Some people might say, "A doctor, a nurse and a pharmacist walk into a room together," and mean it as the starting line of a joke. But that scenario is no joke in Wisconsin. Instead, it describes a healthy reality that came about courtesy of the Wisconsin AFP (WAFP).
Richard Rieselbach, M.D., standing, professor emeritus in the Department of Medicine at the University of Wisconsin-Madison Medical School, facilitates a table discussion at the Wisconsin AFP's first Primary Care Workforce Summit.
For several years before 2012, the chapter had focused on helping members transform their practices into patient-centered medical homes (PCMHs) and then on payment reform to help practices survive, says Larry Pheifer, WAFP executive director.
But that focus changed at the WAFP Board of Directors' strategic planning session for 2012 held in November 2011. "The board realized we should take the lead in bringing together everyone with an interest in primary care to decide on the most important things to do to assure an adequate workforce," Pheifer says. "Because even if practices agree to transform and payment is reformed, if you can't pull together a primary care team, you won't be able to demonstrate the needed outcomes or manage a population to improve health status."
The state already had a primary care shortage, mostly in rural and some urban areas, and without action, the shortage was only going to get worse.
- In 2012, the Wisconsin AFP convened a groundbreaking summit of stakeholders to brainstorm solutions to Wisconsin's primary care workforce shortage, working with state groups representing internists, pediatricians, nurses, physician assistants, pharmacists, hospitals and others.
- At a second summit in 2013, stakeholders agreed to specific action steps that include forming a task force to implement interprofessional team training, advocating for increased funding for primary care education across disciplines and holding a conference on team-based care.
- The chapter now has a stronger relationship with the other stakeholders than it had before the summits, and the state government recently provided funding for a primary care and psychiatry shortage grant program and grants to establish three new family medicine residencies.
The workforce issue was top of mind for Brad Meyers, M.D., when he walked into the strategic planning session for 2012. As incoming president, he was responsible for leading the strategic planning. He and his wife, Gretchen Geist, R.N., had just talked about the workforce issue as a possible next step for the WAFP during his presidential year (see "The Value of Teamwork" below right).
By the end of the session, the board had committed the chapter to reaching out to other stakeholder organizations and convening a summit to brainstorm solutions for the workforce shortage.
Planning the Summit
In January 2012, the chapter invited other groups with an interest in the workforce issue to serve with the WAFP on a steering committee to plan and organize a statewide Primary Care Workforce Summit to be held in November 2012. Twelve other organizations agreed to serve on the committee, including the state's two medical schools and groups representing internists, pediatricians, nurses, physician assistants, pharmacists and hospitals.
The steering committee met monthly for 11 months to plan the summit. Meyers, who chaired the meetings, says discussions were often lively and sometimes veered off course -- no surprise given the diverse viewpoints in the room. "I kept bringing people back to this question: How do we best take care of the primary care needs of the people of Wisconsin?" Meyers says. "That kept the meetings fairly collegial and productive. I never left frustrated; the time went quickly during the planning sessions. We recognized that there was much to do, and much was accomplished."
Tom Jackson, M.D., of Nashotah, a general internist and member of the Wisconsin Council of the American College of Physicians, served on the steering committee. "Having so many primary care stakeholders in the state come together to work on this issue was one of the most positive things about this," he says. "It was the first time in a long time, or maybe the first time ever, that they got together to work on an issue."
Ultimately, the committee decided to focus the summit on five critical question areas: team-based care, payment reform, education to help primary care disciplines work together, recruitment for underserved areas, and legislative initiatives. The committee also agreed that a patient's perspective should be heard during the course of the summit. This led to inviting Sharon Adams, director of programs and co-founder of the nonprofit neighborhood organization Walnut Way Conservation Corp, to speak at the summit.
the Value of Teamwork
Brad Meyers, M.D., and Gretchen Geist, R.N.
Former Wisconsin AFP (WAFP) President Brad Meyers, M.D., knows firsthand the value of team-based primary care. So does his wife, Gretchen Geist, R.N.
The two worked as a team in their solo family medicine practice in Jefferson for 20 years. "The level of quality and the way we served patients in our practice was so much deeper than anything I've ever experienced as a provider or a patient," says Geist, who now is studying to become a family nurse practitioner.
After Meyers, now an employed physician, became WAFP president-elect in 2011, he began thinking ahead to his upcoming year as president and his responsibility for leading the chapter's strategic planning for 2012.
