Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement

Supporting Primary Care Improvement

Implementing high-quality primary care nationwide requires getting the latest evidence from patient-centered outcomes research out to practices (i.e., dissemination). It also requires that practices have the capacity and skills to engage in quality improvement (QI) activities based on that evidence (i.e., implementation). However, engaging in QI is new for many practices, and it requires significant training and support.¹ Implementing QI in care delivery settings requires dedicated time and resources for primary care practices that are already facing challenges, such as declining financial margins, an aging population with increasingly complex medical needs, workforce shortages, and high clinician and staff burnout rates. Fortunately, research shows that external supports can help a wide variety of primary care practices effectively engage in QI.^1,2

In recent years, federal and state initiatives have provided QI support to help improve primary care quality in the United States and align these supports with payment and incentives. These initiatives have included efforts led by the Centers for Medicare & Medicaid Services (CMS) (e.g., Primary Care First and Making Care Primary); the Health Resources and Services Administration (e.g., National Training and Technical Assistance Partners and the Small Health Care Provider Quality Improvement Program for rural health); the Centers for Disease Control and Prevention (e.g., Community Transformation Grants program); and the Agency for Healthcare Research and Quality (AHRQ) (e.g., EvidenceNOW). The large number of these initiatives points to an opportunity to develop sustainable state-based multiorganizational extension programs that can help to support, coordinate, and align primary care QI efforts. 

Primary Care Extension Programs and EvidenceNOW

To improve primary care quality, the Affordable Care Act of 2010 authorized AHRQ to establish a federal Primary Care Extension Program.³ It was modeled on the U.S. Department of Agriculture’s extension program, which was started in the early 1900sto disseminate innovations and best practices from land-grant universities to communities and farmers.^4,5 The Affordable Care Act laid out the purpose of the Primary Care Extension Program: 

“[P]rovide support and assistance to primary care providers to educate providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services (including substance abuse prevention and treatment services), and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice.”⁶

Although Congress has not yet provided funding for this authorization, AHRQ has developed a series of projects to identify and test methods and approaches for primary care extension programs. Starting in 2011, AHRQ developed the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative,^1,3 which was followed in 2015 by the EvidenceNOW initiative. 

The IMPaCT grants (in New Mexico, North Carolina, Oklahoma, and Pennsylvania) focused on studying and spreading the use of state-level primary care extension programs to support QI efforts in small and medium-sized independent practices.¹ These programs also provided technical assistance to partners in other states to assist them in developing their own extension programs. The IMPaCT initiative ultimately led to the establishment of primary care extension services in 17 states.^3,7

The first EvidenceNOW initiative—EvidenceNOW: Advancing Heart Health—funded seven grantees to use primary care extension programs to disseminate and implement evidence-based guidelines to improve heart health.⁸ Based on lessons from this initiative, AHRQ developed the EvidenceNOW Model of primary care extension services. The model includes five core services:⁹ 

1. Practice facilitation. Practice facilitators (also known as coaches) work closely with primary care practices to build their capacity to implement the best clinical evidence and connect with community resources. 
2. Health information technology support. Many practices need support to use their electronic health records (EHRs) for QI purposes. Practice facilitators who specialize in health information technology can help practices minimize the burdens of data entry and build staff’s ability to generate reports with the information necessary to engage in QI improvement and population health efforts.
3. Data feedback and benchmarking. Data feedback is when data on key indicators of interest are tracked over time to assess whether there has been any improvement. The data for this can come from internal practice sources, such as the EHR or registries, or from external sources, such as health information exchanges, payer claims data, or hospital utilization data. Benchmarking is when a practice's performance on selected measures is compared with accepted standards or the performance of other practices or providers.
4. Expert consultation (also known as academic detailing). Short-term education from experts to provide specialized, in-depth information or technical assistance on a targeted topic to help a practice achieve its QI goals. Experts can include physicians, pharmacists, nurses, or others. Typically, expert consultation pairs experts with practice team members from the same professional background.
5. Shared learning collaboratives. Bringing together a group of practices, in person or virtually, to facilitate joint learning and focused improvement in an identified area of need. Learning collaboratives generate and sustain gains in quality by giving primary care practice teams the opportunity to learn from one another and share their experiences and solutions.

Following these initial investments in primary care extension, AHRQ funded three additional initiatives using the EvidenceNOW Model. Two of these initiatives focused on using the model to disseminate and implement patient-centered evidence in new clinical topic areas: EvidenceNOW: Managing Unhealthy Alcohol Use and EvidenceNOW: Managing Urinary Incontinence. The third initiative, EvidenceNOW: Building State Capacity – Advancing Equity in Heart Health, focused on building and sustaining a state-based infrastructure to provide primary care QI support.

The Value of Multiorganizational Extension Programs To Support Primary Care QI 

To be most effective, healthcare extension programs convene an array of public and private partners that are drivers of healthcare improvement in their state. For primary care–focused efforts, these partners typically include: 

• Research universities where patient-centered outcomes research (PCOR) evidence is developed.
• Primary care organizations and associations.
• Quality improvement organizations or practice transformation organizations.
• Practice facilitation providers.
• Public and private payers.
• Public health agencies.
• Community-based organizations.
• Consumer or patient advisory groups.

Organizations participating in extension programs bring expertise in areas such as clinical QI, practice engagement, practice facilitation, evidence-based and patient-centered care, clinical-community linkages, program evaluation, data feedback and benchmarking, and techniques for using EHR and other health information technologies to monitor and support QI.

Bringing together the collective efforts of multiple organizations in a primary care extension program has the following potential benefits: 

• Coordinate efforts. By involving a wide range of partners from across multiple disciplines, an extension program can help coordinate across primary care QI efforts throughout the state. Without such coordination, QI initiatives can end up duplicating efforts and limiting their impact. The cooperative also helps to simplify practice engagement in QI initiatives. Instead of practices being approached by multiple organizations about various initiatives, the cooperative can centralize practice engagement. This may also make it possible for practices to work with the same facilitator across efforts.
  • For example, a heart health improvement initiative pursued independently by the state Medicaid agency and a private payer might end up requiring practices to focus on different quality metrics for different patients within the same practice. Instead, a multiorganizational extension program could engage both payers during project development and work to align quality outcome measures, making practice-level participation simpler.
• Increase impact. By aligning primary care QI efforts across a state, an extension program can maximize the potential impact. Aligning efforts increases the resources available for practice-level QI support, thereby making those resources available for more practices. 
  • For example, multiple organizations might provide practice facilitation services to practices. Instead, coordinating the provision of these services through the extension program helps prevent overlap and ensures that the largest number of practices can benefit from these services.
• Promote broad and equitable inclusion of practices. By engaging large healthcare systems, networks of practices, and independent practices, extension programs can ensure that QI efforts reach primary care practices serving the widest variety of communities and patients within a state.
  • For example, by working across health systems, federally qualified health centers (FQHCs), and independent practices, the extension program can target areas with the most pressing health disparities or highest need, such as urban and rural areas.
• Increase sustainability. Building an extension program that includes payers (including Medicaid and insurance companies) aligns policy and payment with QI goals, thereby increasing the sustainability of these efforts. Including state agencies (such as departments of public health and mental health and state Medicaid agencies) ensures that extension programs focus on the state’s needs as state policymakers have identified them while coordinating across services that state agencies have provided outside of the primary care setting.
  • For example, payment changes could support primary care provision of behavioral or mental health services. Engagement with state policymakers would ensure that those services are coordinated with existing community-based services and are targeted to the areas of greatest need within the state (such as treatment for substance use disorders).