Building State Cooperatives for Healthcare Improvement: Meeting Summary

On September 26, 2024, the Agency for Healthcare Research and Quality (AHRQ) held the Building State Cooperatives for Healthcare Improvement meeting to identify the key components and processes needed for developing state cooperatives for accelerating the implementation of evidence into practice to advise future efforts. On behalf of AHRQ, Abt Global convened 23 thought leaders for this discussion. The participants included 18 thought leaders in the fields of primary care, public health, health information technology, healthcare payment, workforce, health policy, and quality improvement (QI) and five grantee representatives from the AHRQ EvidenceNOW: Building State Capacity (ENOW BSC) program. 

The day started with introductions, short presentations from the ENOW BSC grantee teams on key lessons learned for developing a cooperative, and a brief presentation of the program evaluation findings across the grantees from the Abt Global ENOW BSC team. The meeting attendees were then split into groups for a series of breakout discussion sessions to identify the critical actions that groups establishing a cooperative should take and clarifying key gaps that need to be filled to move the field forward. The specific topics discussed during breakout sessions were:

• Multisector convening of public and private partners to co-develop, coordinate, and align primary care improvement efforts including building a QI workforce.
• Aligning incentives, payment, and state-level resources with healthcare improvement efforts.
• Collecting and sharing data and patient-centered outcomes research (PCOR) evidence to inform state and local decision making.

The meeting ended with the whole group reconvening to share and discuss the main points raised during breakout sessions. 

Below we present key takeaways from across the full meeting. In the following sections, we share more detailed information from each session and breakout topic. 

Summary of Key Takeaways

Sustainability: 

• State cooperatives must become skilled at clearly communicating their strategy to stakeholders and highlighting commonalities with other state initiatives. 
• Design the state cooperative’s implementation strategy with sustainability in mind from the outset by engaging policymakers, payers, providers, and community partners early and often.

Evaluation and Monitoring: 

• The evaluation of the ENOW BSC initiative found that participating practices had significantly higher levels of tobacco cessation counseling, blood pressure control, and practice capacity post-intervention as compared to baseline. However, grantees did not have a common approach to documenting their interventions making it difficult to identify the most effective approaches to supporting QI. Future QI initiatives may benefit from early harmonization and agreement on a minimum set of data and tracking of QI support interventions.
• Invest ample time and resources to establish data governance when planning a state cooperative. Include people on the team who are knowledgeable about the state’s data structures and plan for sustainability of data collection. 
• Quality measures and electronic health records (EHRs) do not always tell the full impact of QI initiatives. Consider capturing and sharing qualitative data from both patients and providers, patient-reported outcomes and/or patients’ health goals, experience of care data from the providers, and financial data.
• Assist providers with understanding their data and methods for using QI resources in their practices to help their patients. 
• Share QI data within and between states to effect changes at a national level. 
• State cooperatives should analyze and translate the QI data, understand where the barriers are to QI efforts, and demonstrate the return on investment.

Multisector Convening and Collaboration: 

• QI exists at the intersection of public health, primary care, and community. Collaboration and alignment across these key stakeholders is the only way to make meaningful progress. 
• Learn to effectively tell the story of the state cooperative’s efforts and objectives to build understanding, alignment, and trust with partners. Cooperatives must know their story and the levers they can use to appeal to different audiences – including providers, payers, and policy makers. It is useful to focus on stories that depict different types of return on investment and can show partners and potential partners how the cooperative efforts will meet their distinct missions over time.

Health Equity and Disparities: 

• Center and embed equity as a core component in all activities of the state cooperative, including governance and QI implementation. 
• Engage organizations that can benefit the most from participating in the cooperative program, even if it takes more effort to recruit them (e.g., community health centers, rural practices, small and medium-sized independent practices). 
• Prioritize equitable data practices by mandating the capture and reporting of data on healthcare disparities and social determinants of health. QI outcomes should be stratified by these data to understand where disparities exist.

Governance: 

• Establish a strong governance structure with clearly articulated roles, responsibilities, and meeting structure to align metrics and incentives to build the trust and relationships needed to execute healthcare extension work. 
• Cast a wide net of stakeholders to be part of the governance structure of a cooperative (e.g., payers, providers, business representatives, Medicaid, managed care organizations (MCOs), patients and caregivers, community-based organizations (CBOs), and legislators).

Engaging Payers: 

• It is crucial to have multipayer engagement and state cooperatives that can serve as the neutral convenor for multipayer alignment. Payers need a separate work group to have dialog and participate actively in the overall state cooperative infrastructure.

Co-design and Co-creation of Initiatives: 

• Allow time and resources to build and continuously maintain durable relationships with organizations and to co-create a shared vision of success with partners and the community. 
• Acknowledge and attend to misalignment of incentives, rewards, resources, motivation, and timing among partners to nurture buy-in and effectively collaborate. 
• Engage the community with skilled facilitation to co-develop the implementation.

Workforce Development: 

• Build a QI workforce at the cooperative level using best practice training and certification processes, and recruit non-traditional workers (e.g., community health workers (CHWs), youth, patients, peers, CBO staff who provide social services).