AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants
Principal Investigator: Arthur Kaufman, MD
Institution: University of New Mexico Health Sciences Center, Office for Community Health
AHRQ Grant Number: U18HS020890
Overview of Primary Care Extension in New Mexico
AHRQ's IMPaCT grants were designed to support State-level primary care improvement efforts using extension agents (i.e., practice coaches)—and to learn how these programs could serve as models for other States.
New Mexico's IMPaCT grant drew on existing community-based efforts to address social determinants of health in the State. The Health Extension Rural Offices (HERO) program's emphasis on social determinants grew out of Dr. Kaufman's background in medical education and a desire to take a broad approach to health improvement to meet the diverse needs of the people of New Mexico. The program was modeled on the land-grant university agricultural Cooperative Extension program and drew on Everett Roger's work on diffusion of innovation.
With AHRQ IMPaCT funding, Dr. Kaufman's team adapted the model to reach small primary care practices, including those in rural areas. Through consultations and a toolkit, the team disseminated what they learned about how to create a statewide primary care improvement infrastructure to its three partner States—Kansas, Kentucky, and Oregon—and beyond.
"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, MD, Principal Investigator
The infrastructure for New Mexico's IMPaCT work was based on partnerships with State agencies and organizations and the HERO program. Health extension coordinators (also called "HEROs") were chosen by the communities in which they serve and live, ensuring that they are locally responsive and culturally and linguistically competent. HEROs are also university employees with backgrounds in health fields and are aware of the resources available in their communities and at the university, making them ideally situated to serve as practice coaches for the IMPaCT project.
Once practices were enrolled in the project, the local HERO made a series of visits to build relationships and assess priority needs. Based on the needs assessment, HEROs worked with the primary care practices in their regions to assist them in practice improvement and link them to needed resources and technical assistance, such as training and advisement from the State's Primary Care Association; assistance with electronic medical record adoption through the State's Health Information Technology Regional Extension Center; and university resources, such as the medical library, the hospital's electronic records system, specialists, preceptorship, housing for families of patients being treated at the hospital, residency, and telehealth. Outreach by physicians was found to be the most successful method for recruiting individual practices to participate in the program.
- 34 small primary care practices throughout New Mexico participated in the project. Of these, nearly half were in rural areas and almost half were minority-led. Half of the enrolled practices were private practices, one quarter were Federally Qualified Health Centers (FQHCs) or Community Health Centers, and the remainder were free clinics, school-based health centers, or tribal clinics.
- In their practice coaching roles, HEROs provided information and advice to practices about the patient-centered medical home (PCMH) model (especially electronic medical records) and linked practices to university resources, such as the medical library and the university hospital medical records system (to access the medical records of patients referred there). Three small clinics affiliated with FQHCs in the State received more intensive technical assistance to apply for PCMH recognition.
- The IMPaCT project also helped spur a growing community health worker program serving high-risk enrollees while helping New Mexico implement Medicaid Managed Care certification for its community health workers. These efforts provided a new employment opportunity while also meeting the workforce needs of low-resource primary care practices.
Dissemination Efforts to Partner States
"We helped a lot of small practices... obtain resources they needed, [which] were easy for us to access but of which the practices were unaware. They now feel more connected to the university, assured we'll respond to their needs."
The New Mexico IMPaCT project did not seek to replicate its own structure in the partner States, but instead emphasized how to build partnerships that could support transformation in the context of each State's needs and resources.
- Kansas: Dr. Kaufman and his team worked closely with the Department of Family Medicine at the University of Kansas to launch a Kansas version of the New Mexico program, exploring a partnership with Kansas State University. Kansas State University, in turn, hosted a statewide meeting presenting and discussing this model, linking health extension with Cooperative Extension.
- Oregon: Oregon Health Sciences University followed the HERO example and explored shared interests in health and agricultural extension through collaboration with Oregon State University's Cooperative Extension Service.
- Kentucky The HERO program consulted with Kentucky about opportunities for a statewide improvement infrastructure.
Shared learning from the New Mexico program continues to build, and it has invited other States, including Michigan, Utah, and Georgia, to learn from its efforts.
In partnership with the Commonwealth Fund, the New Mexico IMPaCT project also created an online toolkit to help other States, academic health centers, and tribes to replicate the health extension model. The toolkit shares experiences from all 17 IMPaCT grant model and partner States and explains the core components of health extension and how they can be applied and sustained in primary care and public health settings. Another grant from the Commonwealth Fund provided funds to support a national invitational conference to discuss the sustainability of the health/primary care transformation model. The conference was organized by the New Mexico IMPaCT project team and was held in Washington, DC in February 2014. Over 40 stakeholder agencies, organizations, institutions, and companies were represented.
Lessons Learned and Implications for Others
- A "demand-driven" rather than "supply-driven" approach is more successful. Through trial and error, the New Mexico IMPaCT team learned that practices were more open to participating in the project if they were able to discuss their priorities and interests than if they were offered a menu of resources to choose from.
- Interest in transformation was not what was anticipated. By communicating with practices about their needs, the team found that most were focused on keeping their doors open in a difficult financial environment and were unable to consider transforming into a PCMH until those needs were addressed. This was also true for the FQHC sites, but since the FQHCs were mandated to achieve PCMH recognition, they had an incentive to take advantage of the assistance the New Mexico IMPaCT project could provide.
- Relationships are vital to success. The University of New Mexico academic health center learned that relationships with practices, especially those outside of the Albuquerque area, were important and in need of strengthening. The project also showed that practice coaches can play a crucial role in building these relationships. Many practices were unaware of the resources they could tap into at the university until they enrolled in the project. Likewise, academic health center leadership became more responsive to the needs of practices outside the health system because of their involvement in the project. As a result, the University of New Mexico health system has begun exploring the idea of a Management Services Unit to provide support to practices around the State.
For More Information:
Kaufman A, Powell W, Alfero C, et al. Health extension in New Mexico: an academic health center and the social determinants of disease. Ann Fam Med 2010;8(1):73-81.
Phillips R, Kaufman, A, Mold J, et al. The primary care extension program: a catalyst for change. Ann Fam Med 2013;11(2):173-8.
Health Extension Toolkit. Web-based Tool. http://www.healthextensiontoolkit.org