Shared Resources | Health Extension Toolkit

Support for primary care transformation, including becoming a patient-centered medical home, adopting electronic medical records and their meaningful use and undergoing the social transformation of new provider and staff roles called for in NCQA-certified levels of change is easier when primary care practices are a part of well-resourced, larger systems of care.

However, with the majority of primary care practices in the U.S. being small and independent, a Primary Care Extension Program can bring together to groups of primary care practices “shared resources” no individual practice could afford on its own.

Health extension agents link small, private practices, small federally qualified community health centers and small tribal practices that have taken their Public Law 638 option and become independent from the Indian Health Service and provided such shared resources as practice transformation coaches,a variety of Telehealth programs, rapid electronic access to the academic health center’s medical library for decision-support tools, linking patients to local food pantries and nutrition education through the Cooperative Extension Service.

What are Shared Resources?

The PCEP provides the necessary infrastructure, particularly for those isolated small clinics, to successfully diffuse research coming from such entities as the Clinical Translational Science Centers and from Practice-Based Research Networks and implement quality-improvement efforts to assist practices in adopting newer methods. However, smaller primary care practices often haven’t the awareness or ability to create or access the many supportive resources needed to achieve the practice transformation they will need to meet the requirements of the changing world of healthcare delivery. One approach devised by the PCEP effort is to have Agents serve as brokers between the practice and the many needed resources that can be brought to the practice or group of practices in a geographic location.

In New Mexico, the HERO program decided to approach practices in a “demand” rather than “supply” mode—what did the practices actually need to improve their quality and contribute to their communities’ health instead of limiting what HEROs offered practices to a set of pre-conceived resources. Such open-ended inquiry led to a much broader set of needs and requests. Here are some examples: A way to get unassigned University Hospital ED patients assigned to a community practice; Help in recruiting physicians and mid-levels; Help in tracking patients referred to UNM HSC for which no information returned to the practice; Help in accessing the medical library and in receiving CME credits; Help in identifying health educators, especially diabetes educators to run groups in the practice; Help in writing grants to support practice innovations; Help in identifying epidemiologic help in evaluating and reporting on clinical programs the practice had developed.

How Shared Resources Address the Struggles of Small, Independent Practices

Eighty percent of primary care practices in the United States have five or fewer practitioners. Most are small and independent. While the trend for primary care practices features practitioners employed by hospitals, large, multispecialty groups, community health centers and federal employment in the military or Indian Health Services, where large group resources can supply resources for primary care transformation, today’s reality finds many small, independent practices struggling to keep their doors open. They don’t have resources to keep abreast on the latest evidence-based medicine that may lead to more efficient practice.

VIGNETTE FROM A HEALTH EXTENSION AGENT:

A small, private primary care clinic in Albuquerque’s South Valley asked for the assistance of a HERO Agent who served that neighborhood. The clinic served a predominantly Hispanic clientele with half the patients uninsured, the rest Medicaid, Medicare and commercially insured. The clinic was staffed with a part time physician and four part time mid-levels. Within two visits, the following Shared Resources were mobilized/borkered for this clinic:

* Link with UNM Financial Services so all uninsured county residents could be enrolled in UNM’s sliding scale or financial assistance program to ease the financial burden on indigent patients with medical need

* Link with LCF Research to ensure their newly acquired EMR could fulfill the criteria for “meaningful use” and receive the $40,000 for which they would then be eligible via Medicaid

* Link with urban Cooperative Extension Agent to provide nutrition counseling and cooking classes for selected patients

* Link to 24/7 Nurse Advice Line so all clinic patients received a refrigerator magnate with instructions on how to access the Line, avoid preventable and costly ER visits.

* Designate the practice as a teaching site for UNM PA students and receive academic benefits for this role

* Link with the UNM Emergency Department’s web-based Primary Care Dispatch so patients discharged from the ED without a medical home could be assigned to this clinic

* Hook up to several UNM Telehealth resources including Project ECHO to offer skills training to their primary care providers in complex chronic diseases via teleconferencing

* Assistance with linking practice computer with UNM Hospital EMR for “read only” capability so the practice could follow outcome of ER visits, specialty referrals and hospitalizations for all their patients referred to the UNM system.

* Linked clinic to the Community Health Worker training program at the local community college with planned assignment of CHW students to help clinic patients with social and enrollment needs.

Examples from NM: Shared Resources for Practices

The chart below illustrates the range of accessible resources with which the HERO program in New Mexico works.

Complementing the state’s IT Regional Extension Center: New Mexico’s program decided to complement rather than duplicate other state-wide resources assisting primary care practices. LCF Research, the non-profit research entity to which the New Mexico state government assigned to apply for and run the state’s Health Information Exchange and its Health Information Technology Regional Extension Center offers all primary care practices and community hospitals assistance in selecting an appropriate electronic health record and its meaningful use. Successful completion of these steps enables each practitioner to receive $40,000 to $60,000 for adequate adoption of this technology in their practice. LCF Research, however, recognized that for more extensive practice transformation consistent with the primary care objectives of the ACA, small practices needed assistance beyond the technological improvements. They called upon HEROs to expand this service.

Insights from Pennsylvania

As PA conducted environmental scans in their state and each of their dissemination states (NJ, NY, VT), they realized the breadth of resources already working to support primary care transformation and the importance of aligning these resources. Its National Advisory Group also challenged their thinking about their role both within PA and with their dissemination states. Therefore, it has developed a more developmental and collaborative model for the Primary Care Extension Service, as shown below.

While Pennsylvania has numerous technical assistance providers and some initial local development of shared services to support smaller practices, no one has worked to foster collaboration and shared learning across these initiatives. That “Clearinghouse/Convener” role is seen as a key role for the Primary Care Extension Service in PA. For the past year, there have been quarterly partner meetings including representatives from government, health systems, payers, the state REC, provider organizations, and other stakeholder groups. They have also begun convening practice facilitators throughout the state to better learn what “facilitation” looks like in Pennsylvania and to begin to share best practices.

Over time, and as needs are identified, it is possible the Primary Care Extension Service may provide more direct technical assistance and shared services for practices and health systems. It also is possible that the Primary Care Extension Service formalizes a collaborative regional infrastructure and looks something like the following: