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

Though it can be difficult to contemplate sustainability planning during the early stages of designing and developing a healthcare extension program, it is important to consider your ultimate goals and plan for sustainability from the outset. This involves identifying both short- and long-term goals for building an extension program and inviting partners that can help develop and realize your vision—including potential future funders. It is useful to review and update your sustainability planning as the program matures, and as the vision and goals evolve over time. In this chapter of the guide, we describe several domains related to sustainability planning for extension programs to consider, and then focus on strategies to secure sustainable funding to ensure program longevity. (Some of the content included in this chapter can also be found in Finding Sustainable Funding for Primary Care Programs [PDF, 7 MB]).

Plan for Sustainability

Planning for program sustainability requires attention to multiple interconnected areas. Table 6 describes seven domains related to sustainability that teams should consider at the design and development phase of their extension program, and then periodically over time.^34-37 

Table 6. Sustainability Domains With Descriptions and Considerations

^i. Funding strategies are discussed below, in the section Find Sustainable Funding for Your Primary Care Extension Program.

Find Sustainable Funding for Your Primary Care Extension Program

Healthcare extension programs are often funded, at least initially, through federal or state grants.⁷ Grant funding can be essential for establishing the coalition of partners throughout a state needed to carry out the work and develop needed statewide infrastructure. However, without ongoing funding for core infrastructure costs, inevitable gaps between grant funding periods occur. These gaps can lead to loss of trained and specialized staff—and with them the collective knowledge, skills, and relationships that allow healthcare extension programs to be efficient and effective.^7,12 Most extension programs have found they need funding from multiple sources to sustain their work. This often includes a mix of both project-based grant funding and ongoing non-project-based funding.

Some extension programs have been successful at securing sequential funding, where previous grant experience is leveraged for new (and often larger) grants across agencies. Other approaches are braiding or layering funding, where multiple funding streams support a program:^c

• In braided funding, the full costs of the program are shared across multiple funding sources, with each funding stream remaining separate so it can be individually tracked. In this strategy, cost-allocation methods are used to make sure program and administrative costs are appropriately shared between funding sources and to prevent any duplication in funding.^38-40 
• In layered funding, existing funding for the program’s core services is supplemented with new funding (from the same source or other sources), allowing the provision of broader or more- comprehensive services.⁴¹ An advantage of this approach is that core services are not disrupted if supplemental funding ends.³⁹

Sequential, braided, and layered funding approaches can all be used to help sustain healthcare extension services over time.

Potential Funding Sources 

In this section we discuss sources of potential funding that can be used to support the work of healthcare extension programs. Below, we provide an overview of various sources of support available for QI efforts in primary care, by the geographic reach of that support (Table 7). 

Table 7. Support for Primary Care Quality Improvement, by Type and Geographic Reach

ACO = Accountable Care Organization. HRSA = Health Resources and Services Administration. QI = quality improvement.

However, healthcare extension programs require financial support beyond QI funding. Below we discuss different types of funding to support healthcare extension programs more broadly. The content shared here draws heavily from interviews we conducted with representatives from programs that provide healthcare extension services: the Oregon Rural Practice-Based Research Network (ORPRN),⁴²the Oklahoma Primary Healthcare Improvement Cooperative (OPHIC),⁴³and the University of New Mexico’s Office for Community Health’s Health Extension Regional Offices (HEROs) program.⁴⁴

Legislative Appropriation in the State Budget

State legislatures can authorize funding for programs focused on primary care improvement. For example:

• OPHIC receives a small amount of annual funding from the state to cover some infrastructure expenses (office space, administrative staff, etc.) and to develop and support interagency community coalitions, called County Health Improvement Organizations. 

