Lessons in Primary Care Extension from Four States

By Larry Hinkle
October 2013


Many states are testing primary care extension as a strategy for supporting continuous quality improvement in practice. Primary care extension is based on the model of the Agricultural Extension Service. In health care this model applies scientific research and new knowledge to practices through provider education – often led by other providers or specially trained practice facilitators.

Primary care extension appears in the Affordable Care Act (ACA). Section 5405 establishes a primary care extension program through the Agency for Healthcare Research and Quality (AHRQ) that will provide support and assistance to primary care providers to: “educate providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services, and evidence-based and evidence-informed therapies and techniques.”

Section 5405 was a motivation for AHRQ’s “Infrastructure for Maintaining Primary Care Transformation – Support for Models of Multi-Sector, State-Level Excellence” (IMPaCT) initiative. The IMPaCT project awarded grants to four states: New Mexico, North Carolina, Pennsylvania and Oklahoma, and was designed to support model state-level initiatives using primary care extension agents to assist with primary care practice quality improvement. The goal for the IMPaCT states was to support, expand, evaluate, and disseminate primary care practice support efforts to transform and develop sustainable infrastructure that supports practice extension and ongoing quality improvement. The models tested by these states could one day potentially serve as an example for a national primary care extension service.


The National Academy for State Health Policy (NASHP) partnered with the University of North Carolina at Chapel Hill to disseminate lessons from North Carolina to four learning community states: Idaho, Maryland, Montana and West Virginia. North Carolina. NASHP supported these states in adapting elements of North Carolina’s robust infrastructure that supports primary care extension along with shared resources to support practices. This includes the various roles assumed by Community Care of North Carolina (CCNC), the North Carolina Area Health Education Centers (NC AHEC), and the North Carolina Health Care Quality Alliance (NCHQA) in North Carolina’s nationally recognized model.


Over the course of the North Carolina IMPaCT project the Learning Community states participated in a number of technical assistance activities to spread best practices from North Carolina. These activities included a site visit to North Carolina where the Learning Community states were able to learn first-hand from experts heavily involved in North Carolina’s extension model. The states also participated in webinars with experts from North Carolina (and other states with strong extension models including Oklahoma and Vermont) on a number of topics about the infrastructure required to support primary care extension: including: data infrastructure, making the business case, performance measurement, care management, engaging practices in quality improvement, and sharing resources in a multi-payer model. The Learning Community also participated on conference calls, allowing the states to learn from one another.


Overall each of the North Carolina IMPaCT Learning Community states took steps forward in building the infrastructure necessary to support primary care extension and shared resources to support practices. Highlights of state accomplishments from the project include:

  • Idaho adapted information learned from North Carolina in Idaho’s successful application for a State Innovation Model (SIM) Design grant, which builds directly upon Idaho’s plan to adapt aspects of North Carolina’s model for primary care extension.
  • Maryland, with guidance from the NC AHEC and CCNC, used an expert consultant to train two Practice Transformation Coaches to assist primary care practices in the transformation process. Maryland secured a care manager embedded in each practice responsible for helping the practice implement the changes necessary to become a patient-centered medical home (PCMH). Maryland also developed a set of 21 metrics to measure the performance of practices.
  • Montana successfully promoted statewide awareness about PCMH. Montana developed a one-page fact sheet to provide key information about PCMH. This fact sheet was helpful in Montana’s effort to pass Senate Bill 84, which removed major barriers to implementing a PCMH program.
  • West Virginia articulated a shared vision in its white paper, Building the Infrastructure for a Healthy and Prosperous West Virginia. The paper touches on plans for performance measurement, care management, leadership development, and partnerships. The white paper has been shared with both the Governor and the West Virginia Health Senate Committee.

In addition to these accomplishments, the North Carolina IMPaCT Learning Community States have many lessons to offer other states interested in developing their own infrastructure to support primary care extension. A recent NASHP publication details the challenges, strategies, lessons and accomplishments of the Learning Community. We encourage those interested in primary care extension and transformation to read the paper to learn more!


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