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

In addition to developing a multiorganizational cooperative, the EvidenceNOW: Building State Capacity grantees were each tasked with building a statewide network of primary care practices interested in receiving resources for ongoing quality improvement (QI) support. The goals for developing the statewide networks of practices included building QI capacity for primary care practices across the state; sustaining QI support beyond any one initiative; and maintaining a group of engaged practices that could be recruited to participate in specific QI projects over time—depending on practice capacity, needs, and interests. In this chapter of the guide, we discuss developing a statewide network of practices and describe strategies for practice recruitment, engagement, and retention. 

Plan a Statewide Network of Practices

As was the case for the EvidenceNOW: Building State Capacity cooperatives, timeline and funding requirements can lead primary care extension programs to first recruit practices for a specific QI project and then develop a network of practices for ongoing QI work, rather than the other way around as was intended. However, it is important to have a plan for how to develop and maintain a broad and ongoing network of practices from the outset.

The first step in planning a statewide network of practices for QI includes deciding which kinds of practices will be included. For example, depending on the goals for your extension program and the identified QI needs in your state, you might choose to target specific types of practices (e.g., small and medium-sized practices, independent practices, or health system–affiliated practices), practices that serve a particular population (e.g., medically underserved or rural populations), or practices without much previous QI experience. For example, Alabama Cardiovascular Cooperative focused primarily on engaging federally qualified health centers (FQHCs). Alternatively, you might want to recruit a large and diverse group of primary care practices to build a broad coalition throughout the state focused on QI in primary care. For example, the Tennessee Heart Health Network recruited a mix of independent and health system practices, academic health centers, and FQHCs. 

Another consideration is whether to start the network of practices in a particular part of the state and then expand it over time, or else develop and maintain multiple hubs throughout the state from the outset. These decisions will likely depend on the size of your state and the existing QI infrastructure. For example, if primary care practices and practice facilitators are primarily located in one key city, it could make the most sense to start in that city and then expand to other regions over time. Alternatively, if there is existing infrastructure throughout the state, a more distributed model could work well from the outset. For example, Healthy Hearts for Michigan partnered with three regionally based QI organizations to focus on reaching rural practices. Practice facilitators were assigned to work with practices near their homes to minimize the distance they would need to travel for their regular in-person visits. 

Recruit Practices

Recruiting primary care practices to participate in a broad network or QI project can be a challenge. Clinicians and practice staff report being hesitant to sign on to new things because of heavy workloads, staffing shortages, and competing priorities including participation in other initiatives—both voluntary and mandatory. One review of the experience of recruiting practices for the EvidenceNOW: Advancing Heart Health initiative found that recruiting practices to participate in a healthcare extension program can be time-consuming and labor-intensive, and cooperatives would be well advised to plan their budget and timeline accordingly.²² Another analysis by one of the EvidenceNOW: Advancing Heart Health cooperatives found that practice recruitment was facilitated by an alignment with practice priorities, using incentives, and building on prior relationships and that retention requires ongoing and close communication.²³ Recruitment strategies that focus on entities with multiple practices, such as health systems and health center networks, can also be an effective way to optimize recruitment efforts.

Many of the recruitment strategies described in this section can be used both for active QI projects and for building a larger network of practices interested in QI—although the focus and intensity of the recruitment activities can vary depending on your specific goals. In the sections below, we draw on the practice recruitment experiences and lessons learned from across the EvidenceNOW initiatives, sharing examples of materials they have developed and used when relevant. In addition to the information and materials shared here, the Agency for Healthcare Research and Quality (AHRQ) has a toolkit for Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives (PDF, 832 KB), which includes specific tips and templates. Another AHRQ guide, for practice facilitators, also includes helpful information for Engaging Primary Care Practices in Quality Improvement (PDF, 1 MB).

