A Feasible Infrastructure To Meet The Country’s Current And Future Health Crisis – Health Affairs

Health Affairs Publichealth Primarycare Sweeney


  • A countrywide infrastructure that leverages trusted relationships―among people, a personal physician, and public health organizations―to identify, track, and manage early and ongoing COVID-19 cases (as well as cases of other diseases as needed) in diverse communities.
  • A public health system that uses this infrastructure to then equitably provide vaccinations and personalized education to address vaccine hesitancy and individual medical concerns.
  • Cooperative extension agents that use established relationships to quickly assist frontline practices with procuring personal protective equipment (PPE), adapting to telemedicine, and communicating changing guidelines to serve patients’ medical and social needs.
  • Statewide networks that foster shared, two-way learning between academic medical centers and community primary care practices, building on the model of the agricultural extension service.

This is not a pipedream. It exists in isolated pockets in the United States. And it could exist en masse if we build on learnings from the highly successful US Department of Agriculture’s Cooperative Extension Services model and listen to recommendations published more than a decade ago to primary care practices with public health and community resources in each state.

A network of agricultural extension agents has been in place for more than 105 years. Applying this model to health care would break down the silos that exist among state medical and mental health organizations and would build up the primary care and public health infrastructure whose underresourcing has been so tragically exposed by the current pandemic.

Grumbach And Mold’s Proposal: The Health Care Cooperative Extension

In 2009, Kevin Grumbach and James Mold proposed the Health Care Cooperative Extension. This idea was included in statutory form in the Affordable Care Act but was never funded. Imagine if it was. With the rising recognition of the need to renew essential US infrastructure, this statute could provide resources to meet the needs of both rural and urban medically underserved communities in each state. The state-based infrastructure and rural and urban focus make it potentially politically appealing to both sides of the congressional aisle.

Grumbach and Mold pictured a reality where small primary care practices, such as small farmers a century ago, were supported and sustained so that the many Americans in their care could be tended to in their local communities. They imagined a US health care landscape that would be accessible, effective, efficient, personal, and equitable.

Turning Imagination Into Reality: The EvidenceNOW Initiative

We can imagine this, too, because we have seen glimpses of it. In 2015, the Agency for Healthcare Research and Quality (AHRQ) funded EvidenceNOW, a $112 million initiative with the goal of implementing patient-centered outcomes research around cardiovascular care. Seven grantees across 12 states organized, created, and implemented seven regional extensions; these comprised more than 160 extension agents (for example, practice facilitators) who worked directly with 1,720 practices, supporting quality improvement and connecting these practices with existing resources. We were funded for the past six years to observe and evaluate this work through a grant called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES).

We have seen these extensions develop or expand. We have watched teams build relationships among academic medical centers and practices, public health departments, and local community resources. We have witnessed these extensions quickly build infrastructure to hire, train, and support agents to implement research translation and clinical quality improvements and help reenergize practices in distress from disruptive changes. In the Midwest, the facilitator workforce grew and was brought together to share and learn from each other. This developed the skills of facilitators, which in turn allowed them to increase their practices’ capacity and operational abilities.

In North Carolina, experienced facilitators came together with state leaders and technical experts working on the health information exchange (HIE) to improve the data they could offer practices. Their agents, and those in other cooperatives, too, assisted with connecting practices’ electronic health record (EHR) to the HIE. Practice facilitators helped practice leaders overcome a number of data challenges: They taught practice managers how to create and export EHR data to produce lists of patients not meeting a measure, organized patient outreach to encourage these patients to schedule a visit with the practice, and assisted practices in helping their patients with self-management by providing information and referrals to local resources such as quit lines and classes on nutrition.

In New York City, facilitators created much needed patient education materials for patients in dozens of languages for clinicians to have in their offices and hand out to increase education about heart health. In Oklahoma, the emerging health care extension increased primary care practices’ awareness of, and access to, health-related resources; the cooperative grew to include connections among statewide public health organizations, local community organizations, and practices.

We have observed cooperatives build learning communities for practice members that aided in developing motivation and resilience to respond to rapid changes. Learning collaboratives in Colorado were day-long events that brought clinicians and clinical team members from practices across the state together to share information on clinical guidelines. Participants identified, discussed, and solved problems together.

The Transformative Potential Of Health Care Cooperative Extensions

By supporting a network of relationships among primary care practices, academic health centers, public health agencies, and community resources, Health Care Cooperative Extensions create learning communities that share best practices and problem-solving strategies affecting the health of their communities. Practices receive education and technical assistance to begin addressing, for example, the lack of data infrastructure that limits population health work.

It’s not hard to imagine what this country’s primary care landscape would look like if this Health Care Cooperative Extension infrastructure had been in place at the start of the COVID-19 pandemic. Cooperative extensions would provide early surveillance, contact tracing, and trustworthy information on the basis of on-the-ground existing trusting relationships and central information sources. They would guide acquisition and coordination of PPE, foster best practices, share learning, and aid in rapid ramp-up of telemedicine. They would deploy and coordinate testing and then vaccination, rather than having to build crude new centralized infrastructures.

Health Care Cooperative Extensions would provide timely referrals to needed community services such as housing, food, shelter, and childcare, based on familiarity with patients and families, rather than the current impersonal patchwork. Clinicians connected through learning communities would disseminate new front-line findings about the ever-changing situation, which could in turn be quickly shared with patients, policy makers, and academic researchers―and vice versa.

Health Care Cooperative Extension is a much-needed infrastructure and can be a catalyst for change. It has been suggested by the National Academy of Medicine as a way to create the stronger primary care and public health partnership needed to solve our health system under-achievements. Health Care Cooperative Extension has been demonstrated to be a path toward a primary care and public health system capable of responding to future crises—and the everyday needs of communities—in a more coordinated, accessible, personal, and equitable manner.

By funding the Health Care Cooperative Extension, we can live this experience instead of imagining it. Imagine that. Let’s act now.

Authors’ Note

We are indebted to Kurt Stange, MD, and William Miller, MD, for their guidance, and to Jennifer Hemler, PhD, and Andrea Baron, MPH, for their analytical work that led to the creation of this piece. This work was supported by the Agency for Healthcare Research and Quality (Grant No. R01HS023940-01).