The fundamental strategy to address the challenges to primary care infrastructure and practice is the concept of Health Extension as a community-based, state-wide, but university-linked network of agents that can assist primary care practices with the best evidence-based practices to support the provision of quality care and practice transformation. These resources are important for the transformation process since many practices do not have the capacity nor could they afford to develop and support these developmental milestones on their own.

The Movement toward Patient-Centered Medical Home

The movement towards Patient-Centered Medical Homes (PCMHs) is a growing national expectation of primary care practices. Practices are expected to ensure that each patient receives continuous care from a clinician; that each clinician takes the lead when referring the patient to specialists; that each practice make meaningful use of electronic health records; and that every patient and family actively participates in their own care. However, aside from federal support for adopting electronic health records and implementing their meaningful use, most primary care practices will not receive external funding to implement other vital components of healthcare reform including the transformation to PCMH. They will need assistance in reallocating existing scarce resources to implement needed change; in finding relevant primary care demonstrations conducted elsewhere; and guidance on how they can adapt different aspects of successful models in their own practice.

Health extension is an established, unique, replicable model addressing priority community health problems with resources from universities and agencies. Health Extension is a method of helping primary care practices overcome barriers to transformation by sharing common resources. It connects resources of the academic health center, public health and other state agencies, to a state’s rural, minority, and underserved communities that depend on primary care practices for immediate access to health care.

PCMH- What’s in it for small practices?

The majority of primary care practitioners work in small or moderate sized practices (10 or less primary care providers). Adoption of a PCMH is difficult for many small, independent primary care sites that are often isolated from one another and in turn are further isolated from specialty and support services required for comprehensive care of various and complex conditions. Health extension offers an opportunity to share resources across practices and geographic distances and to help small practices meet their functional requirements as medical homes.

Supporting Readiness for Change

Improving health and health educational/health delivery systems involve both technical and adaptive change, and their related challenges. Teasing out the adaptive side of institutional change requires looking at the institution as a complex human system. Nationwide, we are currently caught in the gap between early findings of the challenges around readiness for change and adaptive reserve, and the emergence of tools to assess and plan strategies for building the adaptive reserve necessary to tolerate the discomfort and disruption that comes with improvement.

“Patient- and Family-Centered Care Organizational Self-Assessment Tool”

“Seven Leadership Leverage Points”

“Execution of Strategic Improvement Initiatives”

Many organizations offer models assessing primary care practice readiness for change toward PCMH. One of the most organized is from Transformed, a subsidiary of the American Academy of Family Physicians. The components of the Transformed model include an on-line assessment applicable for clinical staff, office staff, and residency programs; a transformation package specially designed for small practices; medical home facilitation offering an on-site practice facilitator; a baseline practice assessment via surveys, interviews, phone conversations and e-mail communications with key practice staff.

Group Health Cooperative offers an Assessment of Chronic Illness Care tool. The survey helps systems and provider practices move toward the “state-of-the-art” in managing chronic illness. The results can help clinic teams identify areas for improvement. Click on the image below to access the assessment.

“Assessment of Chronic Illness Care”


Building Capacity for Technical & Adaptive Change

Strengthened primary care regarding its quality and its service to community health is of vital interest to our society. It is especially the case in the current environment where resources are increasingly constrained, the supply of primary care physicians and providers cannot meet the demand for those seeking a medical home. So it is imperative that, as an effective way to build capacity, many parallel, poorly communicating systems of health care come together and coordinate their efforts, thereby providing a more efficient, more effective health system with less duplication of services and less neglect of important health needs of our patients and their communities. Health extension can draw upon and pull together the following organizations:

Professional Organizations (state and national medical societies; AAFP; APA; ACP: Primary Care Organization; I.H.S.; VA)
It is in their interest to support their primary care constituency, help them learn and thrive in a new, managed care and shrinking resources environment.
Higher Education (community colleges, branch campuses)
Highly effective for being market sensitive in how they develop their education program to address workforce skill to meet the needs of local industry.
Cooperative Extension
Offers a ubiquitous set of professionals skilled in areas of great importance to primary care, yet untapped because as medicine vs. agriculture; flagship vs. landgrant universities, they function as parallel, non-communicating bodies.
Department of Health
Provide shared essential services to many patients who are enrolled in managed care clinics such as WIC, immunizations, STDs, family planning, and have a wealth of community health data. With better coordination, the link between the two could be strengthened for the mutual benefit of both.
Clinical Pharmacists
Have the capacity to monitor patient adherence to primary care physician prescriptions, notify physician when medications are not picked up; have capacity to administer immunizations, check blood pressures and glucose levels.
Managed Care
Managed Care’s bottom line is improved when high risk, high cost enrollees in their health system can have their health and social needs addressed in their home community by culturally competent community health workers (CHWs). These CHWs can help primary care clinics address social and economic risks experienced by their patients, a service primary care clinics would be unable to afford.

Practices have Different Needs

Practices have different needs and change at different rates depending on their readiness for change, history with change, and resources available, including staff and funds.

Practices are often so overwhelmed with patients and feel stretched in terms of staff and resources, so they need help and guidance–which EMR to choose? How to achieve meaningful use? How and where to recruit personnel? How to offer continuing education for their staff? How to keep current with the best evidence of practice when information overload is manifested by the growing pile of unread journals?…


Profile of practice: very new, independent, private, urban inner city practice, 4 part time physicians, 3 mid-levels

Population served: predominantly Hispanic, half uninsured, sizeable percent of undocumented immigrants

Needs: expand patient base, link to community services practice cannot provide, assistance with EMR, health education classes for patients with high rates of diabetes

Services provided to this practice by Health Extension Agent:
* Placed practice on University ER referral list
* Linked practice to IT resource to help practice apply its new EMR to meaningful use and appy for $40,000 Medicaid funds for adopting the technology
* Invited in University PA program director to designate practice as PA training site
* Linked practice with urban Cooperative Extension program to offer patients classes in nutrition
* Linked practice to 24/7 statewide Nurse Advice Line (with interpreter services) free to all patients of the practice
* Linked practice to Telehealth programs of the University
* Assigned Community Health Worker students trained at a nearby community college to this practice to provide social interventions, enroll patients in available health and social welfare programs

Health Extension Role in Primary Care Practice Transformation

Health extension can provide practices with “academic detailing”, a transformation pharmaceutical detailing which instead brings best practices & evidence-based interventions to practices. Click below for more information on this concept:

Health extension agents can help gauge the help practices need and want

Health extension agents can survey the practice regarding readiness for change and suggest where to start along the path to practice transformation– click below for some sample assessment tools:

“Patient- and Family-Centered Care Organizational Self-Assessment Tool”

“Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice”

NCQA PCHM Scoring Summary- 2011

Related Literature & Tools

“What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice”

“The Patient Centered Medical Home Movement: Why Now?”

“Trends in Quality During Medical Home Transformation”

Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide

Building Medical Homes: Lessons from Eight States with Emerging Programs

Core Value, Community Connections: Care Coordination in the Medical Home

Strengthening Primary and Chronic Care: State Innovations to Transform and Link Small Practices

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States



Metrics and Evaluation Financing Message Mapping Building a Movement Chp6 Sustainability Diverse Populations Critical Health Literacy CHWs Chp5 Population Health Beyond PCMH Shared Resources Community Health Systems Small Practices PCEP Chp4 Primary Care Health Outcomes Core HERO Functions Engagement Perspective HERO Model Chp3 Health Extension Model Public Health Cooperative Extension Academic Health Centers Primer for Engagement Chp2 Engagement What is a Hero General Overview Using the Toolkit Chp1 Getting Started