Primary Care Extension Models in Lead IMPaCT States

Section 5405 of the Affordable Care Act authorizes the establishment of a primary care extension program (PCEP) to improve the quality of primary care services by “educat[ing] providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services, and evidence-based and evidence informed therapies and techniques.” The Agency for Healthcare Research and Quality (AHRQ) established the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative as a pilot PCEP. AHRQ awarded IMPaCT grants to four lead states:  New Mexico, North Carolina, Oklahoma and Pennsylvania.  These IMPaCT states have focused on expanding and evaluating primary care practice support efforts to develop sustainable infrastructure that supports practice extension and ongoing quality improvement in primary care practices.  Each of the four lead states partnered with three or four other states to disseminate the lead state’s PCEP model.

This chart examines the PCEP models in place in each of the four lead IMPaCT states, including infrastructure and strategies to support primary care extension and transformation. To learn more, please visit the national health extension toolkit at healthextensiontoolkit.org. Does your state have initiatives to support primary care extension? Do you have an update to a fact we’ve included? Your contributions are central to our community’s ongoing, real-time learning, so tell us in a comment below, or email the author with your suggestion. Felicia can be reached at fheider@nashp.org.

New Mexico North Carolina Oklahoma Pennsylvania
Overview of Primary Care Extension Model Community-based health extension agents located in regional hubs throughout the state. Primary care improvement initiatives built into the regional and network infrastructure of statewide organizations. A state hub, regional extension centers, and county level non-profit entities located throughout the state. A collaborative model bringing together existing practice transformation support infrastructure across the state.
Key Organizations and Roles The University of New Mexico Health Sciences Center’s Office for Community Health (OCH) which includes New Mexico’s Area Health Education Centers Network (NM AHEC), provides resources such as community-based training for the health workforce.OCH’s Health Extension Rural Offices (HEROs) –Ten Regional HERO Officers support HERO Agents who link providers and communities to resources and offer provider education, research, and services such as case management, practice support, and community health assessments.The New Mexico State University Cooperative Extension Service —This network of expert-staffed offices provides research-based information, family and consumer sciences, nutritional support, and family counseling. Community Care of North Carolina (CCNC) – A public-private partnership of regional networks. CCNC assists practices in Quality Improvement initiatives, reforming payment structure, and designing better care. CCNC has 14 distinct provider networks.North Carolina Area Health Education Centers (NC AHEC) – A large-scale practice coaching and improvement network program, serves as the state’s Regional Extension Center (REC). NC AHEC has 9 regional centers.North Carolina Healthcare Quality Alliance (NCHQA) – A forum for major players in the state (state government, insurers, providers, patients) to collaborate on improving health care quality. The Public Health Institute of Oklahoma (PHIO) – A non-profit organization that acts as the state hub for Oklahoma’s extension system and supports county partnerships.County Health Improvement Organizations (CHIOs) -Non-profit organizations that support quality improvement activities in primary care practices and work to improve community health. PHIO directs the certification process for existing community-based coalitions to become CHIOs, which contract with AHECs.Oklahoma Area Health Education Centers (OK AHEC) are a network of 4 regional centers that work with primary care practices on quality improvement initiatives. AHECs also provide educational support to practices. Pennsylvania Spreading Primary Care Enhanced Delivery Infrastructure (PA SPREAD) – A public-private partnership based out of the Penn State College of Medicine coordinating development of a statewide Primary Care Extension Service with a variety of partners.Pennsylvania Area Health Education Center (PA AHEC) – Regional office infrastructure provides local facilitation support for practices.Pennsylvania Department of Health–Leads a multi-payer medical home initiative that is part of CMS’ Multi-payer Advanced Primary Care Practice demonstration. Also coordinated multi-stakeholder development of PA’s Health Care Innovation Plan under a State Innovation Model (SIM) planning grant.
Payment (Payment to providers via Medicaid reimbursement or financial incentives to support primary care extension activities) Participating Medicaid managed care organizations fund Medicaid medical home models, provide payments to practices, and pay capitated monthly payments for community health workers (CHWs) to provide care coordination for high utilizing/high need members. Medicaid provides CCNC practices and the regional CCNC Networks payments to provide patient care, population management strategies, and support practice improvements, and improve the quality of care provided to the Medicaid population. CCNC also supports practices participating in the state’s Multi-Payer Advanced Primary Care Practice Project. SoonerCare Choice (a primary care case management program) payments incentivize practices to become medical homes. Payments include: initial quarterly per-member “transitional” payments to support practice transformation, traditional fee-for-service reimbursement for visits, a PMPM care management payment, andSoonerExcel performance-based incentive payments. In addition to the PMPM and shared savings payments available to practices participating in PA’s state-led multi-payer medical home initiative, several health plans are now also providing network-wide medical home-related pay-for-value payments.
Practice Data and Measurement (How the extension model supports the use of data and quality measurement by practices) HEROs link practices to resources at the university to assist them in choosing electronic record systems, obtaining health workforce data, and improving their quality improvement initiatives. CCNC manages the Informatics Center, an electronic data exchange infrastructure. CCNC care managers and practice facilitators use the Informatics Center to manage patients and understand some quality metrics. The NC AHEC assists practices in implementing electronic health records, and NC AHEC staff analyze practice-reported data. Numerous quality of care reporting systems are used in Pennsylvania. Some are payer- or health system-based. Some are managed by other organizations, including the Pennsylvania Academy of Family Physiciansand the Pennsylvania Health Care Quality Alliance.
