Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (As Developed Under the NYS Health Innovation Plan (SHIP) (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 integration of primary, specialty, behavioral and social care services.

Patient Population

Total population.


      • Project Requirements Milestones and Metrics
      • Summary
      • 2016 Requirements for EHR Incentive Programs: Eligible Professionals
      • Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings, reference guide from the NYS DOH and OMH.
      • Email Encryption – Regular email transmits information in an electronic and unprotected form. Once the message is sent, it is communicated over the internet in an unencrypted fashion. AHI requires the use of email encryption for transmission of protected health information (PHI). PHI should never be transmitted unencrypted and not through regular email. Barracuda is an email encryption service. Email encryption is used to protect the content from being read by entities other than the intended recipients.  Read the Step by Step Barracuda Guide for activation instructions.
      • Care Coordination Quality Measure for Primary Care (CCQM-PC) is a survey of adult patients’ experiences with care coordination in primary care settings.
      • The Evidence-Based Practices (EBP) Web Guide features research findings and details about EBPs used to prevent and treat mental and substance use disorders. EBPs integrate clinical expertise; expert opinion; external scientific evidence; and client, patient, and caregiver perspectives so that providers can offer high-quality services that reflect the interests, values, needs, and choices of the individuals served.
      • Measures That Matter, from HANYS. The Measures That Matter report details the chaotic state of health care reporting and measurement, provides a clear call to action, and vision for the future of quality measurement where stakeholders use a common set of valid, reliable, and evidence-based measures to improve outcomes across the continuum of care.
      • The PCDC PCMH Financial Sustainability Toolkit is intended to give primary care practices and health centers that have been recognized as NCQA Patient Centered Medical Homes (PCMH) for at least six months, information on how well they are sustaining their PCMH activities. Sustainability is looked at across three different areas: process, performance, and outcomes.
      • Prevention Agenda 2013-2018: New York State’s Health Improvement Plan – The blueprint for state and local action to improve the health of New Yorkers in five priority areas and to reduce health disparities for racial, ethnic, disability, and low socioeconomic groups, as well as other populations who experience them.

AHI Support

National Committee for Quality Assurance (NCQA) Recognition

PCMH 2014 Documentation Checklists

PCMH 2017 Redesign

The National Committee for Quality Assurance (NCQA) is overhauling the PCMH Recognition process beginning in 2017, with the goal of strengthening the link between Recognition and practice performance. NCQA plans to provide more support, reduce unnecessary paperwork, leverage health information technology and align PCMH activities with reporting requirements for other initiatives.

New York State’s Advanced Primary Care Model

Physician Champion


    • ACP Pediatric to Adult Care Transitions Toolkit
    • Adolescent Immunization Rates
    • 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 enables 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
    • Community Connections – Obesity/Pre-Diabetes Toolkit
    • Diabetes Prevention
    • Health Disparities
    • Health Extension
      • Health Extension is a method of helping communities and the primary care practices that serve them, to overcome barriers to transformation by sharing common resources. The program is built on the agricultural Cooperative Extension Service model which was successful in the transformation of rural America through the modernization of agriculture. The Health Extension Toolkit is designed to assist practices in adopting transformational learning relevant to their own objectives.
    • High Value Care Coordination
    • 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.
    • Multiple Chronic Conditions Education and Training
      • Persons living with multiple chronic conditions (PLWMCC) experience unique challenges because their health care is more complex and costly than that of persons living with one chronic disease. The U.S. Department of Health and Human Services offers HHS Education and Training Curriculum on Multiple Chronic Conditions that includes tools and information to health care professionals who deliver care to PLWMCC.
    • NCQA Recognition Training
      • NCQA Recognition Programs holds monthly customer education sessions for Patient Centered Medical Home recognition. AHI PPS primary care practices are invited to attend audio (telephone) conference workshops or WebEx training sessions that combine audio and Internet-accessible video presentations.
    • Patient- and Family-Centered Care
      • Patient- and family-centered care is an approach to the planning, delivery and evaluation of health care that is grounded in mutually-beneficial relationships among patients, families and health care professionals. The Institute for Patient- and Family-Centered Care has a number of resources available to assist practices in establishing Patient and Family Advisory Councils, including the Advancing the Practice of Patient- and Family-Centered Care in Primary Care’s “How to Get Started” manual.
    • Patient-Centered Medical Home-Advanced Primary Care
    • Patient Engagement
      • The Center for Patient Partnerships, UW Health, Primary Care Academics Transforming Healthcare and the UW Health Innovation Program have developed the Patient Engagement in Redesigning Care Toolkit for hospital and clinic directors, managers, clinicians and researchers who are interested in a framework and tools for engaging patients as partners in health system quality improvement and change initiatives.
    • Pharmacy Toolkit
      • As part of a patient’s health care team, pharmacists can improve health outcomes by increasing medication adherence, optimizing medication regimens, managing chronic diseases and providing patient planning, education and counseling. The Clinical Pharmacy Resource Toolkit from the University of Colorado provides sample agreements and resources helpful for health systems interested in integrating clinical pharmacists into the care team.
    • Physician Toolkit
      • Gold STAMP Educational Resources – In partnership with the New York State Department of Health, the University at Albany School of Public Health’s Center for Public Health Continuing Education has developed a Physician Toolkit to provide resources and information to further engage physicians in the prevention and treatment of pressure ulcers.
    • Population Health Management
    • Practice Transformation: STEPS Forward
      • The American Medical Association offers practice transformation resources to the physicians of New York through a series of toolkits on the STEPS Forward™ website. The site offers more than 25 free educational modules covering practice transformation topics that range from operations to team building to alternative payment models. These modules are authored by practicing physicians. There is also free continuing medical education (CME) available after the modules. Once you have completed a module as well as the post-test to receive CME credit, the AMA will track the completion of your CME credits for you.
    • Primary Care Imperative
    • Primary Care Providers Working in Mental Health Settings
      • Primary Care Providers Working in Mental Health Settings is a five-part curriculum that can be used to inform primary care professionals working in public mental health settings about the unique aspects of behavioral health settings, the people they serve, as well as the opportunities and roles that primary care professionals play in helping to improve the whole health of individuals with serious mental illnesses.
    • Primary Care Workforce
    • Rural Health Services
      • Rural Services Integration Toolkit – identifies evidence-based models and resources that will benefit rural communities seeking to implement service integration programs.
    • 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.
    • Self-Management Support – Brief Action Planning
      • Brief Action Planning is a structured, stepped-care, self-management support technique grounded in the principles and practice of Motivational Interviewing and behavior change theory and research. It is a way of interacting with patients interested in making a concrete action plan to improve some aspect of their health.
    • 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 states: 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.
    • Third Next Available Appointment
    • Toolbox for Transformation to the Patient Centered Medical Home (PCMH)
      • Toolbox for Transformation to the PCMH – NCQA, together with Eli Lilly and Company, offers a series of educational activities titled A Toolbox for Transformation to the Patient-Centered Medical Home. These recorded activities are directed to primary care physicians and staff on the conceptual framework of the Patient-Centered Medical Home. The underlying principles include: the joint principles of PCMH, lessons learned from PCMH change champions, quality resources for developing your PCMH project plan, and maximizing data/information systems to improve patient care.


Meeting Materials

Meeting Date Meeting Overview