Practice facilitation for primary care

Practice facilitation efforts center around ensuring care timeliness, increasing practice efficiency and patient-centeredness, improving continuity of care, and improving preventive and chronic care (CWF-Grumbach 2012). Efforts are led by practice coaches or facilitators who work with clinic staff to redesign clinical practices and improve the quality of care delivered. Coaches organize quality improvement (QI) efforts, help staff understand and use data to drive QI (Taylor 2013a), use team-building exercises to improve communication, share best practices, and explain how other organizations have improved care. They also help motivate interest in change and help practices choose goals, adopt new work processes, interactively solve process problems, and incorporate health information technology (AHRQ-Coleman 2009).

Expected Beneficial Outcomes (Rated)

  • Increased practice of evidence-based medicine

  • Increased quality improvement activities

Other Potential Beneficial Outcomes

  • Improved care for chronic conditions

  • Improved preventive care

  • Improved work environment

Evidence of Effectiveness

There is strong evidence that primary care practices that work with practice coaches adopt more evidence-based guidelines than practices that do not engage coaches (Baskerville 2012, Mold 2014, Dickinson 2014, Cardarelli 2017, CWF-Grumbach 2012). Coaching also increases the number of quality improvement (QI) initiatives that practices undertake (Alagoz 2018, Baskerville 2012, CWF-Grumbach 2012).

Interventions that are more time intensive (Noel 2014, Dickinson 2014, Baskerville 2012) and those targeted to practice context and needs (Michaels 2017, Baskerville 2012), which may include regular, tailored follow-up with practice coaches (Alagoz 2018), appear to yield stronger effects than weaker or more generic interventions. Practice facilitation interventions which combine educational materials, audits and feedback, and system support are more effective than interventions that use one approach alone (Alagoz 2018). However, additional research is needed to determine the most effective coaching models for long-term effects (Dickinson 2014).

Practices that work with coaches appear to deliver more preventive services and provide better and more frequent primary care than practices that do not (Friedberg 2015, CWF-Grumbach 2012). Coaching can improve care for chronic conditions such as diabetes (Dickinson 2014, Friedberg 2015, CWF-Grumbach 2012) and asthma (Mold 2014, CWF-Grumbach 2012), and appears to improve chronic pain management (Cardarelli 2017). It can also lead to an improved work environment (Michaels 2017, CWF-Grumbach 2012), greater levels of teamwork, and a more learning-focused culture (CWF-Grumbach 2012). A study of the Pennsylvania Chronic Care Initiative suggests that efforts that are part of broader medical home initiatives appear to increase breast cancer screening rates, reduce emergency room visits, hospitalizations, and the use of specialty care (Friedberg 2015).

In general, quality improvement efforts that use data, specific targets, tools such as Plan-Do-Study-Act, and a sustained process are associated with greater success than QI efforts that do not (Dickinson 2014, ). Strong team leadership and a culture that supports QI are also associated with successful efforts (). Training practitioners to use standardized data entry procedures in electronic health records (EHRs) and establishing data correction protocols, such as chart auditing, may also contribute to improved health care quality by ensuring reliable clinical data is available for patient care decisions (Mader 2016).

Practice coaching can cost from $7,500 to $60,000 depending on project goals, coaching and intervention design, and travel expenses (AHRQ-Knox 2011).

Impact on Disparities

No impact on disparities likely

Implementation Examples

Practice coaching is often funded through federal programs such as area health education centers (AHEC), health information technology (HIT) for economic and clinical health regional extension centers (RECs), state governments, and philanthropic organizations (AHRQ-Taylor 2014).

In 2015 the Agency for Healthcare Research and Quality (AHRQ) created EvidenceNOW: Advancing Heart Health in Primary Care, a three-year quality improvement initiative to aid smaller primary care practices in instituting the latest medical research and tools. EvidenceNOW includes seven regional cooperatives across 12 states, each aiding 250-300 small and medium-sized primary care practices (AHRQ-EvidenceNOW).

In 2011 AHRQ granted Oklahoma, North Carolina, New Mexico, and Pennsylvania funding to assist primary care clinics with practice facilitation (AHRQ-Taylor 2014); in 2015 this expanded to include 13 additional partner states (AHRQ-IMPaCT). AHRQ has a how-to-guide on practice facilitation which includes a curriculum, training materials, case studies, and lessons learned (AHRQ-PF).