Align With Practice Priorities 

To effectively recruit practices to participate in your network of practices or QI project, it is helpful to identify their current priorities and what motivates them, and then develop messages to address these motivations. The EvidenceNOW: Advancing Heart Health cooperatives found that to effectively persuade practice leaders to participate, the burden of participation should be minimal or offer “the potential to reduce other pressures or [fill] a particular need for that practice.”²⁴

The Tennessee Heart Health Network held a listening tour with practices from across the state to help inform its recruitment efforts. Through these efforts, it learned that practices were looking to support health coaches, internal QI efforts, and health information technology personnel. In response to what they learned through this process, the cooperative budgeted to include an annual monetary incentive for practices participating in its QI project that could be used toward these expenses (read additional discussion in Provide Incentives later in this chapter). 

The Tennessee Heart Health Network also learned that though practices saw the value of participation, many reported they could not commit to the required time and resources to participate. To help address this barrier, the cooperative created three tiers of engagement: 

• Tier 1 (QI project participants). Practices in this tier participated in the active QI project and received practice facilitation, access to training, and certification for staff in motivational interviewing and health coaching. Practices submitted quality data to the Tennessee Population Health Data Network (TN-POPnet) and received quarterly practice improvement reports to track progress on heart health quality measures. These practices also participated in virtual learning collaboratives to share best practices.
• Tier 2 (active network participants). Practices in this tier submitted data to the TN-POPnet and received quarterly practice improvement reports to track their progress on heart health quality measures. They had access to toolkits, implementation guides, and webinars, and they received regular communications about cooperative activities. 
• Tier 3 (general network participants). Practices in this tier had access to toolkits, implementation guides, and webinars, and they received regular communications about cooperative activities. They did not receive reports or other direct support and were not required to submit any data or commit any time to participation.

In a study across quality initiatives (including EvidenceNOW), researchers looked at the most common barriers to participation and suggested ways to make QI studies more feasible and attractive for practices. Key suggestions included the following:²⁵ 

• Reducing participation requirements for already overburdened physicians, and instead focusing on what other clinicians and practice staff can do.
• Compensating practices for time spent away from patient care.
• Reaching out to practices beyond email alone, as clinicians and practice staff are already inundated by email.

In an analysis of their recruitment efforts for EvidenceNOW: Advancing Heart Health, a research team found that recruiting practices to participate in a QI project was more challenging when no prior relationship existed. They found that among practices where a relationship already existed, or there was a warm handoff from someone with a personal connection, almost 1 in 3 practices agreed to participate. This rate fell to only 1 in 20 for practices with no connection to a person or organization already in the cooperative. In addition, they found that the cost of recruiting practices without an existing connection was seven times greater than that for recruiting practices with a connection.²²

Develop a Value Proposition

A value proposition is a statement that explains how involvement in your program can benefit the target audience (i.e., primary care practices) and makes the case for why they should participate. An effective value proposition reflects your target audience’s needs and motivations and communicates what is unique about what you are offering. Once you have developed your value proposition you can use it to develop recruitment materials. For more information about how to develop an effective value proposition, examples, and sample language, go to AHRQ’s Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives: A Toolkit (PDF, 832 KB).

When recruiting primary care practices to participate in a statewide QI network, a value proposition could highlight the following potential benefits as relevant: 

• Belonging to a statewide effort to improve the quality of primary care for communities served.
• Access to QI resources to support efficient and effective care delivery practices, including implementation toolkits. 
• Opportunities to participate with peers in shared learning activities, including webinars and podcasts.
• Access to future opportunities to participate in specific QI projects to support care delivery.
• Opportunities to participate in a community of practice with other primary care practices.
• Access to data feedback to support focused QI activities.

In addition, it can be helpful to keep requirements for participation in the broad QI network of practices at a minimum, and highlight this low barrier for entry to help motivate practices to participate. 

