The EvidenceNOW Model: Providing External Support for Primary Care

The AHRQ EvidenceNOW Model is a blueprint for delivering external support to primary care practices to improve healthcare quality and implement new evidence into care delivery. It also is designed to help primary care practices increase their capacity for quality improvement with the goals of improving patient and practice health. The Model aligns with the concept of the primary care extension program, which in turn is based on the successful 100-year-old national Agricultural Extension Service. The EvidenceNOW Model recognizes that small- and medium-sized primary care practices, which represent the core of primary care for most Americans, often do not have dedicated staff, resources, or infrastructure for ongoing quality improvement activities. Just as farmers have profited from the Agricultural Extension Service, primary care practices benefit immensely from an external quality improvement support system. Even system-affiliated primary care practices can benefit from this support, just like large farms still consult with the Agricultural Extension Service.

The EvidenceNOW Model was initially implemented in 2015 as part of AHRQ’s EvidenceNOW: Advancing Heart Health initiative to help primary care practices across the country implement evidence shown to improve heart health. Seven EvidenceNOW cooperatives developed customized sets of supports for the primary care practices they worked with, combining five core services that are usually not available to smaller practices:

• Practice facilitation and coaching.
• Health information technology support.
• Shared learning collaboratives.
• Expert consultation.
• Data, feedback, and benchmarking.

Based on what was learned from the Advancing Heart Health initiative, AHRQ is now using the EvidenceNOW Model to continue supporting primary care practices and addressing other health issues for which there is a strong evidence base, such as managing unhealthy alcohol use and managing urinary incontinence in women. Healthcare and quality organizations interested in ensuring primary care practices use the best evidence to deliver high-quality care can use the EvidenceNOW Model to create their own external support infrastructures. They can use the Model as a blueprint to provide ongoing, external supports to primary care practices in order to achieve improvement at the practice level. To implement the EvidenceNOW Model, organizations need to:

• Create an extension program.
• Adopt a quality improvement approach.
• Engage with primary care practices.

Create an Extension Program

Work of this depth and breadth is best carried out through partnerships with multiple stakeholders. For EvidenceNOW: Advancing Heart Health, AHRQ encouraged the development of cooperatives that bring together the skills, experiences, and resources of a wide variety of organizations, including:

• Local, State, and/or regional primary care organizations (such as academic primary care departments of one or more health professional schools from within the region, primary care specialty societies, primary care Practice-based Research Networks (PBRNs), Area Health Education Centers (AHECs), and Primary Care Associations and Organizations).
• Local, State, and/or regional organizations dedicated to improving care (such as Quality Improvement Organizations (QIOs), Chartered Value Exchanges (CVEs), and Regional Extension Centers (RECSs) for Health Information Technology (IT).
• Public health agencies and community-based organizations.
• Private and public payers in the region, in particular, entities responsible for administering the State Medicaid program.
• Consumer/patient advisory and/or advocacy groups.

Extension programs should define a geographic region they will serve. One insight gained from EvidenceNOW; Advancing Heart Health suggests that extension programs that service regions no larger than one State will be most effective. Programs that spanned more than one State faced challenges, because each State has its own distinct medical, political, demographic, and economic milieu. An extension program must respond to its environment and be tailored to fit the local context.

Additional insights on building State-level primary care extension programs can be found in:

• The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons from Five Case Studies
• AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants: A Synthesis Report (PDF, 820 KB)
• Developing and Running a Primary Care Practice Facilitation Program: A How-To Guide (PDF, 3 MB)
• Health Extension Toolkit
• Taking Innovation to Scale in Primary Care Practices: The Functions of Health Care Extension.

Adopt a Quality Improvement Approach

New extension programs will have to define a comprehensive, multi-component, evidence-based approach to providing external quality improvement support. The EvidenceNOW Model uses five core services.

