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Patient Centered Medical Home (PCMH) Certification (2.a.ii)

Clear the Air in the Southern Adirondacks (CASA)

Patient Centered Medical Home (PCMH) Certification (2.a.ii)

Project Objective

To transform all safety net providers in primary care practices into NCQA 2014 Level 3 Patient-Centered Medical Homes (PCMHs) or Advanced Primary Care (APC) Models.

Project Details

A key component of health care transformation is the provision of high-quality primary care for all Medicaid recipients, and uninsured, including children and high-needs patients. This project will address those providers who are not otherwise eligible for the necessary support or resources for practice advancement as well as those providers with multiple sites that wish to undergo a rapid transformation by achieving NCQA 2014 Level 3 Patient-Centered Medical Homes (PCMHs) or Advanced Primary Care Models by the end of Demonstration Year 3 (DY 3). Performing Provider Systems undertaking this project, while focused on the full range of attributed Medicaid recipients and uninsured, should place special focus on ensuring children and parenting adults, and other high-needs populations have access to high-quality care, including the integration of primary, specialty, behavioral and social care services.

Patient Population

Total population.


New York State’s Advanced Primary Care Model

Physician Champion


    • AHRQ Health Literacy Universal Precautions Toolkit
      • The Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
    • Alternative Payment Models in the Rural Setting
      • As part of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services’ Innovation Center was established to develop and test payment and service delivery models, focused on moving from volume-based payment (such as fee-for-service) to value-based payment. This webinar, Alternative Payment Models: Are You Ready?, sponsored by the American Academy of Pediatrics, offers strategies to assist smaller/rural practices in adapting to the change to value-based methods.
    • American College of Preventive Medicine Adolescent Wellness Exam
    • Behavioral Health Integration
      • AHRQ Behavioral Health Integration Playbook – Integrated primary care (or integrated ambulatory care) is an emerging approach for improving health care delivery in order to achieve better patient health outcomes. This Playbook aims to address the growing need for guidance as greater numbers of primary care practices and health systems begin to design and implement integrated behavioral health services.
    • Behavioral Health Screening
      • Behavioral health screenings, primary care, and other health care settings enable earlier identification of mental health and substance use disorders, which translates into earlier care. The SAMSHA-HRSA Center for Integrated Health website offers resources and tools for behavioral health screening.
    • CDC Health Literacy Training
    • LGBT-Friendly Practices
      • The goal of Creating an LGBT-Friendly Practice activity is to help providers and staff gain knowledge and competency in delivering LGBT-friendly care, which may result in improved access and reduced health disparities in the LGBT community.
    • Patient-Centered Medical Home-Advanced Primary Care
    • SBIRT (Screening, Brief Intervention, Referral to Treatment)
      • SBIRT is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels with the goal of reducing and preventing related health consequences, disease, accidents, and injuries. The Office of Alcoholism and Substance Abuse Services (OASAS) website includes comprehensive information about the use of SBIRT, links to training materials, including an SBIRT online Core Training Program, screening instruments, educational videos, and other resource materials.
    • Strategies for Success as a Patient-Centered Medical Home
      • NCQA offers complimentary online CME/CE learning activities to help lead to more effective communication and better patient outcomes. These 30-minute learning activities focus on a team-based approach to the most recent evidence-based approaches to screening, treatment and referral in primary care for disease state: depression, diabetes, dyslipidemia, hepatitis C virus, and obesity. To access the learning activities, visit the complimentary online portal. Log in or create your own account using your email address. Go to “My Apps” in the “Strategies for Success as a PCMH” panel and click “Begin.” Enter the invitation code – PursuePCMH – when prompted. Follow the on-screen instructions.
    • The SHARE Approach
      • AHRQ’s SHARE Approach is a five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.
    • TeamSTEPPS®: Strategies and Tools to Enhance Performance and Patient Safety
      • TeamSTEPPS® is an evidence-based teamwork system aimed at optimizing patient care by improving communication and teamwork skills among health care professionals, including frontline staff. It includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into a variety of settings.


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