The IMPaCT grants were designed to support primary care transformation by building on QI infrastructure already in place in each model State. Therefore, each grant’s State-level enhancement efforts included unique program components and interfaced with other ongoing efforts. In this section, we first provide an overview of the structures and strategies used to develop practice transformation efforts within the four model States. We then describe how the extension program structure engaged primary care practices in developing or deepening QI capacity. Finally, we describe how each State worked to grow participation and coordination in statewide QI efforts across stakeholders through formal structures, relationships, and shared vision. Table 1 summarizes each grant’s State-level efforts, including its structure, participants, use of practice facilitators, population and community health efforts, intersection with State PCMH efforts, and products.
Summary of Model State Program Components
New Mexico
New Mexico’s Health Extension Rural Offices (HERO) program,6 coordinated by the University of New Mexico Health Science Center, used the IMPaCT grant to adapt existing community-based efforts to address social determinants of health in an effort to reach small primary care practices, including those in rural areas. HERO worked to address the needs and priorities of primary care providers and fragmentation of services by: 1) training agents (called health extension rural officers or “HEROs”), who personally visited primary care clinics, and 2) creating a centralized catalog containing useful resources for primary care practices, ranging from the Health Information Technology Regional Extension Center to housing for families of patients receiving treatment at the University of New Mexico Hospital. A core team based at the University of New Mexico Health Science Center supervised the HEROs, mobilized shared resources, and assisted the HEROs and the participating practices with accessing these resources.
North Carolina
IMPaCT funding was used to deepen North Carolina’s existing multipronged approach to primary care improvement, which included practice facilitation, electronic data exchange, and care coordination and case management. The IMPaCT grant funded two collaboratives: the Regional Leadership Collaborative and the Primary Care Transitions Collaborative. Regional Leadership Collaborative participants included Community Care of North Carolina (CCNC) medical directors and QI directors, North Carolina Area Health Education Center (AHEC) QI consultants and medical leadership, and other influential regional organizations. The collaborative formed 13 regional teams and each selected improvement topics based on region and practice priorities. Staff from nine primary care practices participated in the Care Transitions Leadership Collaborative. Each practice established a Care Transitions Improvement Team comprised of at least one physician champion and nurse, with the option to also include an office manager, scheduler, and patient or family member. The IMPaCT team packaged these efforts through a curriculum and change package.7-9
Oklahoma
The IMPaCT program built upon existing community-based organizations at the county level to develop County Health Improvement Organizations (CHIOs) in Oklahoma to act as extension agents for primary health care transformation. IMPaCT developed a mini-grant application process through which 10 CHIOs received $10,000 grants for multipractice QI support interventions provided by experienced practice facilitators. In addition, the Clinical and Translational Science Institute at University of Oklahoma, comprised of representatives from academic institutions, State and county health agencies, and tribal governments, developed an improvement cooperative to further support dissemination of practice transformation throughout the State. To encourage uptake of the extension model and alleviate concern about duplication of efforts in the State, the Public Health Institute of Oklahoma developed CHIO certification criteria and a process for obtaining certification and recertification. Certification provided access to the small QI grants, assistance with other grant applications, and a variety of other resources, including regional coordinators funded with money appropriated by the State for this purpose.
Pennsylvania
The IMPaCT grant in Pennsylvania expanded the Pennsylvania Spreading Primary Care Enhanced Delivery (PA SPREAD) infrastructure previously developed as part of the Pennsylvania Chronic Care Initiative. Two conceptual models, the General Contractor Model and the Developmental Model, guided activities. The General Contractor Model envisions a PCEP as a mechanism to coordinate experts who deliver a variety of services to primary care practices, similar to how a construction general contractor works with expert tradespeople. The Developmental Model lays out three levels of the PCEP role: efforts to convene stakeholders and provide a clearinghouse of information serve as a foundation for technical assistance (e.g., learning collaboratives, practice facilitation, and data benchmarking) and shared services (e.g., care coordination).
