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

Purpose and Focus 

The purpose of this guide is to share guidance about developing and sustaining state-based cooperatives that aim to strengthen the capacity of healthcare systems, other healthcare organizations, and clinicians to deliver evidence-based whole-person care. 

The guide includes effective approaches, lessons learned, and example materials from the Agency for Healthcare Research and Quality (AHRQ) initiatives designed to provide external quality improvement (QI) support for primary care practices. This guide draws mainly from the experiences of AHRQ’s EvidenceNOW: Building State Capacity initiative,^a but also reflects other AHRQ and primary care/healthcare extension efforts. This guide will be useful to groups planning or developing similar infrastructure, including healthcare extension programs with a focus broader than primary care.

Terminology and Naming Conventions 

Primary care extension programs provide external support to primary care practices to help them implement new evidence in care delivery and increase their capacity for engaging in quality improvement (refer to the section on Primary Care Extension Programs and EvidenceNOW for more information). Healthcare extension programs also provide external support for the implementation of evidence-based care, but with a focus across the whole healthcare system. AHRQ refers to the multiorganization programs that provide primary care/healthcare extension services as “cooperatives.” 

In addition to establishing primary care extension cooperatives, AHRQ’s EvidenceNOW: Building State Capacity grantees (located in Alabama, Michigan, Ohio, and Tennessee) were each charged with building and maintaining a statewide network of primary care practices that would benefit from cardiovascular and QI support resources. The grantees also recruited a smaller number of primary care practices to actively participate in a QI project to improve patients’ cardiovascular health through implementing evidence-based findings to improve care. The names of the EvidenceNOW: Building State Capacity cooperatives, their statewide networks of practices, and their QI projects appear in Table 1 and are referred to throughout this guide. 

Table 1. Names of Cooperatives, Practice Networks, and QI Projects, by State

It should be noted that the Tennessee Heart Health Network was part of the broader Tennessee Population Health Consortium, which is similarly working to improve primary care by focusing on diabetes, cancer, and health system improvement. In addition, the Heart Healthy Ohio Initiative was closely aligned with the Ohio Cardiovascular and Diabetes Health Collaborative (CardiOH) (PDF), a statewide initiative to improve health outcomes of Medicaid patients and reduce health disparities.

Overview of Chapters

The guide includes the following chapters: 

1. Background and Introduction. This chapter provides background information about primary care extension programs and AHRQ’s EvidenceNOW initiative. The chapter also discusses the value of establishing programs that include partners from across multiple organizations and disciplines. 
2. Developing and Running a State-Based Extension Program To Support QI in Primary Care. This chapter describes key steps for effectively establishing a multiorganization entity to support statewide QI in primary care. These include:
   • Conducting a landscape review to identify relevant partners, leverage past experience, and coordinate current efforts.
   • Developing a mission statement.
   • Inviting partners.
   • Developing an organizational and governance structure.
   • Forming the program’s regular activities, charter, and bylaws.
   • Assessing partner engagement regularly.
3. Building and Maintaining a Network of Primary Care Practices. This chapter describes approaches for recruiting primary care practices to participate in both a statewide network and specific QI projects, as well as strategies for practice engagement and retention. 
4. Selecting and Delivering Services To Support Quality Improvement. This chapter provides information and examples for understanding the needs and interests of primary care practices, selecting a range of QI support services to provide, and training staff to provide that support. 
5. Moving Toward Sustainability. This chapter describes how to ensure sustainability and strategies to secure sustained funding.

^a. Though this guide includes information about how AHRQ grantees developed the primary care/healthcare extension program (i.e., cooperatives) in their state, it does not go into detail about how they provided QI support or practice facilitation to practices. Those topics are already covered in other sources (go to AHRQ’s The EvidenceNOW Model: Providing External Support for Primary Care and Practice Facilitation resources).