Practice Facilitation – Practice facilitation is a central and unifying strategy in the EvidenceNOW Model. Practice facilitators engage with primary care practices in longitudinal, trusted relationships to build the practice’s capacity to implement the best clinical evidence. Practice facilitators also help provide or connect practices with the other quality improvement supports they need to use their technology {e.g., electronic health records (EHRs)}, harness patient and practice data, and connect with community resources. AHRQ has created a variety of practice facilitation resources that describe exemplary practice facilitation programs, guide program development, train practice facilitators, and advise on their deployment. Facilitators can make use of the EvidenceNOW Tools for Change, a curated collection of more than 100 tools and resources that can help primary care practices in their efforts to improve quality by providing evidence-based care to their patients.

Health Information Technology Support – One of the earliest and most profound findings from EvidenceNOW was uncovering the many challenges faced by primary care practices in using EHRs for quality improvement. Practices reported numerous challenges in generating adequate reports, including functionality limitations, differences between clinical guidelines and measures available in EHR-generated reports, and questionable data quality. There are several factors in the practice that determine whether a practice can effectively use health IT for quality improvement, including practice culture, use of health IT tools, knowledge and skills of staff and practice processes and workflows. Extension programs should be prepared to provide assistance to primary care practices to help them minimize the burdens of data entry and maximize their ability to generate reports that can be used for quality improvement and population health.

Data, Feedback, and Benchmarking – Data feedback (sometimes called audit and feedback) gives practices and teams information on key process and outcome indicators, which are tracked over time to assess improvement. Data can come from within the practice—from its registries, EHRs, or chart audits—or from eternal sources, such as health information exchanges, payer claims data, or hospital utilization data.

Benchmarking entails comparing a practice's performance on selected measures to accepted standards or the performance of other practices or providers. By allowing practices, and teams within practices, to gauge their performance relative to other similar practices and teams, benchmarking can be a powerful approach for motivating practice change.

Expert Consultation – Expert consultation (also known as academic detailing) uses short-term communication and education from experts to provide targeted knowledge that can help a practice achieve its quality improvement goals. Typically, expert consultation involves onsite or virtual contact. A physician might act as an educator, providing information and motivation to a lead physician at the practice seeking assistance. Other consultants might include a pharmacist or nurse, usually working with team members from the same professional background. Consisting of only one or two onsite or virtual visits, expert consultation provides specialized, in-depth knowledge or technical assistance on a short-term basis.

Shared Learning Collaboratives – Learning collaboratives bring together a group of practices, in-person or virtually, to facilitate joint learning. The rationale behind learning collaboratives is that professionals working together are more likely to generate and sustain quality gains due to the opportunity to learn from each other, in part through positive peer pressure and through sharing practical solutions. Collaboratives often focus on a particular topic, such as improving cardiovascular care, but the focus can also support the development of general quality improvement capacity.

Engage with Primary Care Practices

The EvidenceNOW Model for a primary care extension program, like the Agricultural Extension Service, is built on the concept of longitudinal, ongoing relationships between the service and local practices. This model differs qualitatively and quantitatively from one-off targeted improvement activities. The extension service is a continuous resource for the practices with which it partners. Practices may participate in some, but not all, of the initiatives led by the service. Trusting relationships often begin with facilitators meeting practices where they are, identifying their needs, and working on projects prioritized by the practice. Not all primary care practices are interested, willing, or capable of partnering with an extension program. Practices have to possess both a willingness to change and organizational stability and resources. EvidenceNOW: Advancing Heart Health Cooperatives found that recruiting practices for change initiatives can be hard. The implication of EvidenceNOW: Advancing Heart Health research is that extension programs need to budget sufficient time and funding and use a variety of recruitment methods. For insights into how to determine whether a practice is ready to engage in quality improvement and get practice buy-in, go to: Engaging Primary care Practices in Quality Improvement: Strategies for Practice Facilitators and resources for practices facilitators, including the EvidenceNOW Recruitment and Retention Toolkit (PDF, 832 KB).