These models informed IMPaCT’s specific activities that involved: 1) convening stakeholders, especially the Pennsylvania Area AHEC; 2) direct services to practices via practice coaches, information technology assistance, and learning collaboratives; and 3) shared services, including a practice facilitator forum. A key focus of the IMPaCT funding in Pennsylvania was to develop two regional learning collaboratives with a total of 16 practices to test refinements in practice recruitment and support. The collaboratives held four learning sessions to provide practical training to participating practices and a chance for practices to share their experiences with QI. Session topics included planned care, process redesign, implementing plan-do-study-act QI cycles, achieving National Committee for Quality Assurance (NCQA) recognition as a PCMH, and sustaining practice changes. Practices submitted monthly data on population-level diabetes clinical measures and benchmarking reports produced from these data were discussed at learning sessions to catalyze ongoing improvement work.
Building a Culture of Change in Primary Care
Each IMPaCT program worked to involve new practices in QI efforts or to deepen the capacity of practices for ongoing improvement efforts. These efforts were facilitated by leveraging people and organizations that the practices trusted to build interest in the effort. New Mexico identified potentially eligible practices based on partner recommendations, and the PI and practice facilitators approached practices individually to invite them to participate. PA SPREAD leveraged the AHEC network in Pennsylvania to recruit a new group of practices. North Carolina’s two types of learning collaboratives focused on health care professionals and leaders in North Carolina. The collaboratives collectively engaged 13 teams of regional leaders and health care providers from nine practices to strengthen regional leadership and QI capacity and improve transitions between the hospital and medical home. Oklahoma engaged practices via the newly certified CHIOs. The IMPaCT grants tested incentives for practice engagement, including $1,000 in New Mexico, continuing medical education and maintenance of certification for learning collaborative participation in Pennsylvania, and the mini-grants in Oklahoma.
"One of the most satisfying impacts [of this program] was to hear clinicians shift their mental model to one of listening to the patient, partnering with the patient, and letting patients take ownership of their care."
–Robert Gabbay
Pennsylvania IMPaCT PI
Tailoring activities to practice interests proved critical for gaining practice involvement. All of the grantees we interviewed noted that a "demand-driven” rather than “supply-driven” approach was more successful for practice engagement. The IMPaCT programs identified local needs through a combination of existing relationships and programs; QI training, which emphasized teaching practices to identify and act on local concerns; and surveys. The core team created an Initial Visit Survey that gathered information on each practice’s operations, patient population, challenges, and priorities. North Carolina’s learning collaboratives included steps to identify region and practice priorities and chose topics accordingly. Additionally, North Carolina worked to create a feedback loop between primary care practices and State and regional improvement leaders. In Oklahoma, the core team encouraged CHIOs to choose areas identified as important during ongoing county health improvement planning discussions. The small projects funded through the CHIOs focused on depression, diabetes, opioid management, care transitions, and childhood obesity. Pennsylvania surveyed providers10 about their specific needs and attitudes toward practice transformation. The survey results were used by the investigators to tailor the extension program to individual practice needs, prioritize learning activities, and drive discussions among stakeholders. The survey results highlighted that providers were initially most interested in services to identify and coordinate referrals to mental health services, improve office workflow, increase overall revenues, implement evidence-based clinical guidelines, and help patients set self-management goals.
"If I had approached those practices individually and asked, 'Wouldn’t you like to do some quality improvement in your practice?’ or ‘Wouldn’t you like to transform your practice?’ they would have hung up the phone on me. But because it was a countywide project, addressing a real need that the county had identified, and they wanted to be part of something bigger than themselves, they all joined the project. That is a major benefit of forming the CHIOs and doing the project the way we did."
–Jim Mold
Oklahoma IMPaCT PI
Building a Culture of Change Across Stakeholders
Stakeholder participation in IMPaCT extension program structures built upon preexisting relationships and adapted to new needs that were identified over time. For example, in Oklahoma, primary care extension built on the Oklahoma Physicians Resource Research Network, which had established relationships with primary care practices and had a tested model of practice improvement. In North Carolina, formal efforts to align statewide primary care improvement efforts began in 2006 with the formation of the North Carolina Healthcare Quality Alliance. North Carolina’s IMPaCT project grew from two statewide primary care support organizations, CCNC and the North Carolina AHEC, and the IMPaCT funding supported activities to enhance cooperation between the two organizations. Similarly, PA SPREAD had its origins in the Pennsylvania Chronic Care Commission and efforts to improve diabetes care in the State dating back to 2007. New Mexico envisioned substantial expansion of stakeholder participation to produce a “Hub” that included representatives of key State agencies, a core team of program leadership, and the regional HEROs. However, direct communication with practices revealed that they were interested in a more tight-knit structure with direct connections to particular University of New Mexico resources. Therefore, the program structure was designed to engage only selected stakeholders to provide resources to meet practice needs.
