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Health Care

What is PCMH Recognition and Why Does it Matter?

December 6, 2018
What is PCMH Recognition and Why Does it Matter?

Written By: GHC-SCW Chief Medical Officer, Chris Kastman, MD

You may have heard that all GHC-SCW primary care clinics recently earned PCMH Recognition from the National Committee of Quality Assurance (NCQA) but what does that exactly mean and why does it matter?

PCMH Recognition is an award from NCQA that providers and practices can earn when they exhibit evidence-based and patient-centered processes that focus on highly coordinated care and foster ongoing partnerships between patients and their providers. GHC-SCW’s long-standing commitment to improving the quality of care and patient experience while striving to reduce healthcare costs is foundational to PCMH Recognition. Since the organization’s inception, GHC-SCW clinics have employed patient-centered care and initiatives but this award allows us to solidify and celebrate all that we do!

A medical home ensures that the patient is well supported throughout their healthcare journey. This helps diminish fragmentation in care delivery to improve outcomes. GHC-SCW Primary Care Teams which are composed of primary care providers (PCP) and nursing staff who work together to close gaps and coordinate patient care. These teams are further strengthened by Primary Care Behavioral Health experts, Clinical Pharmacists, Nurse Triage, Community Care, Reception and Call Center staff and many others who rally around members who need them. For example, when a patient gets discharged from the hospital, GHC-SCW Care Teams proactively call patients to ensure that they understand the instructions related to their care. They also remind each patient that they are available for ongoing support and are a resource if questions or concerns arise.

Other examples of patient-centered medical home processes at GHC-SCW include:

  • A monitoring report was developed to help ensure that high-risk patients who have a consult visit scheduled with a specialist have been seen in an appropriate timeframe. If the patient has not been seen at the time that their consult was scheduled for, Case Managers and Care Teams can conduct follow-up with a patient to assess if there are barriers to care (such as transportation issues) or concerns that can be addressed.
  • An Asthma Action Plan is a self-management tool that can help patients with asthma stay well. GHC-SCW’s Asthma Educator works with patients to develop plans which show what kinds of medicine to take and when. An action plan also helps patients understand how to handle worsening symptoms, including what to do if they have an asthma attack.

Because of efforts to help patients better manage their conditions and improved coordination during transitions of care, health outcomes improve while simultaneously reducing costs. In fact, research has shown that patient centered medical homes can help reduce emergency room visits and hospital admissions1. Additional research has shown that patients who experience the PCMH model of care value the increased access to healthcare and ease of communication with their provider2.


1)            Harbrecht, M, Latts, L. (2012). Colorado’s Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such as Reduced Hospital Admissions. Health Affairs.

2)            Lydie A. Lebrun-Harris, Leiyu Shi, Jinsheng Zhu, Matthew T. Burke, Alek Sripipatana, and Quyen Ngo-Metzger. (2013). Effects of Patient-Centered Medical Home Attributes on Patients’ Perceptions of Quality in Federally Supported Health Centers. Annals of Family Medicine.