Principal Investigator: Robert Gabbay, MD, PhD, FACP, and Alan Adelman, MD, MS
Institution: Pennsylvania State University Hershey College of Medicine
AHRQ Grant Number: U18HS020988
Overview of Primary Care Extension in Pennsylvania
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.
The Pennsylvania Spreading Primary Care Enhanced Delivery Infrastructure (PA SPREAD) initiative involved State government, 152 (mostly small) primary care practices, 17 payers, and the primary care and business communities in an effort to help primary care practices throughout Pennsylvania transform into patient-centered medical homes (PCMHs). PA SPREAD had its origins in the Pennsylvania Chronic Care Initiative and efforts to improve diabetes care in the State dating back to 2007. PA SPREAD leveraged this work and the PA Area Health Education Center network to recruit a new group of practices (Lehigh Valley Health Network) and realign stakeholders statewide with a focus on primary care transformation. The extension agent program was built on a "general contractor model," where the team would act as a clearinghouse of expertise and provide information depending on the needs of an organization or group of practices (e.g.,, electronic health information technology practice facilitation or data needs), and connect those in need with local or regional experts in Pennsylvania.
Infrastructure Elements
A unique feature of PA SPREAD was a survey of providers about their specific needs and attitudes toward practice transformation. 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 fuel for the success of PA SPREAD was building relationships across stakeholder groups."
–Bob Gabbay, MD, PhD, Principal Investigator
Infrastructure elements of PA SPREAD expanded on those previously developed as part of the Pennsylvania Chronic Care Initiative and included: 1) refining the learning collaborative model, 2) furnishing practices with further information technology infrastructure assistance, and 3) recruiting new practices and providing a larger network of facilitators. Direct transformation services included convening a learning collaborative, providing practice coaching, and assisting with data analysis.
The PA SPREAD learning collaborative included primary care practices, government agencies, payers, and professional organizations. Four sessions were held to provide practical training on planned care, process redesign, plan-do-study-act quality improvement cycles, achieving PCMH recognition from the National Committee for Quality Assurance, sustaining practice changes, and sharing experiences between practices. Practice coaches acted as conveners, skill builders, knowledge brokers, and problem solvers in order to help practices achieve their transformation goals. Coaches provided onsite practice facilitation as well as monthly written feedback on reported changes. They also held individual conference calls to evaluate the testing and implementation of critical changes, address specific questions and concerns, and assist the teams in monitoring and using data to define improvement (i.e., goals). Additionally, practice coaches helped facilitate collaboration between participating practices by organizing onsite visits for practices wishing to see exactly how processes were implemented at other sites. Site visits proved particularly effective in helping practices understand how exactly to implement various components of the PCMH model. Monthly data reporting was another critical component of practice facilitation that coaches used to drive change.
"One of the most satisfying impacts 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."
–Bob Gabbay
PA Spread convened in-person stakeholder meetings that brought together the PA Area Health Education Center, Department of Health, Department of Public Works, Pennsylvania Academy of Family Physicians, Pennsylvania Regional Extension and Assistance Center for Health Information Technology, commercial payers and Medicaid, and hospital systems. This led to the development of trust between partners statewide, which was critical to the program's overall success.
A defining feature of PA SPREAD was the general contractor model, where the program acted as a hub for practices to help them access needed information and expertise. PA SPREAD connected practices with people who could assist with EHR implementation, direct practice facilitation, or data needs.
A second defining feature of the program was the use of a staged process of transformation. Stage one involved convening stakeholders; stage two involved providing direct services to practices via practice coaches; and stage three involved providing shared services through the general contractor model.
Program Impacts
- Three practice facilitators assisted 19 practices in southcentral and north west Pennsylvania become PCMHs.
- Several practices reported that participation in the program greatly facilitated their achievement of National Committee for Quality Assurance PCMH recognition, because they already had the required elements in place after participating in the PA SPREAD project.
- PA SPREAD had an enduring impact on relationships among participating stakeholders throughout Pennsylvania. The relationships built from this project led to the development of a State Innovation Model grant through the Center for Medicare & Medicaid Innovation.
- PA SPREAD also led to the formation of a national advisory group. The group, which met regularly, included luminaries of primary care transformation as well as other IMPaCT grantees who were able to share their ideas and experience.
Dissemination Efforts to Partner States
Stakeholder meetings were held with the partner States: New Jersey, New York, Pennsylvania, and Vermont. Transformation leaders from each State met regularly to share their experiences. Because each State was at a different point on the continuum of practice transformation, PA SPREAD acted as a conduit of information sharing among them. The general contractor model proved effective in disseminating transformation activities to the partner States. New Jersey was at the beginning of the process of implementing practice transformation efforts, New York was well along the path of transformation, and Vermont was an excellent example of accomplished practice transformation. The partner States learned as much or more from sharing their experiences with each other as they did from the lessons learned from Pennsylvania (the model State).
A second important component of the spread activities in the partner States involved bringing together individuals from within those States who were previously unknown to each other. Meetings allowed time for State-level representatives to talk about intrastate issues. This type of relationship building was critical in the success of spread activities within Pennsylvania, and New York was able to further its transformation efforts by connecting work being done in the Adirondacks, Hudson Valley, and Beacon communities and bringing in United Health Group as a partner. These efforts culminated in a State Innovation Model grant submission in New York.
Challenges and Sustainability
The general contractor model, which was rolled out in three stages, was a key element of sustainability in the partner States. In particular, this model allowed for economies of scale and efficiencies in providing transformation services across multiple practices. Also, the emphasis on relationship building between stakeholders and the trust that was built across practices were integral to sustainability.
"New York was really connecting the dots. There were pockets of great work being done—a bunch of great stuff. But most people in the State didn't know about those things. So they all connected, and as a result they really catapulted to the head."
–Bob Gabbay
There were three key challenges for this project. First, 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. "PCMH transformation" ranked at the bottom of their priorities. Second, recruiting practices was difficult because of competing efforts within Pennsylvania. Some other hospital-based collaboratives were well funded and could provide individual practices with financial incentives for change. These types of incentives were not available through PA SPREAD. Engaging employers as stakeholders also proved to be a challenge because there were too many employers, and the contacts at the various companies didn't understand the importance of practice transformation or the medical home.
Lessons Learned and Implications for Others
Serving as a clearinghouse (i.e., the general contractor model) proved to be a low resource-intensive approach, which should be feasible to replicate in any State. This model employs a hub that provides oversight and training but makes resources available to smaller practices—like a public utility that is available for anyone to buy into. Rolling out transformation in stages was also found to be a successful approach. Additionally, providing technical assistance (e.g., practice facilitation, data analysis, and learning communities) followed by shared resources (such as care managers) was useful for practices undergoing primary care transformation. Finally, building relationships among stakeholders engendered familiarity among players, trust, and a willingness to come together to solve problems.
For More Information:
PA SPREAD: Pennsylvania Spreading Primary Care Enhanced Delivery Infrastructure. Available at: http://paspread.com/.
