary care practices specifically play a key role in treating kidney disease through managing risk factors such as hypertension or hyperglycemia, prescribing medications and encouraging a healthy lifestyle. Primary care clinicians also play a pivotal role in determining when to refer to a specialist. So, NCQA, with the financial support of Bayer Healthcare Pharmaceutical, Inc.B, has composed a toolkit to help you navigate and sustain this new recommended approach. It includes a heat map that will help you analyze test results and provide benchmarks for additional tests or a referral to a nephrologist.

But the key is to start with regular testing, and then to use results to better advise and educate your patients.

Download the toolkit now.

The post Diabetes and Kidney Health: A Toolkit for Clinicians appeared first on NCQA.

Kidney disease affects 37 million American adults, but 90% are unaware they even have it. NCQA and The National Kidney Foundation (NKF) hope to change that with a new Kidney Health Evaluation for Patients with Diabetes they developed together. The new HEDIS measure will improve kidney disease testing in people with diabetes which is a key risk factor for developing kidney disease.

Kidney Health: The Measure

Clinical guidelines recommend people with diabetes should be routinely tested to detect kidney disease. While the tests associated with kidney disease detection and diagnosis are inexpensive and widely available for routine clinic visits, fewer than 50% of people with diabetes get both tests. The new Kidney Health Evaluation HEDIS Measure reveals these gaps in care for clinicians, healthcare leadership and health plan executives.

“For almost two years, NKF has been working in partnership with NCQA to advance the development of the Kidney Health Evaluation measure,” said Joseph Vassalotti, MD, Chief Medical Officer, NKF. “The inclusion of the new measure in the HEDIS Measurement Year 2020 & Measurement Year 2021 publication is a giant step towards engaging the nation’s health plans, integrated health networks, and individual primary care practitioners to improve the diagnosis of kidney disease.”

The new measure tracks the percentage of adults with diabetes (age 18-85) who received an annual kidney health evaluation, including both an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR). The NKF-developed Kidney Profile is one way to amplify testing that combines the eGFR, which assesses kidney function, with the uACR, which assesses kidney damage. Results of the Kidney Profile provide health plans, physicians and patients with the critical information they need to identify chronic kidney disease (CKD) and develop a treatment plan which may include additional testing, lifestyle changes, medicine, and a referral to a nephrologist for further evaluation.

“We value this successful collaboration with the National Kidney Foundation, especially the new measure we’ve crafted together. Its inclusion only strengthens the HEDIS mission to improve care for all patients, but especially those who live with diabetes and kidney disease,” said Dr. Mary Barton, Vice President, Performance Measurement, NCQA. “We know measures work, in terms of accountability. They give health plans and providers a focal point for improvement. This measure will ultimately lead to better care and improved kidney health across the country.”

Measure Development

The development of the Kidney Health Evaluation HEDIS measure was the result of a large multidisciplinary, multi-stakeholder technical expert panel (TEP) drawing on expertise from governmental, private practice, and health care organization representatives. The TEP was comprised of kidney patients, clinical experts in kidney disease, diabetes, and public health, primary care professionals, researchers, and medical informaticists who contributed to the measure design. The development of the measure was also supported by several NCQA Measurement Advisory Panels including those focused on diabetes, geriatrics and the technical implications of HEDIS.

“Kidney disease is under-diagnosed in primary care with as many as 90% of people unaware they even have the disease. This includes as many as 50% of people with advanced kidney disease who may ultimately require dialysis or a transplant to survive,” added Dr. Vassalotti.  “Because kidney disease is asymptomatic in its earliest stages, routine testing among those at the highest risk for developing the disease is the only way to diagnose it early and help stave off its life-threatening complications. “

Representatives of several important stakeholder groups participated in the development of this measure including the American Diabetes Association, American Medical Group Association, Centers for Disease Control and Prevention, Indian Health Service and the National Institute of Diabetes and Digestive and Kidney Diseases.

Practices and plans, we want to hear from you. What are you doing to improve your patients’/members’ kidney health? Will this measure improve your performance?  Please, weigh in. The comment section is below.

About HEDIS Measures

The Healthcare Effectiveness Data and Information Set (HEDIS) is one of health care’s most widely used performance improvement tools. Approximately 191 million people are enrolled in plans that report HEDIS results. HEDIS includes more than 90 measures across 6 domains of care: effectiveness of care, access/availability of care, experience of care, utilization and risk-adjusted utilization, health plan descriptive information, measures collected using electronic clinical data systems. For more information visit ncqa.org.

About Kidney Disease

In the United States, 37 million adults are estimated to have chronic kidney disease—and more than 90 percent unaware of it.  1 in 3 American adults are at risk for chronic kidney disease.  Risk factors for kidney disease include diabetes, high blood pressure, heart disease, obesity and family history. People of African American, Hispanic, Native American, Asian or Pacific Islander descent are at increased risk for developing the disease. African Americans are 3 times more likely than Whites, and Hispanics are nearly 1.5 times more likely than non-Hispanics to develop end-stage renal disease (kidney failure).

About the National Kidney Foundation

The National Kidney Foundation (NKF) is the largest, most comprehensive, and longstanding patient-centric organization dedicated to the awareness, prevention, and treatment of kidney disease in the U.S. For more information about NKF, visit www.kidney.org.

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