The primary care cooperative extension service and beyond

Discussions around healthcare usually come back to the importance of primary care. We have written about primary care extensively on this site, and one cannot look through the news of late and not see primary care somewhere in the conversation.

One idea that was written about in 2009 by Drs. Grumbach and Mold was to take an older successful program, the Cooperative Extension model, and apply to a traditional problem; primary care, in this case. From their brilliantly constructed JAMA article on the topic:

“The Cooperative Extension was launched in 1914 as a collaboration among federal, state, and county governments, agricultural experts at land grant universities, and farmers. This program sped adoption of innovations through coaching by local change agents in every county, with whom farmers developed a trusting relationship. Agents are linked to a regional hub of an agriculture department at a land grant university, a resource for research evidence on best practices and promising innovations. Extension agents and farmers work collaboratively to solve problems.”

The basic premise of the Cooperative Extension was that there existed a community around you who you could turn to for information. This community would not only help you with your problems, but offer new ideas and solutions to the problems. This community could be a source of innovation.

Some authors have argued that medical organizations are complex adaptive systems, and that while it may be helpful to understand the current characteristics of an organization while supporting improvement efforts, many of these characteristics are neither predictive of future success, nor are they likely to be stable over longer periods of time. Thus, it is argued that creating a “learning” organization or learning communities is one key to successful improvement, not further study of an array of organizational characteristics. The key component in these efforts is to allow practices the ability to connect to one another in an attempt to share and learn from each other.

While no doubt continued investment in new health innovation and primary care should be supported, it does not appear to be sufficient in and of itself to “revitalize” unless “combined with a strategy for disseminating and implementing innovations and best practices.”

Grumbach and Mold highlight why something like a Cooperative Extension should and could be applied to primary care and other healthcare system innovations:

“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 to the nation’s well-being. Practicing physicians need something akin to the agricultural extension agent who was so transformative for farming.”

How can we take such an approach and apply it across healthcare? Is this possible? Often competing demands and priorities rather keep people in competition with one another than in a place where they want to share their best ideas and learn from someone else. It is a shame that this level of competitiveness often keeps us from collaborating and bettering one another; however, there are some out there willing to risk offering up their “original” idea in the hopes that someone can make it a better idea.

Who knows, maybe when we set aside some of our protective tendencies we can achieve what was seen a century ago in the farming community. Maybe we can see a joining of forces and willingness to learn from others that ultimately benefits the delivery of healthcare but also meets the needs of all our communities. Regardless of what we do, one thing is clear, in healthcare no one has got it all figured out by themselves. We must start to look around at what is working and collaborate and share as often as possible to collectively move forward.

For more information on ideas like the Primary Care Cooperative Extension, see the excellent resource “Ensuring access to a modern, Medical Home: The role for a primary care extension program in health reform” on the Robert Graham Center website.

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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Posted in Community, Contagion, healthcare, Innovation
  • http://www.cfha.net/?page=CollaboBlog Randall Reitz

    Ben,
    As always, stellar writing about big ideas. I have benefited from a number of time-limited learning collaboratives (PCMH, integrated care, chronic care model, etc) and have participated on a decade-long community-based consortium that functions loosely like you describe. Based on these experiences, I concur with your support for this model.

    These cooperative experiences bring together the great local partners that serve common constituencies and encourage them to work together toward something larger than each group could accomplish individually. That being said, the model I like is probably a little more competitive than what you describe. I think the collaborative should function more like a healthcare chamber of commerce. That is, people come because they believe that partnership will benefit their own bottom line (or advance their mission).

    • http://flavors.me/collaborativecare Ben Miller

      Randall,

      Thanks for the comment. First of all, I think you are on to something about individuals coming together to benefit their bottom line. You are right that people often don’t just do things because it is the right thing to do; they sometimes need an incentive or a reason that benefits them. In thinking about learning communities there is inevitably a piece of “what can I take away that will benefit or profit me.” In a perfect world we would all work toward the collective good, but it would be naive to think that this would/could happen in the current healthcare climate.

      Excellent point to raise!

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