Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension

Abstract

Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.It is well established that robust primary care is essential to a high-value health care system. 1-3 However, the US primary care system faces considerable challenges. 4,5 Strategies are needed to assist practices in adapting to a rapidly changing health care landscape. 6,7 While there is no single solution to address these primary care needs, a program implemented in agriculture in the early 1900s that brought research and education directly to rural communities has been suggested as a model that could bring similar assistance to primary care. 8,9 The Cooperative Extension Service, established in 1914 under the Smith-Lever Act, was a cooperative undertaking of county, state, and federal partners. 10 The federal government funded each state's land-grant university to develop the workforce and infrastructure to spread agricultural expertise, create bidirectional communication between farmers and academic sites of knowledge production, and facilitate the diffusion of agricultural innovations. A key aspect of extension was the placement of extension agents in close proximity to communities to ensure consistent understanding of needs and delivery of services. 11 This effort introduced new technology and resources to farmers and contributed significantly to making food affordable and accessible. 12,13 Federal and state leaders have championed the use of the extension model to support and improve primary care. 1,8,9,13,14 Evidence shows that primary care practices benefit from external support to develop quality improvement infrastructure and expertise, 6 but strengthening the primary care infrastructure requires reaching many practices -small and large, rural and urban-across the nation to rapidly diffuse innovation and facilitate quality improvement. A cooperative extension for health care called the Primary Care Extension Program was included in the Affordable Care Act (ACA), although no funds were appropriated for it. This article presents a first look at early empirical findings from the...

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies

“…For communities, it may be encouraging youth to stay in school, to grow a local health workforce, and to help improve the local economy. The ESCALATES evaluation team has documented varied targets of extension programs, from taking evidence to scale 8 to reducing electronic health record challenges 16 to alleviating clinician burnout in small primary care practices. 17 (4) Health extension is a collaborative multidisciplinary undertaking.…”

“…Two grant programs from the Agency for Healthcare Research and Quality (AHRQ)-Infrastructure for Maintaining Primary Care Transformation (IMPaCT) and EvidenceNOW-have supported 22 states in applying the concepts of health extension. 8 Through IMPaCT, AHRQ awarded $4 million for a 2-year cooperative agreement with institutions in 4 states: New Mexico, Oklahoma, North Carolina, and Pennsylvania. Each award funded state-level quality improvement initiatives and practice transformation infrastructure applying the primary care extension model to small primary care practices.…”

“…The cooperatives help practices adopt the latest evidence-based cardiovascular risk guidelines by applying health extension approaches in quality improvement and practice transformation. 8 AHRQ chose ESCALATES-Evaluating System Change to Advance Learning and Take Evidence to Scale-as the team to evaluate EvidenceNOW using a multimethod approach.…”

A Qualitative Analysis of Implementing EvidenceNOW to Improve Cardiovascular Care

“…AHRQ's goals for the regional cooperatives included recruiting 250 primary care practices; incorporating practice coaching and facilitation; using practice data, feedback, and benchmarking; applying peer-to-peer local learning and expert consultation; and conducting a rigorous evaluation that included measurements at baseline, every 3 months during the intervention and 6 months afterward. 3 Launched in May 2015, regional cooperatives were required to initiate the intervention within 6 months of award and complete quality improvement support within 24 months. 4 Nevertheless, AHRQ granted time extensions for project development and evaluation activities.…”

Facilitating Practice Transformation in Frontline Health Care

“…Their study echoes both a qualitative study of family physicians participating in TCPI about their reasons for doing so, 17 and a study by the EvidenceNOW evaluation team, ESCALATES. 18 The dashboard became a tool for practice facilitators to help practices develop quality improvement plans and celebrate success, but fewer than one-half of practices still found the information to be actionable. Khanna et al 16 reiterate the lesson that "smaller practices are most likely to lack resources to review, interpret, and act on data."…”