University Funding and Nonfinancial Support

Often, healthcare extension programs are coordinated through one or more universities—often the clinical and translational science center at a state university. This relationship with the university can benefit the program through financial investment and infrastructure support, as well as through staff- and faculty-sharing arrangements. For example:

• ORPRN, which exists as a standalone unit within the School of Medicine at Oregon Health & Science University, gives all indirect funding from its grants to the university. In return, ORPRN does not pay for any overhead costs (such as for office space, central finance, human resources staff, etc.). This arrangement provides stability for the program when it experiences gaps in funding between large grants. 
• OPHIC is organizationally situated within the University of Oklahoma’s federally funded Clinical and Translational Science Institute, which serves as its dissemination and implementation arm. 
• The University of New Mexico’s Health Sciences Center provides continuous, sustainable funding for administration of the HEROs program and for partial funding of program positions. 

Federal Grants

Though it is not recommended that healthcare extension programs rely solely on federal grants, these grants often make up a sizeable portion of overall funding. Several federal agencies provided funding to support healthcare extension services, including the agencies presented in Table 7 above. You can view all available grants at Grants.gov and set up to receive notifications for current and projected funding opportunities  (Tip: A successful application for a federal grant requires staff with grant-writing skills and experience. Programs that are not run through a university might want to partner with one for this type of support or hire professional grant writers for their team.)

State Contracts and Funding

State departments of health (including public health or mental health) and Medicaid agencies often contract with healthcare extension programs to support QI. For example:

• The Public Health Division of the Oregon Health Authority has supported several ORPRN initiatives, generally related to working with primary care clinics to improve prevention activities, such as screening for heart disease or diabetes and referral to self-management programs. In addition, ORPRN had several contracts with the State of Oregon (state Medicaid and the vaccine program) to support primary care practices with COVID vaccine storage and handling. 
• OPHIC has had several subcontracts with Oklahoma’s Departments of Health and Mental Health to gather data to support chronic disease management and to design and implement systems to screen for alcohol and substance use disorders. 

Some states have funds designated for health promotion, such as cigarette tax revenues or tobacco settlement money (and eventually opioid settlement money), that are a possible source of funding for QI efforts. For example:

• Oregon provided ORPRN with start-up funding from tobacco settlement funds.

Contracts With Payers and Other Entities for Technical Assistance, Training, or Other Services 

Payers (including private health insurance plans and Medicaid or Medicare managed care plans), provider associations, health systems, primary care practices, or other entities will sometimes contract with healthcare extension programs. Contracted services include technical assistance or staff training for QI activities, practice facilitation, information technology support, and multidisciplinary case management infrastructure. For example:

• Medicaid Coordinated Care Organizations (CCOs) in Oregon contracted with ORPRN to provide technical assistance and education to primary care practices and other health system partners on improving quality measures such as depression screening. Technical assistance included training practice staff in QI methods to build practices’ QI capacity. ORPRN also helped CCOs in Oregon develop and implement tools and strategies to analyze community needs, to inform community health improvement plans.
• New Mexico’s Medicaid funding of its managed care organizations has been a significant, long-term funding source for the University of New Mexico’s community health worker programs, including funding the role of some HEROs. 

Fees or Membership Dues

Payers, health systems, primary care practices, or other entities sometimes pay healthcare extension program fees or membership dues for services. For example: 

• ORPRN runs its Extension for Community Healthcare Outcomes (ECHO) program using a membership model. ECHO provides remote education from clinical specialty experts to help primary care providers manage patients with health conditions that would otherwise have to be referred to specialty care. Currently, most payers in Oregon, including the state Medicaid program, pay to be members and then can invite a certain number of providers to participate based on their share of the cost of the program.
• Some primary care extension programs receive fees for providing technical assistance to consult with other states on establishing statewide QI infrastructure. 

Funding From Foundations, Private Trusts, or Individual Donors

Some healthcare extension programs have had success getting supplemental funding from foundations or individual donors. For example:

• New Mexico’s health extension program receives substantial funding from local foundations and private donors. W.K. Kellogg Foundation of New Mexico and the local JF Maddox Foundation fund the health extension work in rural and urban underserved areas. 
• OPHIC receives modest funding for its primary care extension program though individual donors. 

