The Patient Centered Medical Home

About Us

The Patient Centered Medical Home (PCMH) is a philosophy of health-care delivery that moves from a model of symptoms and illness episodic care to a system of comprehensive coordinated care for children, youth and adults. Patient centeredness refers to an ongoing, active partnership with a personal primary-care clinician who leads a team of professionals dedicated to providing proactive, preventive and chronic-care management through all stages of life. These personal clinicians are responsible for coordinating each patient’s care across the medical neighborhoods utilizing registries, information technology and health-information exchanges. With a commitment to continuous quality improvement, care teams apply evidence-based medicine, shared decision making support tools and population care data analysis to transform practice workflows and processes with measureable positive patient outcomes and decreased costs.

These skills and transformed processes require a structured approach in order for an advanced primary-care practice to achieve national recognition as a PCMH. The National Committee for Quality Assurance (NCQA) is the leader in health care quality accreditation and has a method for measuring and qualifying a practice’s services and operation, quantitatively scoring a practice’s performance and ranking a practice against a national standard of recognition.

We have a track record of success in helping organizations realize PCMH status.

What We Do

NJII provides established practice transformation support services, including NCQA PCMH Recognition coaching. We assist practices at all levels of transition to meet the specific requirements for NCQA PCMH Recognition and certify that documents are uploaded and submitted through the NCQA Survey Tool. This includes but is not limited to QA/QI documentation, policy and procedures to define practice operations, in-office work flows and clinical-, utilization- and patient satisfaction data collection.

Our process involves the following:

  • The practice completes an official Practice Readiness Assessment.
  • We conduct a telephone interview with the practice team to better understand capabilities, gaps, needs and desires.
  • We propose an agreement outlining the scope of our professional services. Once accepted, we assign a PCMH-certified Coach to the practice to begin its transformation into a NCQA-recognized PCMH.
  • The practice leadership and PCMH-certified Coach identify clinical, administrative and health information technology champions who learn and spearhead the effort for their clinical team.

Depending on the level of transition as assessed above, as well as practice size, number of clinicians and /or number of office sites, this process can take from six to nine months to complete.


NCQA recognition as a PCMH assures that practices:

  • Get appropriate recognition as a valuable care team capable of participating in alternative payment models with third-party payers including Medicaid/Medicare (these models include additional payments for individual care coordination and population care).
  • Improve practice earnings on the treatment of the current patient population.


For more information, contact Thomas Ortiz, M.D., at or call 201-463-2234. For more information on NCQA and PCMH Recognition, visit the NCQA website.