With IMPaCT funding, the model and spread States tested a number of strategies for supporting and expanding primary care transformation, including:
- Partnering with key stakeholders involved in transformation, including engaging high-level State policymakers.
- Sharing lessons learned and collaborating with other States on best practices.
- Building upon existing primary care transformation and medical home initiatives.
- Identifying and integrating public agencies into plans for building sustainable infrastructure.
- Implementing QI capacity-building strategies, including learning communities.
- Advancing practice facilitation training.
- Building IMPaCT projects into other initiatives to support sustainability.
- Partnering with State and federal resources such as academic institutions to provide the evidence base and expertise for interventions.
While each model and spread State had its own strategy for utilizing IMPaCT funding, we found there were common lessons to be learned from across the IMPaCT grants. These lessons are described below.
Extension efforts require coordination. The ability of the IMPaCT project leaders and practice facilitators to connect practices with each other and to other initiatives stood out as a key part of the projects’ success. The PIs were passionate about their work and had spent their careers building relationships with practices and other stakeholders involved in primary care improvement. In addition, formal structures (e.g., boards, alliances) helped launch and sustain relationships that were critical to the success of each State’s efforts. For example, New Mexico’s coordination structure was designed so that some representatives participated in multiple groups involved in these efforts. For the IMPaCT grants, the composition and geographic scale of the coordinating team varied. Many States used the existing structure of primary care or community health improvement efforts. Most of the efforts to spread transformation capacity were fairly informal. However, North Carolina used a formal approach including an application process and partnership with the National Academy for State Health Policy. This organized approach supported spread efforts; the application process demonstrated interest in participation and there were dedicated resources to coordinate the partnership.
IMPaCT grants built and sustained the complex partnerships that were necessary for the multiparty efforts required for successful extension programs. This was achieved through a combination of partnership engagement and technical assistance. Greenhalgh’s model of diffusion and innovation in service organizations shows that horizontal networks are “more effective for spreading peer influence and supporting the construction and reframing of meaning.”5 Technical assistance efforts, particularly structured learning collaboratives, also promoted partnerships across primary care practices and other stakeholders. For the IMPaCT grants, academic medical centers were important sources of innovation ideas and evidence-based interventions.
Local tailoring is essential. There is no one model for primary care transformation that will work across the country or even across a single State. All of the efforts to ascertain local needs found differences by site. Within States, tailoring relates to both clinical/improvement emphasis areas as well as governance structures. For example, Oklahoma’s focus on “primary health care” is broader than “primary care” and encompasses public health, mental health, and all community organizations and agencies with a focus on improving the health of the population at a primary level (i.e., primarily wellness and prevention). This focus made it possible to help the counties create “neutral convener” organizations within which goals are aligned, resources are shared, and performance metrics are congruent.
The focus of spread activities was on creating capacity for improvement through State partnerships rather than replication of the specific model used in the model State. Model and spread State interactions focused on communicating about how the cultural or logistical elements of the model State’s approach could be applied to the existing networks within the spread State. IMPaCT grants helped to develop and disseminate packaged resources; for example, North Carolina’s change package and the health extension toolkit. However, these resources seemed to be most helpful when they were technical in nature (e.g., a training program or electronic health record tool).
Structured peer-to-peer learning improved capacity at all levels of primary care transformation support. This was true for QI activities within practices, as well as for the North Carolina Regional Learning Collaboratives and cross-grantee meetings. Convening both State and interstate in person meetings helped to solidify relationships and build a sense of mutual goals and of working across silos. Site visits proved particularly effective in helping Pennsylvania practices understand how exactly to implement various components of the PCMH model.
Gaining practice buy-in is critical. Encouraging practice participation required mechanisms to foster motivation in addition to imparting knowledge or offering expertise and external incentives.13 In Pennsylvania, Oklahoma, and New Mexico, PCMH recognition held limited appeal, but there was great interest in learning how to improve practice problems that also aligned with the IMPaCT program’s overall objective of practice transformation. As the PI of the Oklahoma program said, practices wanted to join because the project was “addressing a real need that the county had identified, and because they wanted to be part of something bigger than themselves.”
External influences also relate to practice buy-in. While the focus/purpose of participation was not specifically about receiving official recognition as a PCMH, participation did improve the chances for participating practices if they chose to seek it. Primary care practices, QI organizations, professional organizations, and State administrators were keenly aware of the rapid growth in ACOs and the demand for higher health care quality at lower costs. It is likely that future motivation to engage with PCEPs and undertake practice transformation will depend on practices’ anticipation of joining or forming ACOs in order to participate in shared savings and/or receive incentive payments for quality performance. Where there is resistance to practice transformation, attitudes are likely to change when payers begin driving the process with payment reform (i.e., payment for quality rather than quantity of services provided).
Practice facilitators provide essential support to practices. Several training and certification approaches were used by IMPaCT grantees, and continued development and evaluation of training approaches and curricula will be important to learn how to make coaches successful.