EvidenceNOW/ESCALATES: A welcome approach to answering the “how” and “why”of practice engagement and change

phillips_0005Robert Phillips, MD, MSPH Vice President of Research and Policy, American Board of Family Medicine

ESCALATES leaders and partners have a deep understanding of what good primary care looks like, how practices experience and react to change, and how they can filter learning from angst.


With several practice facilitation efforts currently in the field, including those funded by AHRQ, CMS and Milbank, I am pleased to see the team assembled as ESCALATES for the evaluation of EvidenceNOW.

These current projects are all welcome after long, labored efforts to gain support for practice coaching. Many of us have worked for the better part of a decade to document successful coaching models in the field, particularly in Oklahoma and North Carolina. Our AHRQ work led to the IMPACT trial dissemination of current models to partner states, to EvidenceNOW, and to consultations with CMS that produced the Transforming Clinical Practice Initiative (TCPI).

As the ABFM Support and Alignment Network lead for TCPI, I share EvidenceNOW’s struggle to recruit practices after many lost faith in previous initiatives that promised to help them move to new models of care: patient-centered Medical Home, primary care payer demonstrations, Comprehensive Primary Care Initiative, Meaningful Use, etc.  It is no wonder physicians are left wondering where they find the payoff in their investment and leap-of-faith changes.

However, EvidenceNOW evolves out of a rich and evidence-based history of practice facilitation, steeped in relationships and meeting practices where they are. And while its underpinning methods and efforts are not particularly innovative (thank goodness) they are transformative.  This is a dissemination and implementation trial on a grand scale. Its importance, and that of its evaluation, is not in finding out if it worked, but where, how and why it worked. What is it about relationships, trust and early wins that give clinicians the confidence to change?  Equally important, it identifies where change efforts have failed, so fruitless efforts can be pruned away to create space for effective practices to take hold.

Yes, there are challenges to capturing adequate information and discerning differences across EvidenceNOW’s wide geographic reach and variety of facilitation teams. EvidenceNOW also starts with one hand tied, simply because there is no payment or reward for being part of this initiative. ESCALATES provides the right evaluation model to meet these challenges, offering both quantitative and qualitative learning, built on related evaluations honed by an approach of directly engaging practices about their experience. Its leaders and partners have a deep understanding of what good primary care looks like, how practices experience and react to change, and how to filter learning from angst.

I’m interested to learn how successful practices find the resources and will to follow through and sustain change. If CMS is smart, it will borrow from the EvidenceNOW evaluation plan, so that it can learn from AHRQ’s investment, and to offer some alignment of how we learn from these important projects.