"The Regional Leadership Collaborative and the work around that really advanced the CCNC/AHEC/practice relationship and developed both regional strength and experience in those teams, as well as at the statewide level."
–Darren DeWalt North Carolina IMPaCT PI
Formal structures were developed to build partnerships across participants and stakeholders and took the form of boards, alliances, and certification programs. For example, Oklahoma mandated a communitywide board of directors to include representatives from public health, mental health, social services, hospitals, and primary care, which resulted in enhanced communication between various sectors to build a broader infrastructure to support practice transformation efforts. In Oklahoma, as described previously, the State-level partners established a formal certification process to motivate CHIO formation.
Shared and co-created vision shaped the nature of formal structures and drew on previous efforts in the health sector and beyond. For example, the PA SPREAD partner discussions in 2012 began with general agreement on the value of collaboration, stemming from the success of collaboration in the State’s Chronic Care Initiative and Regional Extension Center. In largely rural Oklahoma, a familiarity with the agricultural extension agency model translated to a methodology for spreading innovations in primary health care improvement through the development of CHIOs. Similarly, the certification concept was familiar because of other certification programs already in place (e.g., Certified Healthy Communities, Certified Healthy Businesses, Certified Healthy Schools).
Who Were the Extension Agents?
Each of the IMPaCT PIs and their core teams functioned as linkage agents, who used their longstanding relationships in their State to help build critical statewide partnerships. They also conducted active trust-building across participating practices and stakeholders. For example, PA SPREAD invested significant time and energy into strengthening relationships and partnerships within Pennsylvania to develop a sustainable infrastructure for practice support. They convened meetings that included more than 25 organizations throughout Pennsylvania to discuss the will to collaborate and potential opportunities to do so. The use of practice facilitators was the core of all four State’s efforts to work with practices and build connections across stakeholders, however their role, organizational affiliation, and training varied across projects.
"Since a number of us have been around for a very long time and have trained a lot of the practitioners around the State, there was a trust relationship upon which we could build."
–Arthur Kaufman New Mexico IMPaCT PI
New Mexico’s HEROs have experience in primary care practice transformation in such areas as QI, practice redesign, accessing community resources, and staff development. HEROs are chosen by the communities in which they serve and live, ensuring that they are locally responsive and culturally and linguistically competent. They are also university employees with backgrounds in health fields, and therefore are aware of both the resources available in their communities and at the university. HEROs link practices to needed resources by visiting practices, administering needs assessments, and providing connections to resources.
In North Carolina, the Regional Leadership Collaborative was used to enhance the effectiveness of existing AHEC and CCNC practice facilitators for leading change, mentoring practices, and aligning the activities of practice support organizations.
In Oklahoma, practice facilitators were AHEC employees identified within specific geographic portions of the State. The mini-grants provided an opportunity for three AHEC employees and an individual hired by the Little Dixie Community Action Agency to complete practice facilitation training and certification through the State University of New York at Buffalo’s Millard Fillmore College. Their required field work was supervised by experienced practice facilitators at the University of Oklahoma.
Pennsylvania also chose AHEC staff to function as practice facilitators because of their strong relationships with primary care practices in their regions and their understanding of the contextual factors unique to each region. Two regional Pennsylvania AHEC directors were trained as learning collaborative practice facilitators. PA SPREAD developed and tested a practice 2.5-day facilitator training program that focused on five core competencies: 1) clinical knowledge, 2) QI methodology, 3) practice facilitation, 4) communications, and 5) information management. They also created an ongoing statewide Practice Facilitator Forum to foster networking and learning among practice facilitators working for numerous organizations across the State.
Reach and Results Within Model States
Table 1 summarizes IMPaCT practice participation, stakeholder partnerships, and products, along with certification efforts. The type of PCMH recognition or other certification initiatives or programs that was of interest to practices varied. Systematic results on clinical improvements are not available from this set of grants. However, the IMPaCT learning collaboratives in North Carolina and Pennsylvania saw improvements on some clinical measures in some practices. For example, in Pennsylvania, learning collaborative participants improved diabetes process and outcome measures. By 12 months after the learning collaborative was established, both blood pressure and low-density lipoprotein cholesterol levels were significantly lower.
