Know and Manage Your Patients (PCSP)

Why is this important?

A key characteristic of highly-functioning specialty practices is the focus on providing excellent care to individuals and the entire population of patients served – referred to as “population management.” This includes those patients who come to the office as well as those patients who may not have been seen recently but are still part of the practice. In order to provide excellent population management, the practice must collect the right information in a way that is searchable for the purposes of identifying groups of individuals that may need specific elements of care (e.g., medication management, laboratory monitoring, preventive/screening procedures).

How will these tools help?

The questions based on the NCQA PCSP Standards and Guidelines (2019 edition) will assess whether your practice meets various competencies of patient-centered care and the foundations of the medical neighborhood.  Depending on your responses t 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.



Target Audience

Target Audience

  • Physicians

  • Physician Assistants

  • Nurse Practitioners

  • Registered Nurses

  • Medical Assistants

  • Practice Managers

Learning Objectives

What does this module cover?

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.

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



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

Drs. Carol Greenlee and John Cox were major contributors to this section of ACP Practice Advisor®. 

This activity is supported by an educational grant from Lilly USA, LLC

Practice Advisor Content Manager

Jillian Schneider, MHA

Manager Practice Support, American College of Physicians


The questions and references to NCQA are from the NCQA Patient-Centered Specialty Program and used with permission of NCQA.

Available Credit

  • 0.00 Attendance


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