Care Management (Care management assistance provided to practices through the extension model) HERO agents help train CHWs, who provide case management services for patients with high urgent or emergent care utilization.  CHWs educate patients and connect them to support services such as transportation to help them access primary care. CCNC networks have care managers that help identify patients with high risk conditions or needs, assist providers in disease management and follow up, assist patients in coordinating care and accessing services, and collect data on measures. CHIOs can hire care managers that expand the capabilities of primary care practices through patient education, training, care coordination, and advocacy. Care managers, often nurses or social workers, work within primary care practices and contract with CHIOs. PA SPREAD and its partners widely support development of practice-based care managers in medical homes. Partners help practices identify high-risk patients and support care transitions. The Department of Health also offers networking calls for care managers.
Practice Facilitation (Training and facilitation offered to practices) HERO Officers provide practice facilitation and coaching, helping practices to assess readiness for change and track progress. NC AHEC and CCNC offer practice facilitation on performance improvement, advanced care planning, Meaningful Use, and Patient-Centered Medical Home Recognition. The NC AHEC regions employ Quality Improvement Consultants that work closely with the CCNC networks to support practices in process improvements. OK AHEC will hire, deploy and supervise practice facilitators. Each AHEC hires ~18 practice facilitators. Specific activities may include performing practice audits and providing feedback, conducting patient surveys, training staff, and coordinating quality improvement initiatives. PA SPREAD and many of its partners offer practice facilitators to assist practices in transforming into medical homes. PA SPREAD has formed a Practice Facilitator Forum to bring together facilitators from across the state to learn from and support one another.
Population and Community Health (Efforts to connect communities and medical/social services, and promote health literacy and health equity) HERO Officers help primary care providers understand and adapt to local culture. HEROs contribute to compiling County Health Report Cards, and HERO agents collaborate with Department of Health Community Health Councils to track and address health disparities locally. CCNC’s population-based management approach aims to provide both disease management and prevention. CCNC also collaborates with local health departments and other community-based organizations that support patients. CHIOs develop a County Health Improvement Plan (CHIP). This coincides with the Medicare requirement that non-profit hospitals must now conduct community needs assessments and demonstrate a commitment to improving community health. PA SPREAD provides education/training on facilitating patient self-management by connecting practices with community resources capable of supporting patients in addressing their particular needs and achieving their health-related goals. Key partners in public and community health outreach include PA AHEC and the PA Department of Health.
Funding and Sustainability (How primary care extension activities are maintained and integrated into state infrastructure) Funding comes from various sources, such as university special appropriations, project-specific state and national grants, and partnerships with community organizations. For example, funding partners include Blue Cross Blue Shield, Molina, The Commonwealth Fund, Univeristy of New Mexico Clinical and Translational Science Center, and Centers for Disease Control sub-awards. NC AHEC‘s budget comes from dedicated state funding, state and national grants/contracts (e.g., REC), and contracts with individual health sytems.  CCNC Networks return a portion of their PMPM monthly for each enrollee to support the central office.  The NCHQA has helped secure funding from Blue Cross Blue Shield of North Carolina and the state’s share of the Tobacco Master Settlement Agreement. Value-based funding will come from contracts and project-specific state and national grants. Specific funding sources include Medicaid, the Tobacco Settlement Endowment Trust, private health insurance carriers, Medicare, and the Oklahoma State and Education Employees Insurance Group. CHIOs are required to develop a long-term sustainability plan. PA SPREAD has pursued several grants and contracts that foster collaboration in supporting primary care practices. Pennsylvania received a (SIM) Design grant from the Center for Medicare & Medicaid Innovation.Pennsylvania’s State Health Care Innovation Plan builds on the infrastructure in place and features the development of a Transformation Support Center, which aligns with the concept of the PCEP.
Assessing Overall Impact (Examples of overall impact of model on costs and health outcomes) There are cost savings and a return on investment of $4 per $1 invested in community health workers. CCNC has saved North Carolina $1 – $1.5 billion in health care costs and increased PCP utilization whiledecreasing hospital inpatient and ER utilization. CCNC providers also perform better on HEDIS measures than commercial managed care on chronic disease care. The program components closely resemble the SoonerCare Health Management Program, which has saved the state $139.2 million. Pennsylvania practices engaged in medical home initiatives have achieved widespread quality improvement, as reported in the literature. Several medical home initiatives also have documented reductions in utilization (ED visits, hospitalizations, readmissions) and costs.
IMPaCT Partner States (States that partnered to learn about and adopt the lead state’s PCEP model through IMPaCT) Kansas, Kentucky, Oregon Idaho, Maryland, Montana, West Virginia Arkansas, Colorado, Missouri New Jersey, New York, Vermont

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Chart Produced by: Felicia Heider, Carrie Hanlon, and Larry Hinkle, National Academy for State Health Policy