Building a statewide support system to transform primary care

By Jill Rosenthal

June 2012

North Carolina’s success in developing a statewide infrastructure that supports a robust primary care system has resulted in better health outcomes, lower cost, and a new way of organizing and improving health in the state.  This success is due largely to its ability to synchronize and align initiatives within the state.  A recent issue brief, The North Carolina Healthcare Quality Alliance: Lessons in Aligning Quality Improvement Strategies Statewide, released by the National Academy for State Health Policy (NASHP) focuses on the evolution of the North Carolina transformation model, and the support and collaboration that have enabled it to succeed


This issue brief is one product of NASHP’s role in North Carolina’s Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative.  North Carolina was one of four states selected by the Agency for Healthcare Research and Quality (AHRQ) through this initiative, designed to support, expand, evaluate, and disseminate leading state-level primary care practice support efforts to transform primary care practices, develop sustainable infrastructure for quality improvement in primary care practices, and serve as potential models for a national primary care extension service. With support from AHRQ and The Commonwealth Fund, NASHP manages North Carolina’s dissemination activities, which include supporting efforts in Idaho, Maryland, Montana, and West Virginia to adapt the North Carolina model to their own unique environments.


Over the past two decades, North Carolina has developed regional networks of providers working together through a medical home model; an innovative payment structure that rewards coordinated care; primary care residency and professional training focused on performance improvement activities; learning networks of practices and quality improvement consultants; and supports that include technology, care management techniques, decision support tools, self-management, and protocols to standardize care.  These components are coordinated and aligned among public and private payers, resulting in an infrastructure that supports ongoing quality improvement.


The major components of North Carolina’s model are the following:

The North Carolina Healthcare Quality Alliance (NCHQA), originally the Governor’s Quality Initiative, provided a forum for these initiatives and all of the major players (state government, insurers, providers, patients) in North Carolina to collaborate on improving health care for North Carolinians through promotion of evidence-based primary care.  The Medicaid program’s innovative payment structure and support for the CCNC data infrastructure have been critical to success.  Blue Cross and Blue Shield, the state’s dominant insurer, also joined in.

A focus on finding synergies among initiatives is a critical lesson for other states interested in North Carolina’s model.  North Carolina’s leaders are masters at identifying mechanisms to ensure stakeholders satisfy their own self-interests at the same time they promote a greater good.  For instance, partners build their system components in a collaborative manner that enables them to:

  • streamline technical support for providers;
  • avoid competing requirements (e.g. data reporting) that would increase the burden on providers;
  • build on, and take advantage of, existing systems;
  • determine how to weave collaborative goals into grant applications in order to share resources and support continued efforts to align initiatives.

The NASHP issue brief identifies these lessons:

  • Develop a platform for cross-initiative collaboration outside of the on-the-ground, day-to-day efforts of the partners.
  • Provide a neutral forum for leaders to address high-level, often sensitive policy issues, such as transparency and competition.
  • Choose leaders carefully.
  • Engage additional payers to help spread quality improvement efforts.
  • Carefully weigh the benefits of forming an organization that sits within state government versus forming as a non-profit organization
  • Nurture personal relationships among board members and stakeholders to build trust and success.
  • Identify key opportunities to collaborate.
  • Foster public/private sector collaboration to ensure that initiatives are statewide and reach a large portion of the population.

Look for follow up information on North Carolina and the states adapting this model at NASHP’s 25th Annual State Health Policy Conference, October 15-17, in Baltimore, Maryland.



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