2025 PCMH Reporting Requirements: Navigating the New Landscape 

The 2025 Patient-Centered Medical Home (PCMH) reporting requirements are here! Released annually, these updates are eagerly anticipated by practices and reflect the ongoing evolution of healthcare standards. This blog provides an overview of the requirements and highlights specific Core criteria included in next year’s reporting standards.  

Key Changes From 2024 to 2025 

The 2025 annual reporting requirements build on the previous year’s framework but introduce more specific and detailed measures. Notable changes include: 

• Greater emphasis on comprehensive health assessments, covering a broader range of health determinants. 

• Increased specificity in care management criteria, with a stronger focus on evidence-based care plans and patient-provider collaboration. 

The 2025 Reporting Criteria Breakdown 

Team-Based Care and Practice Organization (AR-TC) 

Key Measures: 

1. PCMH Transformation Leads (AR-TC 1) NEW FOR 2025  

• Requirement: Practices must have a clinician lead and a staff person managing ongoing patient-centered care. 

• Evidence: Attestation confirming the presence of these roles. 

2. Structure and Staff Responsibilities (AR-TC 2) NEW FOR 2025  

• Requirement: Clear definition of organizational structure and staff responsibilities. 

• Evidence: Upload an overview of staff structure and descriptions of staff roles and responsibilities. 

Knowing and Managing Your Patients (AR-KM) 

Key Measures: 

1. Comprehensive Health Assessment (AR-KM 1) NEW FOR 2025 

• Requirement: Conduct and document comprehensive health assessments covering medical, mental health, social, and developmental factors. 

• Evidence: Attestation confirming the practice’s compliance. 

2. Diversity (AR-KM 2) USED IN 2024  

• Requirement: Collect and report data on race, ethnicity, sexual orientation, gender identity, and one other diversity aspect. 

• Evidence: Upload a report containing the collected data. 

3. Community Resource Needs (AR-KM 3) NEW FOR 2025  

• Requirement: Collect and analyze data on community resource needs. 

• Evidence: Attestation confirming the practice’s compliance. 

Patient-Centered Access and Continuity (AR-AC) 

Key Measures: 

1. Clinical Advice Documentation (AR-AC 1) NEW FOR 2025 

• Requirement: Document clinical advice provided during and outside of office hours. 

• Evidence: Attestation confirming the practice’s documentation practices. 

Care Management and Support (AR-CM) 

Key Measures: 

1. Identifying Patients for Care Management (AR-CM 1) NEW FOR 2025 

• Requirement: Use at least three categories (e.g., behavioral health conditions, high cost/utilization, poorly controlled conditions) to identify patients for care management. 

• Evidence: Attestation detailing the categories considered. 

2. Care Plans for Care Managed Patients (AR-CM 2) USED IN 2024, 2022, & 2021 

• Requirement: Develop comprehensive care plans for identified patients, demonstrating collaboration between patient and provider. 

• Evidence: Upload three de-identified care plans. 

Care Coordination and Care Transitions (AR-CC) 

Key Measures: 

1. Referral Management (AR-CC 1) USED IN 2021 

• Requirement: Implement a documented process for managing referrals, including communication with specialists and tracking referrals. 

• Evidence: Attestation confirming the process. 

2. Post-Hospital/ED Visit Follow-Up (AR-CC 2) NEW FOR 2025 

• Requirement: Follow up with patients after hospital admissions or ED visits. 

• Evidence: Upload evidence of follow-up processes. 

Performance Measurement and Quality Improvement (AR-QI) 

As you prepare for the 2025 PCMH reporting requirements, keep a sharp eye on your current measure performance. The reporting period for QI standardized measures is CY 2024, therefore paying attention to these measures now will ensure high performance and a successful annual reporting submission to NCQA’s Review Oversight Committee.   

Standardized Measures:  

1. Clinical Quality Measures (AR-QI 1) 

• Requirement: Monitor at least five clinical quality measures across four categories: immunization, preventive care, chronic/acute care, and behavioral health. 

• Evidence: Enter measure data via the Measures Reporting Tile. 

2. Resource Stewardship Measures (AR-QI 2) 

• Requirement: Monitor at least two resource stewardship measures related to care coordination and health care costs. 

• Evidence: Enter measure data via the Measures Reporting Tile. 

3. Patient Experience Measure (AR-QI 3) 

• Requirement: Monitor at least one measure of patient experience in areas like access, communication, and coordination. 

• Evidence: Report patient experience data. 

