• Arthur Kaufman, W Perry Dickinson, Lyle J Fagnan, F Daniel Duffy, Michael L Parchman, and Robert L Rhyne.
• Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico AKaufman@salud.unm.edu.
• Ann Fam Med. 2019 Aug 12; 17 (Suppl 1): S67-S72.

AbstractPassage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.© 2019 Annals of Family Medicine, Inc.

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