With the January 1, 2027 implementation date for National Committee for Quality Assurance’s (NCQA) updated Patient-Centered Medical Home (PCMH) Standards and Guidelines quickly approaching, many primary care practices are asking the same question: Where do we start?

While understanding the new requirements is important, successfully adopting them requires more than simply updating documentation. The practice that will thrive under the new standards are the ones that begin evaluating workflows, engaging staff, and strengthening care coordination processes ahead of the Jan. 1, 2027 implementation date.

Mastery of the new requirements will require not only updating processes and reevaluating workflows centered around team-based care, coordinated patient tracking and continuous quality improvements mapped to NCQA standards, but also assessing how staff can be more engaged and empowering them to be engaged, as well as fostering operational cohesiveness and strengthening care coordination processes. After all, your staff are your core assets, and they are essential to timely and patient-centered care delivery.

Early planning and preparation can improve operational efficiencies and cohesiveness, improve patient outcomes, and position your practice for a successful PCMH Recognition or Renewal process which is built on evidence-based processes.

1. Evaluate Your Current Care Management Process

The care management requirements place greater emphasis on identifying and supporting high-risk patients through structured interventions and ongoing monitoring. Now is the time to assess:

• How high-risk patients are identified
• Whether risk stratification processes are consistently applied
• How care management activities are documented
• Whether follow-up and outreach activities are tracked and measurable
• Review new standards to better understand your current processes as you evaluate gaps and opportunities

Practices should review existing workflows to determine whether they can demonstrate consistent management activities across the patient population.

Ask yourself and your team: Can we clearly show how our team identifies, engages, and monitors patients with complex healthcare needs?

2. Strengthen Your Care Planning Process

The addition of SMART goals represents a significant shift toward more measurable and patient-focused care plans. To prepare, practices should ensure care plans include:

• Specific health objectives
• Measurable outcomes
• Alignment with patient priorities
• Realistic and achievable goals
• Timeframes for evaluation

We encourage patients to be active partners in developing these goals. Collaborative care planning helps increase patient engagement while aligning with patients’ priorities and providing evidence that care is truly patient-centered.

Organizations may also need to train clinicians, nurses, and care managers in creating consistent care plans that meet the updated standards. Utilization of robust, EMR-created care plan templates will provide the foundation for consistent care. If you don’t have a template, consider consulting with your Electronic Medical Record vendor on capabilities to provide such tools.

3. Review Access and Communication Workflows

Patient access continues to be a cornerstone of PCMH Recognition. Under the updated standards, practices must demonstrate same-day access, timely communication, and continuity with the patient’s care team. Consider evaluating:

• Same-day appointment availability
• Telephone response procedures
• Patient portal messaging turnaround times
• Scheduling practices that support continuity with the primary clinician

Many organizations discover that simple scheduling adjustments and refining communication expectations with patients can significantly improve performance in this area.

Patient-centered access is not only about meeting standards; it is about exceeding expectations which contribute directly to patient satisfaction, loyalty, and improved health outcomes.

4. Close the Referral Loop More Effectively

Referral management remains a challenge for many healthcare organizations. The updated PCMH standards require evidence that referrals are completed and that specialist recommendations are communicated back to the referring provider. A successful referral process should include:

• Referral tracking from start to finish
• Documentation of specialist reports
• Follow-up on incomplete referrals
• Clear communication between providers

Practices should evaluate whether current systems allow staff to easily identify outstanding referrals and act before gaps in care occur. The goal is not simply to send referrals. The goal is to ensure patients receive the care they need and that the primary care team remains informed throughout the process.

5. Build a Consistent Transition of Care Plan

Patients experiencing ‘transition of care’ can be a time filled with questions and confusion, guidance is often needed to navigate the healthcare system. The updated standards facilitate the ease of navigation, ensuring patients are provided with support and any necessary coordination of care. The updated standards place focus on demonstrating timely follow-up after a hospital or facility discharge. Best practices include:

• Receiving discharge notifications promptly
• Conducting outreach within established timeframes
• Scheduling follow-up visits
• Completing medication reconciliation
• Documenting all transition-of-care activities

Organizations that establish standardized discharge follow-up workflows often see benefits far beyond PCMH compliance, including reduced readmissions and stronger patient engagement.

Success Requires a Team Approach

One of the most important themes across the 2027 PCMH updates is collaboration. Care management, care planning, referral tracking, patient access, and transitions of care cannot be owned by a single individual. Successful implementation requires engagement from:

• Providers (including mid-levels)
• Nurses
• Care managers
• Front office staff
• Practice administrators
• Quality improvement teams
• Accountable Care Organizations and Clinically Integrated Networks

Creating clear responsibilities and accountability throughout the organization will help ensure your practice is ready when the new standards take effect.

Don’t wait until 2027.

Practices that begin preparing now will have more time to identify gaps, implement workflow improvements, train staff, and gather the documentation needed to thoroughly and accurately demonstrate compliance.

At RMS, we help organizations navigate every stage of the PCMH journey, from readiness assessments and workflow optimization to documentation review and Recognition support. Our team understands the operational challenges these updates can create and works alongside practices to develop practical, sustainable solutions.

Ready to prepare your practice for the 2027 PCMH Standards?

Contact Shannon Sawyer, Senior Director of Healthcare Operations, at 315.635.9802 ext 212 or [email protected] to discuss how RMS can help your organization successfully adapt to the upcoming changes.