A health care cooperative extension service: transforming primary care and community health.

RIMARY CARE IS THE ESSENTIAL FOUNDATION FOR AN effective, efficient, and equitable health care system.Callstorebuildthecrumblingprimarycareinfrastructure in the United States are reaching receptive ears, with public and private advisory groups includingtheMedicarePaymentAdvisoryCommissionand the National Business Group on Health recommending increased payments for primary care. 1 The American RecoveryandReinvestmentAct(ARRA) 2 of2009appropriated$19 billion for the purchase of health information technology (HIT), with primary care physicians’ offices slated to be among the beneficiaries. Policy makers expect that new investments will transform primary care by creating more effective and efficient patient-centered medical homes. The primary care physician community acknowledges the need for new practice models that provide accessible, comprehensive, integrated care based on healing relationships over time. 3 New investment in primary care is necessary but not sufficienttorevitalizeprimarycareunlesscombinedwithastrategy for disseminating and implementing innovations and best practices. Acquiring an electronic health record (EHR) will not create a highly functioning medical home unless it can be used to create functional patient registries. Receivingenhancedpaymentsforcarecoordinationwithoutaworkable plan for hiring and training health coaches for patient self-management leaves a gap between expectations and reality. Large, organized delivery systems such as Geisenger, Kaiser Permanente, and the Veterans Administration have theinstitutionalwherewithalandeconomiesofscaletoimplement practice redesign in a systematic and successful manner. However, two-thirds of office-based physicians work in practices of 4 or fewer physicians. 4 These clinicians oftenhavelittleornotechnicalassistancetodeployandmaintain new practice improvements like EHRs. To successfully redesign practices requires knowledge transfer, performance feedback, facilitation, and HIT support provided by individuals with whom practices have established relationships over time. The farming community learned these principles a century ago. Primary care practices are like small farms of that era, which were geographically dispersed, poorly resourced for change, and inefficient in adopting new techniques or technology but vital tothenation’swell-being.Practicingphysiciansneedsomething akin to the agricultural extension agent who was so transformativeforfarming. 5,6 AnationwidePrimaryCareCooperative Extension Service, modeled after the US Department of Agriculture’s Cooperative State Research, Education,andExtensionService(CooperativeExtension),which so successfully accelerated farm transformation, should be created.County-basedhealthextensionorganizationswould supportprimarycarecliniciansinthesamemannerthatthe agricultural model assists family farmers, providing infrastructureforlocallearningcommunitiesandpracticetransformation. ARRA establishes a Health Information Technology Extension Program 2 to “assist health care providers toadopt,implement,andeffectivelyusecertifiedEHRtechnology,” which could serve as the nidus for a broader program to revitalize primary care and community health.