Various Ways to Organize a Practice Extension Service – Seven Approaches

Sarah Ono, PhD ESCALATES Qualitative Team Co-Lead, Jennifer Hemler, PhD Qualitative Team Analyst, Deb Cohen, PhD Principal Investigator, ESCALATES


The Affordable Care Act (ACA), better known as Obamacare, has formalized the proposal of the Primary Care Extension Program. The idea of building health care extension infrastructure is not new, however, as Jim Mold, MD, MPH explained last month. The seven Cooperative’s in AHRQ’s EvidenceNOW initiative provide different examples of organizations of different types and at different stages that are or might emerge into a practice extension. In order to clarify these differences, ESCALATES generated an organizational diagram for each Cooperative.

Our goal in creating these diagrams was to make it easier for policy makers, care delivery leaders, and others interested in the development of practice extensions to understand both the variety of approaches that are feasible and also the way these organizations emerge as networks of partnerships, and fit to the needs and contours of different regions.


For example, looking at the Midwest Cooperative’s organizational structure, here are some things we can learn from this diagram about their geographical area, partner organizations, and level of support:

  • The Midwest Cooperative covers a multi-state region.
  • Northwestern University oversees the evaluation (conducting research) and partners with organizations such as the American Medical Association, Illinois Department of Public Health and others to bring quality improvement (practice facilitator support/provider), health information technology (technical expertise) and public health expertise to the practices in the Cooperative.
  • There are partners in each state that have the workforce to engage practices in these efforts and regional partners to help support quality improvement (practice facilitators).

Then, we can compare the Midwest (MW) to the New York City (NYC) Cooperative.

  • These Cooperatives share some similarities: both have Academic institutions overseeing the evaluation/research aspects, partner organizations that can support the data needs of the practices, and a workforce that is being cultivated by their partnerships (note, however, that differences could exist due to how workforce is trained, supported and how quality is assured).
  • These Cooperatives have some basic differences: NYC covers five boroughs, a small geographic region within a single state, and the MW is a multi-state Cooperative; MW’s academic lead is working with multiple partners, while NYC’s academic lead is working with two.


We want both our study team and others to be able to see what organizations and institutions are involved in this ambitious effort, including the type and number of organizations, and where they are located across the regions they serve. Some Cooperatives are working with numerous partners, cultivating new relationships through this collaboration, while others have fewer partners and a history of working together. The infrastructure each Cooperative developed, and the model that emerged, depends on what organizations and expertise existed in each region before EvidenceNOW even began. You can see that the EvidenceNOW Cooperatives are organizing their extensions in multiple ways, allowing us to explore the effects of those differences on patient outcomes through ESCALATES. We hope that other regions or potential leaders of future practice extensions can look to this range of examples to identify and inform their own extension efforts.


Take a closer look at each of the Cooperatives