Implementation Resources

AHRQ-Knox 2011 - Knox L, Taylor E, Geonnotti K, et al. Developing and running a primary care practice facilitation program: A how-to guide. Rockville: Agency of Healthcare Research and Quality (AHRQ); 2011.

AHRQ-Taylor 2014 - Taylor EF, Peikes D, Geonnotti K, et al. Quality improvement in primary care: External supports for practices. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2014.

AHRQ-PF - Agency for Healthcare Research and Quality (AHRQ). Implementing the PCMH: Practice facilitation. Patient centered medical home (PCMH) resources.

AF4Q 2014 - Aligning Forces for Quality (AF4Q). Practice coaching: What is a practice coach?

Citations - Evidence

* Journal subscription may be required for access.

CWF-Grumbach 2012 - Grumbach K. Facilitating improvement in primary care: The promise of practice coaching. New York: The Commonwealth Fund (CWF); 2012: Issue Brief.

Baskerville 2012 - Baskerville N, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Annals of Family Medicine. 2012;10(1), 63-74.

Kaplan 2010* - Kaplan H, Brady P, Dritz M, et al. The influence of context on quality improvement success in health care: A systematic review of the literature. Milbank Quarterly, 2010;88(4), 500-559.

AHRQ-Knox 2011 - Knox L, Taylor E, Geonnotti K, et al. Developing and running a primary care practice facilitation program: A how-to guide. Rockville: Agency of Healthcare Research and Quality (AHRQ); 2011.

Friedberg 2015 - Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC. Effects of a medical home and shared savings intervention on quality and utilization of care. JAMA Internal Medicine. 2015;175(8):1362-1368.

Alagoz 2018 - Alagoz E, Chih MY, Hitchcock M, Brown R, Quanbeck A. The use of external change agents to promote quality improvement and organizational change in healthcare organizations: A systematic review. BMC Health Services Research. 2018;18(1):42.

Michaels 2017 - Michaels L, Anastas T, Waddell EN, Fagnan L, Dorr DA. A randomized trial of high-value change using practice facilitation. The Journal of the American Board of Family Medicine. 2017;30(5):572-582.

Mold 2014 - Mold JW, Fox C, Wisniewski A, et al. Implementing asthma guidelines using practice facilitation and local learning collaboratives: A randomized controlled trial. The Annals of Family Medicine. 2014;12(3):233-240.

Dickinson 2014 - Dickinson WP, Dickinson LM, Nutting PA, et al. Practice facilitation to improve diabetes care in primary care: A report from the EPIC randomized clinical trial. Annals of Family Medicine. 2014;12(1):8-16.

Mader 2016 - Mader EM, Fox CH, Epling JW, et al. A practice facilitation and academic detailing intervention can improve cancer screening rates in primary care safety net clinics. The Journal of the American Board of Family Medicine. 2016;29(5):533-542.

Noel 2014 - Noël PH, Romero RL, Robertson M, Parchman ML. Key activities used by community based primary care practices to improve the quality of diabetes care in response to practice facilitation. Quality in Primary Care. 2014;22(4):211-219.

Cardarelli 2017 - Cardarelli R, Weatherford S, Schilling J, et al. Improving chronic pain management processes in primary care using practice facilitation and quality improvement: The Central Appalachia Inter-Professional Pain Education Collaborative. Journal of Patient-Centered Research and Reviews. 2017;4(4):247-255.

Citations - Implementation Examples

* Journal subscription may be required for access.

AHRQ-Taylor 2014 - Taylor EF, Peikes D, Geonnotti K, et al. Quality improvement in primary care: External supports for practices. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2014.

AHRQ-PF - Agency for Healthcare Research and Quality (AHRQ). Implementing the PCMH: Practice facilitation. Patient centered medical home (PCMH) resources.

AHRQ-IMPaCT - AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants. Project profiles. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2015.

AHRQ-EvidenceNOW - EvidenceNOW: Advancing Heart Health in Primary Care. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2017.

Date Last Updated

Apr 26, 2018