What Innovations in Farming Can States Apply to Primary Care?

Sixteen states are supporting primary care transformation through IMPaCT, a pilot program authorized by the Affordable Care Act to implement primary care extension, a strategy modeled after agricultural (cooperative) extension. Here, we talk with Robert Phillips, MD, VP of Policy and Research at the American Board of Family Medicine, about why and how we might apply a farming model to health care to support primary care improvement.
How does agricultural extension provide a successful model for primary care?
Agricultural extension agents worked over the past 100 years to transform farming. We have good evidence that the agricultural extension agent transformed farming between World Wars I and II. They spread innovation and made improvements in farming technology happen faster.  They identified innovators—the top 5-10 percent of farmers—and disseminated what was and wasn’t working. That’s what we want in health care.
Primary care extension provides a workforce to speed uptake of innovation that can make primary care more effective and comprehensive, so that we can lower costs and raise health status. The Regional Extension Centers demonstrated this by speeding up primary care practice adoption of electronic health records—primary care extension can build on this to help practices use their population and neighborhood data to make primary care a more potent force in affecting the impact of social determinants on patients’ health.
What key components of agricultural extension are important in primary care extension? 
First, the extension agent, who brings the farmers information on innovations working elsewhere and talks to them about which innovation might work best for them. In health care, primary care extension agents help practices learn about and use new tools. They monitor practices’ progress, giving them data and feedback, and help struggling practices approach things in different ways. New Mexico and Oklahoma are examples of states that have demonstrated the effectiveness of the primary care extension agent.
Second, test farms, which the USDA created to test new farming methods or technology. The health care correlate is practices with providers who are accustomed to rapid trials of new ideas, methods, technology, and, perhaps, payment. They try out new things, tweak them, and figure out how to implement them. Then those practices teach extension agents in order to help other practices improve. IMPaCT is like test farms for primary care. We can learn from innovative IMPaCT states, such as Oklahoma, and think about how their work can be translated for another state.
Third, agricultural extension agents promoted shared resources in the community.Agents helped farmers create local cooperatives so they could purchase things at a lower price with group purchasing, or store grain, or process crops in ways that they could not afford individually.  In primary care these types of shared resources are mental health resources, information technology or data resources, and shared staff such as care managers or social workers. Vermont and North Carolina have shown that shared community resources can improve health outcomes and costs.
Why implement primary care extension?

Most primary care practices are running as hard as they can, but don’t have the resources or understanding of how to implement change.  It’s difficult to do this alone, and it can be expensive to make mistakes. We have seen a lot of practices obtainPatient-Centered Medical Home (PCMH) certification, but it doesn’t really mean they’ve transformed their practices. An extension agent will help them incorporate real change into the way they deliver care.
What advice would you give policymakers or providers who want to pursue primary care extension?
Look at one of the existing models in health care that is working well and see how it was developed, and start small with the intention to ramp up. Learn from the successes of effective Regional Extension Centers. Talk with agricultural extension agents about their relationships with farmers, and talk to Area Health Education Centers or a Quality Improvement Organization about their existing relationships to see if there is already an infrastructure upon which you can build. Develop a physician engagement strategy to identify and partner with innovators.
Know that, as with agricultural extension, this is not a “one model fits all” approach–not even within a state. Primary care extension agents will look different in rural and urban areas because they adapt to the needs of the population and the practices they serve. The model requires flexibility built in to identify and understand the needs of practices and patients, and modulate the speed of innovation, implementation, and dissemination based on local tolerance and readiness.
Finally, we need patience. It took 20 years for agricultural extension to make a big impression, but the need for intense investment decreased as transformation became easier. We need to maintain support for primary care extension agents, but we will be able to reduce it as transformation takes hold.
To learn more about primary care extension, please visit the national health extension toolkit at healthextensiontoolkit.org, watch a recent NASHP State Refor(u)m webinar, or read about community health teams as a shared primary care resource.