The value proposition for practices participating in specific QI projects can be more focused. In their value propositions, the EvidenceNOW: Building State Capacity grantees outlined the following benefits to practices from participation in their QI projects: 

• Improving the health and healthcare of patients:
  • As heart health was the focus of both EvidenceNOW: Advancing Heart Health and EvidenceNOW: Building State Capacity, the cooperatives highlighted the high burden of cardiovascular disease in their state or region, and developed messages to harness the strong motivations of clinicians to improve patient outcomes.
• Assistance to increase value-based payments and alignment with national quality initiatives:
  • Connecting value-based payments to participation can be a particularly effective way to get buy-in from practice leadership. The EvidenceNOW cooperatives highlighted how practice facilitators taught participating practices to increase value-based payments through the implementation of chronic care management, telehealth, and health coaching to improve quality outcomes.
  • Some cooperatives promoted their alignment with federal quality reporting requirements. For example, Healthy Hearts for Michigan highlighted that practice facilitation support could help practices improve their Merit-based Incentive Payment System (MIPS) and Healthcare Effectiveness Data and Information Set (HEDIS) quality reporting scores.
• Improved staff skills, practice workflow, and capacity for QI:
  • Skills development can lead to professional growth and contribute to higher satisfaction, engagement, and retention. Cooperatives promoted access to no-cost training to improve staff skills in shared decisionmaking, health coaching, motivational interviewing, patient engagement, patient navigation, and QI techniques. Tennessee Heart Health Network offered evidence-based health coach training to participating practices.
  • Cooperatives called attention to how participation could improve overall practice functioning. Healthy Hearts for Michigan shared that participation could help improve practice workflows, team-based care, and provider-to-provider referrals. 

Examples of value propositions are included in the recruitment materials of Tennessee Heart Health Network (PDF, 320 KB) and Alabama Cardiovascular Cooperative (PDF, 1.3 MB). 

Provide Incentives

Offering incentives to practices for their participation helps signal appreciation for their time and energy and often makes practices more receptive to your pitch. Though participation in a QI project ultimately might help practices share in cost savings through value-based payment programs, there are likely costs associated with their participation before those benefits can be realized. For example, participation might require staff to take time away from billable activities. Although unlikely to cover all costs to practices, financial incentives (within the limitations and guidelines of your funding agency) can be used to help offset some of the upfront costs for practices participating in a QI project. 

The limitations of participation-specific financial incentives are something that partnerships with payers could potentially address. For example, if a QI project aims to reduce rates of uncontrolled blood pressure and the practice needs to improve on this measure to optimize value-based payment, linking the QI project to this payer priority can demonstrate other financial benefits of participation beyond a symbolic incentive recognizing participation.

Build on Existing Relationships 

The EvidenceNOW: Advancing Heart Health cooperatives and others found that building on existing relationships is one of the most successful strategies for recruiting practices. Given this, programs might want to start recruitment efforts by reaching out to their own contacts, along with those of their partners. As described previously in Identify Needed Expertise in chapter 2, the program can select some partners from the outset specifically for their credibility among and ability to reach primary care practices. As also described in chapter 2, specific partners can help with recruitment both broadly and within select groups (e.g., those in rural or remote areas, those that provide care to underserved populations). 

The EvidenceNOW: Building State Capacity cooperatives used existing relationships to recruit practices: 

• Alabama Cardiovascular Cooperative relied on connections between its two principal investigators and three existing networks of practices and other related entities within the state (the Alabama Practice-Based Research Network, the Deep South Continuing Medical Education Network, and the Rural Research Alliance of Community Pharmacies) to reach clinicians serving high-risk and underserved communities.
• Heart Healthy Ohio Initiative relied on its partnerships with professional organizations (including those for physicians, nurse practitioners, nurses, pharmacists, physician assistants, and dieticians), three regional health improvement collaboratives, and seven academic medical schools across the state. 
• In addition to using its professional association partners and the Quality Innovation Network-Quality Improvement Organization in its region to help with practice recruitment, Tennessee Heart Health Network drew on the deep connections of its physician partners, who are health leaders who have helped train many of the primary care physicians working throughout the state. 

When a direct relationship with a practice does not already exist, it can be helpful to get a warm handoff or a referral. Ask participating practices to introduce you to other practices or clinicians or share testimonials about their reasons for joining your initiative.²⁶ 

Though relying on existing relationships is an effective approach for recruitment, it can have the unintended consequence of limiting the types of practices you are reaching, preventing you from reaching the practices that could most benefit from your support. To avoid this pitfall, be sure to partner with organizations that specifically focus on practices that could be hard to reach, such as rural practices or those that focus on traditionally underserved populations. 

