Care Coordination and Transitions (PCSP)

Why is this important?

It is discouraging that access to care is one of the U.S. health system’s greatest challenges. Commonly recognized factors include lack of health insurance, high out-of-pocket costs, and multiple socioeconomic factors. Workforce (clinician supply) plays a role, but often difficulties with access are due to the structure and processes used by practices. Timely access to specialty care is an area of frustration for many referring practices as well as patients who may be extremely anxious during a time of delayed care for a potentially serious condition. While highly-functioning specialty practices cannot solve the national issues with access to care, well-organized specialty practices can significantly contribute to the overall efficiency of local and regional health care.

How will these tools help?

The questions based on the NCQA PCSP Standards and Guidelines will assess whether your practice meets various competencies of patient-centered care and the foundations of the medical neighborhood.  Depending on your responses to the questions, resources from the Resource Library will be presented to help your practice address any gaps identified.  Among the tools are policy templates that your office can customize and use to train personnel and guide new processes.

The questions and references to NCQA are based on the NCQA Patient-Centered Specialty Practice (2019 Edition) and used with permission of NCQA

Target Audience

Target Audience

  • Physicians

  • Physician Assistants

  • Nurse Practitioners

  • Registered Nurses

  • Medical Assistants

  • Practice Managers

Learning Objectives

Learning Objectives

This module will help with the NCQA Patient-Centered Specialty Practice Standards and Guidelines (2019 Edition, V1). 

To achieve recognition in the PCSP program, practices must:

  • Meet all 38 core criteria in the program PLUS
  • Earn a minimum of 20 (of possible 72) elective credits across 5 (of 7) concept areas.

The 7 concept areas, that include core and elective criteria in different competency categories, are as follows:

  1. Team-Based Care and Practice Organization (5 core criteria, 3 elective criteria)
  2. Initial Referral Management (8 core criteria, 11 elective criteria)
  3. Knowing and Managing Your Patients (8 core criteria, 13 elective criteria)
  4. Patient-Centered Access and Continuity (3 core criteria, 3 elective criteria)
  5. Plan and Manage Care (6 core criteria, 12 elective criteria)
  6. Coordinating Care and Care Transitions (5 core criteria, 8 elective criteria)
  7. Performance and Quality Improvement (3 core criteria, 10 elective criteria)

For more details about requirements for each criteria within the concept areas, refer to the complete NCQA Patient-Centered Specialty Practice Standards & Guidelines which can be downloaded for free.


Course summary
Available credit: 
  • 1.00 Attendance
Course opens: 
Course expires: 
Parent activity set: 

Practice Advisor Content Manager

Jillian Schneider, MHA

Manager Practice Support, American College of Physicians


The questions and references to NCQA are based on the NCQA Patient-Centered Specialty Practice (2019 Edition) and used with permission of NCQA.

Available Credit

  • 1.00 Attendance


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