Practice facilitation efforts include comprehensive approaches to ensuring care timeliness, increasing practice efficiency and patient-centeredness, improving continuity of care, and improving preventive and chronic care1. 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 QI2, 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 technology3.
Expected Beneficial Outcomes (Rated)
Increased practice of evidence-based medicine
Increased quality improvement activities
Improved care for chronic conditions
Other Potential Beneficial Outcomes
Improved preventive care
Improved work environment
Improved health outcomes
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 coaches1, 4, 5, 6, 7. Coaching also increases the number of quality improvement (QI) initiatives that practices undertake1, 4, 8, 9 and improves care for chronic conditions8.
Practice facilitation improves care for chronic conditions such as diabetes, asthma1, 8, cardiovascular disease, and cancer8; practice facilitation can improve health outcomes for these conditions8 and appears to improve chronic pain management7. Practices that work with coaches appear to deliver more preventive services including screenings for breast, cervical, and colorectal cancers8 and provide better and more frequent primary care than practices that do not1, 8. A study of the Pennsylvania Chronic Care Initiative suggests that efforts which are part of broader medical home initiatives appear to increase breast cancer screening rates, reduce emergency room visits, hospitalizations, and the use of specialty care10.
Interventions that are more time intensive4, 6, 11 and those targeted to practice context and needs4, 12, which may include regular, tailored follow-up with practice coaches9, 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 alone9. However, additional research is needed to determine the most effective coaching models for long-term effects6 and full practice engagement13.
In general, QI 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 not6, 14. Strong team leadership and a culture that supports QI are also associated with successful efforts14. 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 decisions15. Practice facilitation combined with clinical data from EHRs can support QI efforts such as care coordination8. Practice facilitation can also lead to an improved work environment1, 12, greater levels of teamwork, and a more learning-focused culture1.
Studies of EvidenceNOW: Advancing Heart Health in Primary Care, a three-year QI initiative, suggest that small and medium-sized primary care practices may have challenges engaging practice coaches due to disruptive events (e.g., changes in practice ownership, physicians, key staff members)16 or lack of data capacity13, 17.
Financial incentives included in merit-based payment systems may draw practices into practice facilitation and QI efforts13. In a South Texas-based study, practice facilitation cost between $9,670 and $15,098 per practice per year; two fewer hospitalizations per practice per year made participation cost-neutral18.
Impact on Disparities
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 organizations19.
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. An ongoing national evaluation is on schedule for completion in 201920, 21.
In 2011, AHRQ granted Oklahoma, North Carolina, New Mexico, and Pennsylvania funding to assist primary care clinics with practice facilitation19; in 2015 this expanded to include 13 additional partner states22. AHRQ has a how-to-guide on practice facilitation which includes a curriculum, training materials, case studies, and lessons learned23.
AHRQ-EvidenceNOW Tools - EvidenceNOW: Advancing Heart Health in Primary Care. Tools and resources. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2019.
AHRQ-PF handbook - Practice facilitation handbook: Training modules for new facilitators and their trainers. Rockville: Agency for Healthcare Research and Quality (AHRQ).
ESCALATES - Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES). Successful practice facilitation part 1: It’s more than data collection and feedback, it’s sparkle. National evaluation of the EvidenceNOW Initiative.
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?
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.
* Journal subscription may be required for access.
1 CWF-Grumbach 2012 - Grumbach K. Facilitating improvement in primary care: The promise of practice coaching. New York: The Commonwealth Fund (CWF); 2012: Issue Brief.
2 Taylor 2013a - Taylor EF, Machta RM, Meyers DS, Genevro J, Peikes DN. Enhancing the primary care team to provide redesigned care: The roles of practice facilitators and care managers. Annals of Family Medicine. 2013;11(1), 80-;83.
3 AHRQ-Coleman 2009 - Coleman K, Pearson M, Wu S. Integrating chronic care and business strategies in the safety net: A practice coaching manual. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2009.
4 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.
5 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.
6 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.
7 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.
8 Wang 2018a - Wang A, Pollack T, Kadziel LA, et al. Impact of practice facilitation in primary care on chronic disease care processes and outcomes: A systematic review. Journal of General Internal Medicine. 2018;33(11):1968-1977.
9 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.
10 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.
11 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.
12 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.
13 McHugh 2018 - McHugh M, Brown T, Liss DT, et al. Practice facilitators’ and leaders’ perspectives on a facilitated quality improvement program. Annals of Family Medicine. 2018;16(1):S65-S71.
14 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.
15 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.
16 Mold 2018 - Mold JW, Walsh M, Chou AF, Homco JB. The alarming rate of major disruptive events in primary care practices in Oklahoma. Annals of Family Medicine. 2018;16(1):S52-S57.
17 Hemler 2018 - Hemler JR, Hall JD, Cholan RA, et al. Practice facilitator strategies for addressing electronic health record data challenges for quality improvement: EvidenceNOW. Journal of the American Board of Family Medicine. 2018;31(3):398-409.
18 Culler 2013 - Culler SD, Parchman ML, Lozano-Romero R, et al. Cost estimates for operating a primary care practice facilitation program. Annals of Family Medicine. 2013;11(3):207-211.
19 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.
20 AHRQ-EvidenceNOW - EvidenceNOW: Advancing Heart Health in Primary Care. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2019.
21 AHRQ-EvidenceNOW Cooperatives - EvidenceNOW: Advancing Heart Health in Primary Care. Cooperatives. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2019.
22 AHRQ-IMPaCT - AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants. Project profiles. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2015.
23 AHRQ-PF - Agency for Healthcare Research and Quality (AHRQ). Implementing the PCMH: Practice facilitation. Patient centered medical home (PCMH) resources.
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