The recently enacted Patient Protection and Affordable Care Act (PPACA) provides policy and funding support for important aspects of practice transformation geared to improving care quality while reducing cost. Section 5405 of PPACA authorized the creation of a national primary care extension program. However, many portions of the Act that encourage innovation through national demonstration and pilot projects were authorized but unfunded. It is now left to states to generate their own innovations which will create a marketplace of healthcare issues.

Role of the Affordable Care Act

With passage of the Affordable Care Act in 2010 (ACA), Congress mobilized unprecedented support for innovations in health service delivery and improved access to care in the U.S. Elements supported by the ACA, such as the patient-centered medical home, the role of community health workers, the support of health teams, the support of Teaching Community Health Centers and the Comprehensive Primary Care initiative all bolster the role of primary care within the U.S. healthcare system. These ACA elements built on years of innovation, modeling primary care practice transformation using practice facilitators, building infrastructure necessary for electronic medical records, and piloting different forms of collaborative practice. The elements were tied together in unifying goal, first articulated by the Institute for Healthcare Improvement and adopted by the Center for Medicare and Medicaid Service— the Triple Aim: improve the patient’s experience, improve the health of populations, and reduce per capita costs of health care.

In New Mexico, the concept of a “Health Commons” as a one-stop-shop for care was created which integrated in one clinic the services of primary care, behavioral health, oral health, social services and public health with clinic/community liaisons (community health workers). Two of the Health Commons models are housed in a federally qualified community health center and, via an MOU with the UNM HSC, serve as continuity clinical training sites for residents in Family Medicine. Those clinics were very popular training sites in primary care and have attracted the most residency graduates to practice in those locations, thus becoming de facto “Teaching Community Health Centers.”

Section 5405- A Primary Care Extension Service

As part of the creation of the ACA, the staff of the Senate Health, Education, Labor and Pensions (HELP) Committee, the committee tasked with writing the bill, invited the Health Extension programs from New Mexico and Oklahoma and champions of the concept from the American Association of Family Physicians and UC-San Francisco to contribute ideas for writing a piece of the legislation entitled the Primary Care Extension Program. Drafts were written and this group invited to meet the HELP Committee staff helped edit and rework the concept which eventually became Section 5405, the Primary Care Health Extension Program. While extension programs in different states followed different models and had different scopes, the ACA section focused on those aspects of Health Extension that were related to primary care in light of the significant role the ACA developers saw for primary care in the new healthcare system.

Section 5405 was intended to assist primary care providers to implement a patient-centered medical home to improve the accessibility, quality, and efficiency of primary care services. It would accomplish this through the local deployment of community-based practice improvement facilitators and health connectors (“Health Extension Agents”). And states receiving funding through this section could implement discretionary activities beyond practice facilitation roles such as “collaborating with local health departments, community health centers, tribes and tribal entities and other community agencies to identify community health priorities and local health workforce needs, and participate in community-based efforts to address the social and primary determinants of health, strengthen the local primary care workforce, and eliminate health disparities.”

The ACA authorized the Agency for Healthcare Research and Quality (AHRQ) to create the national Primary Care Extension Program. Federal funding for this section would be allocated through AHRQ. Though Congress authorized Section 5405, it did not appropriate funds for it. However, AHRQ mobilized $4 million of its own resources to fund four states directly to develop Primary Care Health Extension and for each to disseminate their model to at least three other states.

The PCEP Model

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.

In NM, the HEROs program 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. HEROs connects resources of the academic health center, public health and other state agencies, and the state’s predominantly rural, minority, and underserved communities that depend on primary care practices for immediate access to health care.

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 model of how HEROs functions as a “Primary Care Extension Program” is demonstrated below:

In Oklahoma, it is recognized that the transformation of primary care cannot be accomplished by focusing entirely on practices. Links between primary care and subspecialists, hospitals, home health and hospice agencies, public and mental health departments, and community resources must be strengthened. Because health and illness are multi-determinant, health improvement requires community wide collaboration and multi-level interventions. Problems like obesity,
inactivity, and smoking cannot be solved without community-wide collaboration. Even problems like hypertension might be better addressed at a community level. In addition, small and medium-sized primary care practices will not be able to afford to employ, train, and supervise the staff required to support many components of the PCMH including care management, registry management, and patient education. Their survival will depend therefore on their ability to share key personnel and resources across practices. Over the past decade, Oklahoma researchers have contributed to a body of knowledge that suggests that the combination of performance measurement with feedback, academic detailing, practice facilitation, and HIT support, with or without local learning collaboratives, consistently enhances implementation of specific evidence-based practices and facilitates transformative changes in small to medium-sized primary care practices.

Application of Health Extension to Primary Care Transformation

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

Health extension 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

“The Health Commons and the Care of New Mexico’s Uninsured”

“Infrastructure for Large-Scale Quality-Improvement Projects: Early Lessons From North Carolina Improving Performance in Practice”

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

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



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