Family Physician Calls for Cooperative Extension Service for Primary Care

The federal government should establish a cooperative extension service modeled after that used by the U.S. Department of Agriculture to help primary care physicians transform their practices into patient-centered medical homes, according to a family physician who spoke here on April 23.

AAFP member Kevin Grumbach, M.D., professor and chair of the department of family and community medicine at the University of California, San Francisco, laid out some of the provisions of a cooperative extension service for primary care during a forum sponsored by the Society of Primary Care Policy Fellows.

According to Grumbach, states could form centralized hubs to organize practice transformation programs in their respective states or regions of the country. The hubs would deploy personnel to work with private health care practices, community-based primary care practices, community health centers and hospital outpatient departments to promote practice transformation. The federal government would fund and direct the program via HHS, but the real action would happen at the local level, with county extension office personnel who would work directly with practices, said Grumbach.

"(Local agents) would create a sense of local learning communities among all primary care practitioners in a county, or a group of counties, or in sparsely populated rural counties," said Grumbach.

For example, local agents could help practices implement health information technology, or HIT, in a useful way by showing them how to create a patient registry or a reminder system to alert physicians about needed services, said Grumbach. Local agents also could help practices build team-based models of care or create practice-based research networks to develop a process for generating new knowledge and sharing it to support local workforce development, he said.

Grumbach alluded to the U.S. Department of Agriculture's Cooperative State Research, Education and Extension Service as an example of how a similar program could work in health care. The federal agriculture department's extension program is a partnership between state agriculture departments, land-grant universities and farmers, according to Grumbach. The program places an extension agent in every county in the United States. The agent serves as a coach to help farmers adopt new technologies and new methods of farming. The agent also helps facilitate the sharing of best practices and the exchange of information.

One of the goals of an extension program for primary health care would be to create a shift from a reactive to a proactive model of care that includes managing a defined patient population and focusing more on proactively managing chronic diseases and providing preventive care, according to Grumbach.

"At this point, we know what a high-performing, advanced primary care medical home looks like," he said. "The problem is, change is hard, particularly in primary care. While you are on that hamster wheel running as fast as you can, it is very hard to step off and engage in the process of practice change."

Grumbach pointed out that two-thirds of primary care physicians work in practices with four or fewer physicians, making primary care very decentralized in many instances. "It is remarkable how many primary care providers are working in small offices, including health centers that are relatively modest in size, throughout the United States," he said. "They just don't have the institutional infrastructure to support the change process."

Unlike most family physicians, hospitals have entire HIT departments to support the needs of their employees. "What do you do when you are out there on your own, and you get a nice new machine, and you turn it on, and you want to know how many diabetics are in your practice … and you have no idea how to do that?" Grumbach asked. An extension program for primary care could help address these types of situations, he said.

A few primary care programs in the United States already operate programs that are similar to the extension program Grumbach described. For example, he said, the University of Oklahoma's Department of Family and Preventive Medicine started an extension program about 15 years ago. That program currently deploys about 250 clinicians in 110 counties throughout Oklahoma. Their mission is to provide community physicians with access to information and education to enhance their practices and generate new knowledge, said Grumbach.

"They have something very analogous to the agricultural cooperative extension agent that they call a practice enhancement assistant, known as a PEA," Grumbach said. "They develop a relationship with four, six, eight practices in their community in a sustained, ongoing local way.

"This is not parachuting in, doing a workshop and leaving," he said. "This is ongoing relationship-building, just like that agricultural extension agent (who)would go and lean across the fence and talk with the local farmer about what is going on."

The Oklahoma program has resulted in demonstrated improvements in diabetes and preventive care among patients who visit participating practices during the past 15 years, said Grumbach.