The Agency for Healthcare Research and Quality (AHRQ) funded four cooperative agreements from September 2011 through September 2013 called "Infrastructure for Maintaining Primary Care Transformation (IMPaCT): Support for Models of Multisector, State-Level Excellence." Each award funded State-level initiatives that had previously demonstrated success in providing a quality improvement (QI) and practice transformation infrastructure for primary care, specifically through the use of a primary care extension model approach. Teams in New Mexico, North Carolina, Oklahoma, and Pennsylvania received the four AHRQ IMPaCT grants.
The purpose of this report is to describe the key efforts and activities of the IMPaCT grants; synthesize lessons learned across the grants about effective approaches to primary care QI capacity-building; and discuss opportunities for future research, sustainability, and expansion.
What Is a Primary Care Extension Program?
As defined in Section 5405 of the Patient Protection and Affordable Care Act, the charge of a primary care extension program (PCEP) is to "provide support and assistance to primary care providers to educate providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services… and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors."1 A central component of an extension program is the use of extension agents who work as practice facilitators, also referred to as "health extension agents" or "practice coaches." Practice facilitators collaborate with health departments, universities, and other community health agencies to facilitate and provide technical assistance for QI or system redesign.2 In addition, extension agents may “collaborate with local health departments, community health centers, tribes and tribal entities, and other community agencies to identify community health priorities and local health workforce needs, and participate in community-based efforts to address the social and primary determinants of health, strengthen the local primary care workforce, and eliminate health disparities.”1
Often, PCEPs support patient-centered medical home (PCMH) redesign efforts, which include utilizing a QI strategy, implementing population management techniques for a defined panel of patients, organizing care to use a primary care team, engaging patients in their own and their families’ health, and coordinating care across settings. As defined by AHRQ,3 the PCMH is a model of care that encompasses the following five functions and attributes:
- Comprehensive care.
- Patient-centered care.
- Coordinated care.
- Accessible services.
- Quality and safety.
A number of national and State PCMH recognition and accreditation programs exist. Many practices use practice facilitation to support QI activities regardless of whether they choose to pursue PCMH recognition.
AHRQ IMPaCT Initiative
AHRQ designed the IMPaCT initiative to support State-level primary care QI and transformation efforts and to learn how these programs could serve as models for other States.4 The initiative had three purposes:
- Provide multiple examples of how a PCEP could be built.
- Expand existing programs to allow primary care practices and communities to benefit now.
- Facilitate teaching and learning across States.
Each of the four IMPaCT grantees, or "model States," collaborated with three or four "partner States" (also called "spread States") to share the successful infrastructure model they had established. In total, 17 States were involved in the initiative to develop, expand, and improve the State-level programs to assist primary care practices with their QI and redesign efforts (Figure 1). Since the grants were cooperative agreements, AHRQ program officials were engaged with grantees during the entire project period. AHRQ supported cross-project learning through regular teleconferences and awarded a small conference grant that enabled all model and partner States to meet in person in 2013.
More information on the work of the IMPaCT grants can be found at the AHRQ project Web site, which includes a catalog of tools and resources developed by the IMPaCT grantees and partner States to help support and train others in primary care transformation and QI, short profiles that summarize key aspects of each project, and success stories highlighting a unique accomplishment of each grant in one of their partner States.