Design Effective Outreach Strategies 

Effective practice recruitment requires a multifaceted approach. EvidenceNOW cooperatives found it necessary to use multiple modes of outreach and a layered approach to effectively reach practices and get the word out about the opportunity to participate in the statewide QI network and QI projects. 

The following strategies can help recruit practices:

• Promoting the project widely, including through partner social media accounts (i.e., LinkedIn, Facebook, Twitter); primary care listservs, newsletters, and blogs; presentations at state conferences and events focused on primary care; press releases to local media; and project and partner websites. 
• Sending an initial outreach letter from a source that practices know and trust.
  • Select for an example outreach email (PDF, 204 KB) from Healthy Hearts for Michigan.
• Emailing, mailing, or faxing a fact sheet or flyer that describes participation benefits as well as any obligations or requirements. (Note that faxing can be an effective way to reach practice staff.)
  • Healthy Hearts for Michigan found it effective to purchase a list of primary care physicians in its state and send recruitment letters via U.S. Mail addressed directly to them. Select for examples of recruitment flyers (PDF, 847 KB) for Healthy Hearts for Michigan.
• Holding informational webinars and developing recruitment videos, which can be recorded and shared on a project website. 
  • Watch example recruitment YouTube videos that Heart Healthy Ohio Initiative developed: Heart Healthy Ohio Quality Improvement Project–Join Today! and Join the Heart Healthy Ohio Initiative!

In addition to the outreach approaches described above,  it can be helpful to follow up with phone calls and in-person visits to reach the practice leaders responsible for decisionmaking, answer practices’ questions, and clarify project requirements. For practices that expressed an interest in participation, the EvidenceNOW: Building State Capacity cooperatives held in-person or virtual meetings with practice leaders to clarify project requirements (e.g., any required electronic health record capabilities), discuss the expectations for participating practices, and describe the different levels of engagement available. 

Finally, primary care extension programs should regularly revise their practice recruitment strategies, messages, and outreach materials to focus on the approaches that have been the most effective.

Additional Recruitment Strategies for Recruiting Practices for a QI Project

Additional strategies that can be helpful for recruiting practices to participate in a QI project include targeting practice leaders, tailoring your pitch, and sharing the requirements of participation in detail up front. 

• Target practice leaders. When recruiting practices to participate in your QI project, it is helpful to identify and reach the leaders within a practice who are responsible for decisionmaking. Practice leaders vary across practices and might be a physician in one practice and a practice manager in another. Leadership can variously reside with a person or a group. For example, Healthy Hearts for Michigan found that when it was not able to reach enough practices through mail, email, and phone outreach alone, it was useful to show up in person at practices and ask to speak directly with the practice manager or a head clinician.
• Tailor your pitch. Think through what will likely be the most successful messages for recruiting different types of practices (e.g., FQHCs, independent practices, health systems) as well as different types of leaders within a practice (e.g., clinician, office manager), and then develop tailored recruitment messages. Each of these unique audiences can have different motivations for and barriers to participation. 
• Share program details up front. The EvidenceNOW: Advancing Heart Health cooperatives were surprised by the amount of information that practices wanted about the program before signing up. For example, practices asked for specific information about requirements and expectations, expected time commitments, what exactly was required to receive incentives, what level of data reporting was necessary, what EHR capabilities were required, what training the practice facilitators had received, and what strategies for QI were planned.²⁴ Recruitment flyers and other materials should clearly include information about the requirements and expectations of participation in addition to the benefits. In addition, to help recruiters provide consistent and detailed information to answer these types of questions, it can be helpful to develop an FAQs document in addition to recruitment scripts.
  • A template for developing an FAQs document for recruitment purposes is included in AHRQ’s Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives: A Toolkit (PDF, 832 KB)

Engage and Retain Practice Participation 

After practices are recruited, effective onboarding and regular contact can help ensure practices stay engaged over time. 