4. Goals and Actions to Improve Measures (AR-QI 4) 

• Requirement: Set and act on goals to improve at least three clinical quality measures and one resource stewardship measure. 

• Evidence: Upload the Goals and Actions Workbook. 

Overview of evidence to prepare  

By understanding these requirements, practices can ensure they maintain recognition by providing evidence to NCQA supporting the selected Core criteria for Annual Reporting. 

1. Team-Based Care and Practice Organization (AR-TC) 

• AR-TC 1: Team-Based Care 

• Evidence Type: Attestation, Evidence Upload 

• Requirements: Practices need to provide policies and procedures that demonstrate team-based care, including staff roles and responsibilities, team huddles, and communication strategies. 

• AR-TC 2: Practice Organization 

• Evidence Type: Evidence Upload 

• Requirements: Documentation showing organizational structure, including leadership roles and governance, meeting minutes, and practice workflows. 

2. Knowing and Managing Your Patients (AR-KM) 

• AR-KM 1: Patient Information 

• Evidence Type: Evidence Upload, Report 

• Requirements: Patient demographic data, health information exchange capabilities, and examples of how patient information is utilized in care management. 

• AR-KM 2: Evidence-Based Care 

• Evidence Type: Evidence Upload 

• Requirements: Documentation of clinical guidelines and protocols, patient education materials, and care plans tailored to individual patients. 

3. Patient-Centered Access and Continuity (AR-AC) 

• AR-AC 1: Access to Care 

• Evidence Type: Evidence Upload, Report 

• Requirements: Data on patient access to care, including appointment availability, after-hours access, and use of telehealth services. 

• AR-AC 2: Continuity of Care 

• Evidence Type: Evidence Upload 

• Requirements: Policies on continuity of care, patient follow-up procedures, and evidence of ongoing patient-provider relationships. 

4. Care Management and Support (AR-CM) 

• AR-CM 1: Care Management 

• Evidence Type: Evidence Upload 

• Requirements: Care management plans, patient risk stratification data, and examples of care coordination for high-risk patients. 

• AR-CM 2: Medication Management 

• Evidence Type: Evidence Upload, Report 

• Requirements: Medication reconciliation processes, patient education on medication use, and documentation of medication management outcomes. 

5. Care Coordination and Care Transitions (AR-CC) 

• AR-CC 1: Care Coordination 

• Evidence Type: Evidence Upload, Report 

• Requirements: Coordination of care plans, referral tracking, and evidence of communication between primary and specialty care providers. 

• AR-CC 2: Care Transitions 

• Evidence Type: Evidence Upload 

• Requirements: Processes for managing care transitions, follow-up procedures after hospital discharge, and patient handoff documentation. 

6. Performance Measurement and Quality Improvement (AR-QI) 

• AR-QI 1: Clinical Quality Measures 

• Evidence Type: Data via Measures Reporting Tile 

• Requirements: Submission of data on at least five clinical quality measures across four categories: immunization, other preventive care, chronic/acute care, and behavioral health. 

• AR-QI 2: Resource Stewardship Measures 

• Evidence Type: Data via Measures Reporting Tile 

• Requirements: Submission of data on at least two resource stewardship measures related to care coordination and health care costs . 

• AR-QI 3: Patient Experience Measure 

• Evidence Type: Data via Measures Reporting Tile 

• Requirements: Submission of at least one patient experience measure related to access, communication, coordination, or whole-person care . 

• AR-QI 4: Goals and Actions to Improve Measures 

• Evidence Type: Evidence Upload 

• Requirements: Documentation of goals and actions to improve at least three clinical quality measures and one resource stewardship measure . 

DAS Health: Your Partner in Annual Reporting 

Why Choose Our Annual Reporting Assistance 

1. Expert Guidance: Our team is well-versed in PCMH standards set by NCQA. We offer expert guidance to ensure your practice aligns with these standards. 

2. Streamlined Documentation: We help you compile and organize necessary data, simplifying the process and saving you time. 

3. Quality Improvement Strategies: We work with your practice to identify areas for continuous improvement, enhancing patient-centered care and overall performance. 

4. Timely Submission: We ensure your Annual Reporting is submitted accurately and on time. 

Partner with DAS Health to navigate the complexities of annual reporting requirements and provide an organized and efficient reporting strategy. To learn more about our Annual Reporting Assistance Program and how it can benefit your practice, reach out to our team. We’re here to help with any questions you may have! 

Written By: Kimi Watson