PCMH Policies and Procedure Documents

Following are examples of policies and procedures (P&Ps) used by Region VIII CHCs to adopt practices that adhere to Patient-Centered Medical Home (PCMH) principles.  Each P&P is presented in a different format.  It is recommended that CHCs adopt a specific P&P format as well as an adoption, sign-off, and review process for their PCMH P&Ps.


Admission and Scheduling
Community Collaboration
Emergency Transfer of Patients
Making Internal and External Referrals

NMPCA Required Policy Listing and Policy Templates
The listing of policies that may be required of a health center by HRSA, FTCA, state or federal laws, PCMH standards, etc., was developed and kindly shared by the New Mexico Primary Care Association (NMPCA).  The listing is followed by ten policy templates that NMPCA developed in response to requests from the health centers in their state.


Below are examples of documentation submitted by two Colorado CHCs which received National Committee for Quality Assurance (NCQA), Level 3, PCMH recognition under the 2008 PPC-PCMH (Physician Practice Connection®–Patient-Centered Medical Home™) program.
The documents labeled CHC A below were prepared by Clinica Family Health Services, with five sites in the Denver/Boulder area.
The documents labeled CHC B below were prepared by High Plains Community Health Center, with five sites in northest Colorado.

Congratulations to both Clinica Family Health Services and High Plains Community Health Center for achieving the highest level of NCQA PCMH recognition!  We greatly appreciate the tremendous work of these two CHCs as well as their willingness to share their documentation and spread their best practices to other CHCs.  We also want to thank Colorado Community Health Network (CCHN) for the training and technical assistance (T/TA) they provided to these CHCs and continue to provide to other Colorado CHCs applying for PCMH recognition.

Although NCQA developed new standards in 2011, many of the standards in the 2008 application continue to be required in the 2011 application.  The documentation provided below is also useful as a review of best practices developed by CHCs who have become a recognized PCMH.

All identifying information has been removed from these documents.  The submitting CHCs blocked-out all patient-identifying information before submitting the documentation to NCQA.  CHAMPS blocked out all CHC- and provider-identifying information before posting the documents to this webpage.

The following documents are organized under each Standard/Element of the NCQA 2008 PPC-PCMH recognition program:

PPC 1: Access and Communication

Element A: Access and Communication Processes
CHC A (PPC 1, Element A document)
CHC B (PPC 1, Element A document)

Element B: Access and Communication Results
CHC A (PPC 1, Element B document)
CHC B (PPC 1, Element B document)

PPC 2: Patient Tracking and Registry Functions

Element A: Basic System for Managing Patient Data
CHC A (PPC 2, Element A document)
CHC B (PPC 2, Element A document)

Element B: Electronic System for Clinical Data
CHC A (PPC 2, Element B document)
CHC B (PPC 2, Element B document)

Element C: Use of Electronic Clinical Data
(there is no available documentation for this Element)

Element D: Organizing Clinical Data
CHC B (PPC 2, Element D document)

Element E: Identifying Important Conditions
CHC A (PPC 2, Element E document)
CHC B (PPC 2, Element E document)

Element F: Use of System for Population Management
CHC A (PPC 2, Element F document)
CHC B (PPC 2, Element F document)

PPC 3: Care Management

Element A: Guidelines for Important Conditions
CHC A (PPC 3, Element A document)
(PPC 3, Element A document)

Element B: Preventive Service Clinician Reminders
CHC A (PPC 3, Element B document)
(PPC 3, Element B document)

Element C: Practice Organization
CHC A (PPC 3, Element C document)
(PPC 3, Element C document)

Element D: Care Management for Important Conditions
(there is no available documentation for this Element)

Element E: Continuity of Care
CHC A (PPC 3, Element E document)
CHC B (PPC 3, Element E document)

PPC 4: Patient Self-Management Support

Element A: Documenting Communication Needs
CHC A (PPC 4, Element A document)
CHC B (PPC 4, Element A document)

Element B: Self-Management Support
(there is no available documentation for this Element)

PPC 5: Electronic Prescribing

Element A: Electronic Prescribing Writing
CHC A (PPC 5, Element A document)
CHC B (PPC 5, Element A document)

Element B: Prescribing Decision Support-Safety
CHC A (PPC 5, Element B document)
CHC B (PPC 5, Element B document)

Element C: Prescribing Decision Support-Efficiency
CHC A (PPC 5, Element C document)
CHC B (PPC 5, Element C document)

PPC 6: Test Tracking

Element A: Test Tracking and Follow-Up
CHC A (PPC 6, Element A document)
CHC B (PPC 6, Element A document)

Element B: Electronic System for Managing Tests
CHC A (PPC 6, Element B document)
CHC B (PPC 6, Element B document)

PPC 7: Referral Tracking

Element A: Referral Tracking
CHC A (PPC 7, Element A document)
CHC B (PPC 7, Element A document)

PPC 8: Performance Reporting and Improvement

Element A: Measures of Performance
CHC A (PPC 8, Element A document)
CHC B (PPC 8, Element A document)

Element B: Patient Experience Data
CHC A (PPC 8, Element B document)
CHC B (PPC 8, Element B document)

Element C: Reporting to Physicians
CHC A (PPC 8, Element C document)
CHC B (PPC 8, Element C document)

Element D: Setting Goals and Taking Action
CHC A (PPC 8, Element D document)
CHC B (PPC 8, Element D document)

Element E: Reporting Standardized Measures
CHC A (PPC 8, Element E document)
CHC B (PPC 8, Element E document)

Element F: Electronic Reporting-External Entities
CHC B (PPC 8, Element F document)

PPC 9: Advanced Electronic Communication

Element A: Availabillity of Interactive Web Site
CHC B (PPC 9, Element A document)

Element B: Electronic Patient Identification
CHC A (PPC 9, Element B document)

Element C: Electronic Care Management Support
CHC A (PPC 9, Element C document)

Please click here to access the CHAMPS main PCMH Information and Resources webpage.