Onboard Practices

Some EvidenceNOW cooperatives required practices to complete a readiness assessment prior to engaging in the QI project. Readiness assessments commonly measure the following elements: willingness to change, organizational function, practice resources, and leadership engagement.²⁷ For example:

• Alabama Cardiovascular Cooperative administered two questionnaires to assess practice readiness for participation: the Change Process Capability Questionnaire (PDF, 130 KB) for organization leaders (i.e., lead provider, quality manager, or chief executive officer); and the Organizational Readiness for Implementing Heart Health Improvement Project (PDF, 96 KB), which was meant to be completed by as many practice staff and administrators as possible. Cooperative leadership reviewed practices’ readiness scores before official enrollment. 

During onboarding, practices joining an active QI project should be asked to identify a practice champion, and practices joining either an active QI project or a larger QI network should identify a primary point of contact. Practice champions are essential for successful QI implementation efforts because they can help overcome organizational resistance, address day-to-day issues that arise, and maintain staff enthusiasm. EvidenceNOW cooperatives found it useful to ask practices to also name an alternative point of contact at each practice, to reduce disruptions if the champion or primary contact left the practice, became too busy, or was otherwise unavailable (e.g., the champion went out on maternity leave for several months).²⁶ Heart Healthy Ohio Initiative asked practices to identify a clinician and staff champion duo, to help promote a team-based approach.

Practices that want to participate in an active QI project should sign a letter of agreement (also known as a letter of intent or letter of participation) outlining the agreed-upon program expectations. For example, it is essential to be clear up front with practices about the amount and type of data required and to assess their internal capacity to pull data as needed. The letter of agreement should also indicate what practices can expect from participation in the cooperative. An example is Tennessee Heart Health Network’s letter of intent (PDF, 229 KB) Similarly, extension programs could need to enter into a business associate agreement (BAA) or a data use agreement with practices that will be sharing data. These agreements outline contractual and legal permissions for using and sharing data, include safeguards to prevent unauthorized use, and require notification of any breach.^28,29 The U.S. Department of Health and Human Services provides sample BAA language. 

Maintain Practice Engagement

Once practices are onboarded, the focus shifts to keeping them engaged. EvidenceNOW cooperatives used multiple strategies to disseminate program information and create a sense of community to keep practices engaged. For practices in the network or the QI project, this included the following strategies:

• Program websites to help participating practices access programmatic information.
• E-newsletters or listservs to share relevant information such as new evidence-based guidelines; share program updates, deadlines, and information about upcoming events; and share practice success stories or celebrate milestones and accomplishments. For example, access a PDF version of Tennessee Heart Health Network’s e‑newsletter (4 MB). 
• Webinars, videos, and podcasts to share information more conveniently; for example: 
  • Lunch & Learn webinars from Healthy Hearts for Michigan.
  • A series of podcasts developed by Heart Healthy Ohio Initiative. 
  • Video stories from patients, clinicians, and others developed by Tennessee Heart Health Network.
• Ongoing tailoring of learning collaborative curriculum around expressed needs of the practices to ensure continued value from the QI activities. 

For practices involved in a QI project, some EvidenceNOW cooperatives chose to hold a kickoff meeting prior to engaging in any QI activities. These meetings served to introduce program staff and partners to one another, share a timeline, provide an overview of upcoming activities, and build collaboration and collegiality between cooperative staff and the practices. It can also be helpful to provide practices with recognition of their participation and celebrate their successes over time. For example, extension programs can consider the following:  

• Acknowledge participating practices publicly on project websites, in social media, in state medical association journals, and via other modes including local media, as relevant. 
• Provide practices with a poster or plaque to display on their wall; a virtual “badge” to post on websites, newsletters, and social media; or lapel pins for clinicians and practice staff to wear. For example: 
  • Alabama Cardiovascular Cooperative created a digital badge that participating practices could post online (see graphic).
  • Healthy Hearts for Michigan and Heart Healthy Ohio Initiative gave participating clinics lapel pins for staff to wear to promote the program. 
• Recognize individual practice successes when a practice meets early and intermediate goals for QI implementation. 
• Share practice-related publications and results.