Endowments can offer long-term, stable funding for primary care extension. For example:

• In New Mexico, a substantial amount of support for extension work in research and with community-based organizations comes from private donors. The University of New Mexico identifies private donors through its Development Office.

Healthcare conversion foundations (PDF, 15.2 MB) (also known as health legacy foundations) could potentially provide funding for healthcare extension programs. These foundations, which are formed when a hospital, health system, or health plan is converted from nonprofit status to for-profit status, are intended to fund efforts that improve the health of the community that the original institution serves.^45,46

Other Funding Strategies and Tips

In addition to seeking broad funding, other strategies can help healthcare extension programs sustain their work. 

• Consider different funding sources for different components of the work. It could be more effective to pitch parts of your program to certain funders, rather than pitching the full program. As one researcher described, “Outcomes meaningful to Medicaid-managed care insurers may differ from outcomes of interest to the local, nonprofit community.”⁴⁴ For example:
  • Some funders (e.g., local foundations) might be more interested in funding practice facilitators than in funding the healthcare extension program more broadly. 
    • The Agency for Healthcare Research and Quality’s guide Developing and Running a Primary Care Practice Facilitation Program (PDF, 3 MB) includes ideas for finding funding to support such positions. 
• Community health workers (CHWs) are sometimes included in a healthcare extension program. Because CHWs provide a direct service to patients, it might be easier to show a short-term return on investment from their work (e.g., a reduction in hospitalizations) than from practice facilitators, whose impacts are more indirect and long term. Because of this, a hospital or health system might be more willing to help cover the salaries of CHWs. 
• Pitch relationships with practices to funders. Healthcare extension programs can pitch their strong and trusting relationships with primary care practices, and knowledge of community needs and organizations throughout the state or region, to potential funders. For example:
  • According to ORPRN’s Anne King, “It helped that we had staff embedded in communities because Oregon is a really huge state, and we had staff in communities where there wasn't anybody else.” ORPRN was able to bring on funders, including payers, by showing them “we have relationships with primary care practices, that we understand how they operate, we know how to get in and help facilitate change.”⁴² 
  • OPHIC maintains the most complete and accurate database of primary care practices within Oklahoma, which it then markets as a valuable resource to various state agencies and offices.
• Invite potential funders to serve on your Advisory Board or Board of Directors. One way to build relationships with potential funders is to invite them to participate in your program early on. For example:
  • OPHIC founder Jim Mold described how it did this during an earlier iteration of the program in Oklahoma: “We established a Board of Directors that included representatives from many of these groups, including Medicaid and the health department—anybody we thought might be interested and have some money. [By doing this] we got to know the folks and how their funding systems work.”⁴³
• Make use of intragovernmental transfers. State-based public entities can often share funding with other state entities without a contract, using an intragovernmental transfer. For example, a state-based hospital, the state Medicaid program, or a state’s department of health could fund a primary care extension program housed in a state university for services that benefit patients in the state, without entering into a contract or grant. This type of arrangement is appealing to the state because it is easier and more flexible than a contract. For primary care extension programs run by state entities, the arrangement can mean easier access to significant amounts of funding. For example:
  • The University of New Mexico’s Office for Community Health and University of New Mexico Hospital negotiated an intergovernmental transfer of funding with the state’s Human Services Department, which runs state Medicaid. This funding was used to support work of the Office’s HERO and CHW programs in the service of Medicaid patients.
• Another strategy some organizations use is to house a healthcare extension program in an organization that has a broader overall mission, which allows the program to use funds that might not be available otherwise. For example:
  • The health extension program in New Mexico is not limited to primary care or even clinical settings, but rather provides broad services to improve the health of people throughout the state. 
  • Other groups provide extension services as part of a practice-based research network that conducts research on quality improvement, pragmatic clinical trials, and patient-centered outcomes research in primary care. 

^c. Another funding strategy is blending, referring to mixing together funds from multiple sources such that individual funding sources lose their program-specific identity and cannot be tracked separately. We did not find any examples of blended funding to support primary care extension programs.