Health Extension Cooperatives: Three States Show the Way 

The Agency for Healthcare Research and Quality (AHRQ) has released applications for funding up to 15 state-based health extension cooperatives, a key component of AHRQ’s newly launched Healthcare Extension Service. The agency hopes to support state-based health care practice transformation using an approach that is similar to cooperative extensions that the US Department of Agriculture successfully has operated through land-grant universities for over a century to support food and agricultural transformation. The program is funded through the Patient-Centered Outcomes Research Trust Fund established under the Affordable Care Act.

The health extension cooperatives will work with state Medicaid and local stakeholders in a statewide approach focused on, but not limited to, behavioral health to deliver patient-centered care and reduce health disparities. There are three key components of the program: 1) engagement with health care delivery and community partners, as well as training, education, and assistance; 2) monitoring, feedback, and evaluation; and 3) administrative support. Eligible applicants for the five-year cooperative agreements include state agencies, higher education institutions, nonprofit, and for-profit entities.   

Below, we describe the experiences of three states — New Mexico, Vermont, and Maryland — that independently developed successful models for statewide health care transformation similar to the health extension cooperatives model, but using resources unique to the context of each state.  New Mexico’s longstanding Health Extension Regional Offices (HERO) program is led by the University of New Mexico (UNM) and has multiple braided funding sources, including state Medicaid dollars, philanthropy, and the University of New Mexico. Vermont’s Blueprint program was established by statute and continues to be sustained with state funding. The Maryland program was developed using CMS Innovation Center dollars and has ongoing funding through CMS’s States Advancing All-Payer Equity Approaches and Development (AHEAD) Model. Although different in their details, each state relies on the three elements of the health extension cooperatives as described in the AHRQ funding opportunity: transformation assistance, monitoring and feedback, and a governing council.   

Applicants for the AHRQ opportunity can learn from and build on the efforts of these states. Each of these states have made this journey relying on a different palette of resources while maintaining fidelity to principles around primary care transformation, as highlighted in a recent Milbank report. The health extension cooperatives Notice of Funding Opportunity (NOFO) offers states the chance to support transformation, leveraging extension strategies derived from experience in the agriculture and health care sectors.    

Three State Experiences with Health Extension Cooperatives

New Mexico. New Mexico’s HERO program addresses health-related social needs in hospital and primary care settings by integrating population health into clinical care. This model accelerated in 2023 when CMS, as part of its Inpatient Quality Reporting Program, required hospitals to screen adult inpatients for five social drivers: housing, food, transportation, utilities, and safety. To address this requirement, community health workers (CHWs), who help patients navigate to appropriate resources, are placed in clinics and hospital inpatient services. After hospital discharge, health extension “agents” work with community partners and CHWs in county and tribally based “Extension Hubs” to create community resources where none exist, especially in rural and frontier areas. UNM’s health extension now accesses expertise from all of its colleges to better address the breadth of community need. 

The success of this clinic-to-community extension infrastructure, with its evidence of improved care quality and decreased cost, continues to attract sustained funding from county and state agencies like New Mexico Medicaid, the Department of Health, and Aging and Long-Term Services.  

Vermont. The Vermont Blueprint for Health utilizes a network of regional extension hubs in each of the state’s 14 Health Service Areas (HSAs). This network has been an essential component of Vermont’s community-oriented advanced primary care program at each stage, supporting early multipayer pilots in three HSAs and extending the program statewide when Medicare joined as part of the CMS Multi-payer Advanced Primary Care Practice Demonstration program.  

Vermont’s program includes patient-centered medical homes (PCMHs) and community health teams (CHTs), which are located in each HSA to support participating PCMHs with additional staff such as nurse coordinators, community health workers, social workers, and mental health counselors. In addition to the CHTs, the extension network in each HSA employs a Blueprint program administrator and practice facilitators, supported at the state level with data, shared learning, and multi-stakeholder governance.  

For more than 15 years, this network has been sustained by the state to support an array of extension activities, including working with practices to qualify and maintain certification as PCMHs; supporting data-guided quality improvement initiatives; managing a network of self-management programs; and working with PCMHs and CHTs in each HSA to expand access and incorporate new service models such as a hub and spoke model for opiate addiction. Vermont Act 78 of 2023 leverages the Blueprint’s extension network to further enhance access to services for mental health and substance use disorders by expanding CHTs to include more CHWs, mental health counselors, and social workers.             

Maryland. The Maryland Primary Care Program (MDPCP) was launched in 2019 as part of the statewide Total Cost of Care model, which is a partnership between CMS and the State of Maryland. From the outset, MDPCP has had oversight from a broad stakeholder advisory council with members appointed by the Secretary of Health and governed by the independent Maryland Healthcare Commission. MDPCP has a central program management office within the Maryland Department of Health and supports regional care transformation organizations to provide staffing, resources, training, and technical assistance to integrate behavioral health, care management and advanced health information technology into over 525 participating primary care practices.  

The MDPCP program coordinates collaboration with community-based organizations, utilizes a web-based bidirectional community-based organization primary care referral system, coordinates diabetes and mental health programs with regional hospitals, and facilitates the introduction of standardized social needs screening and the use of CHWs in primary care practices. MDPCP, together with CRISP, the state health information exchange, developed a data visualization dashboard for primary care practices that includes predictive analytics.  

Lessons Learned 

Collectively these three states’ experiences demonstrate the extension of new services and models over ~143,247 square miles, offering insights for states responding to the AHRQ health extension cooperatives funding opportunity. Applicants for the NOFO can learn from and build on three successful state models by applying the following high-level lessons:  

1. Create a strong, aligned coalition of interested parties and organizations for sustained success.  In each of the three states, the programs are sustained by a broadly represented governing group. In Vermont the governing group was legislatively defined and required when the Blueprint program was established. 
2. Build trusted governance and strong political support and, if possible, codify the program in legislation. Maryland and Vermont had both legislative and gubernatorial support in statute. While these programs are accountable for progress and impact each year, the guiding legislation helps to assure that each program is not as vulnerable to shifting political and budgetary considerations. 
3.  Expand and integrate into the health care team new members with trusted ties to communities served and advanced skills to address social determinants of health. In New Mexico, CHWs and health extension agents play these roles.  In Vermont, Community Health Teams include mental health counselors and social workers in addition to CHWs. 
4. Braid and leverage resources from as many programs as possible to create more sustainable funding, broader reach, and greater impact. Each of the state programs received financial and in-kind support from affiliated programs. New Mexico’s program obtained funding from its Medicaid agency to fulfill its CMW Innovation Center mandate to screen and intervene in adult inpatients with adverse social determinants. Maryland’s program was built around support from the state’s health information exchange, while Vermont’s program coordinates with programs agencies such as Medicaid and the Department of Disabilities, Aging and Independent Living. 

State Medicaid and other leaders can take advantage of this opportunity to serve the health needs of their constituents in a sustainable manner while paving the way to building a national health extension cooperatives program. Moreover, this funding opportunity comes at an opportune time as 20+ states are actively engaged in transforming primary care payment and delivery, and CMS’s Innovation Center is promoting state-led multipayer primary care delivery reform in value-based care models. The CMS Innovation Center’s Making Care Primary (MCP) and AHEAD models require states and providers to address population health while delivering patient-centered care in cooperation with community-based organizations and public health. Both models require significant changes in the way primary care delivered and reimbursed. The new regional health extension cooperatives can offer a powerful, complementary strategy to meet the educational and resource needs of states that are working to strengthen primary care, which is key to better population health and health equity.