It was Geist who lit the spark that eventually flamed into a workforce summit. "I told him (Meyers) I was tired of hearing everyone argue about who's going to be in charge of the primary care team, who's going to get more money and so on," says Geist, who maintains that the patient is in charge. "I said I wanted everyone in primary care to just get in a room and talk about what we could do together to forward the goal of an adequate primary care workforce, and not always be against each other."
Meyers took the idea to the 2012 strategic planning session, and the board decided the WAFP would take the lead in bringing stakeholders together to address the workforce issue.
Prior to the summit, each group was asked to prepare documents sharing its vision for primary care delivery and the barriers to it, as well as a list of recommendations for overcoming those barriers. The recommendations related to each question area were then combined and consolidated. All of the information was made available to attendees before the summit.
Held in Pewaukee and emceed by Meyers, the summit brought together 108 individuals representing 38 organizations. It began with a presentation on primary care workforce issues at the national level, followed by a panel presentation from eight of the stakeholder representatives. A luncheon presentation by Adams reminded participants of their ultimate focus -- the people of Wisconsin, their patients.
Three tables were assigned to each critical question area. Participants were assigned to tables based on interest and, facilitated by a table discussion leader, spent 90 minutes discussing the recommendations for that area, eventually selecting eight to 12 recommendations as having the highest priority.
The table leaders combined the recommendations selected by their tables and presented them to the full group. All participants voted on the relative importance of the recommendations, and the highest-priority recommendations in each area were presented as the issues that should be addressed.
After the summit, the WAFP hired a writer to prepare a white paper summarizing the findings.
"Little did we know how hard it would be to put together a white paper and have 13 groups sign off on it and say they agree with it," says Pheifer. The process took months, and in the end, only two other groups agreed to display their names on the cover of the document along with the WAFP, although all 13 are listed near the end of the document.
"At the 30,000-foot level, we could get people to say this is what we should do," Pheifer says. "But it was hard to get the groups to agree to specifics since each group had a different viewpoint." In the end, the white paper was more generic and less specific than originally envisioned. Clearly, something had to be done to reach consensus on specific action steps.
That something was "Summit 2.0." Held in Madison in November 2013, the second summit brought together about 54 participants. Using the white paper as a starting point, participants brainstormed and reached consensus on next steps that should occur. The next steps include forming a task force to implement interprofessional team training, advocating for increased funding for cross-disciplinary primary care education and holding a conference on team-based care.
Steering committee members have been reviewing the next steps and deciding which ones to work on, either alone or with other stakeholders. Some of the groups are moving ahead with plans for a conference on team-based care this November.
After two intense years of working on the summits, the WAFP will be stepping back from its leadership role this year to focus on other priorities, says Pheifer. But the chapter will still encourage members to implement the PCMH and will work with other stakeholders to make sure team-based care has the kind of reach it needs, he says. The chapter also will remain politically active on education and training issues and will continue to push payment reform.
Some good things have happened since Summit 2.0. The state recently enacted legislation providing $2 million for a primary care and psychiatry shortage grants program. Family physicians, internists, pediatricians, psychiatrists and general surgeons who trained in Wisconsin medical schools and residency programs and who practice in the state's underserved areas can apply for unrestricted grants of $20,000 a year for up to three years.
In addition, the Wisconsin Department of Health Services recently awarded more than $3.3 million in grants to establish new residency programs in rural and underserved areas during the next three years. Three of the six grant recipients will establish family medicine residencies.
Facts About the Wisconsin AFP
Chapter executive director: Larry Pheifer
Number of chapter members: 2,700
Year chapter was chartered: 1948
2015 annual meeting: to be held virtually in January
Meyers and Pheifer say the chapter's relationship with other stakeholders has strengthened since the summits. "The Pharmacy Society of Wisconsin asked for our input on a program they were considering that involved pharmacists and primary care physicians, and the Wisconsin Nurses Association invited us to a meeting regarding changes they would recommend to the legislature regarding the law covering LPNs, nurses and advanced practice nurses," says Pheifer. "These (things) never would have happened before the summits."
"I think the summits created some momentum -- people are talking about these things," says Jackson. "Even our ACP (American College of Physicians) chapter, which is traditionally education-oriented, I think has a lot more positive discussion about team-based care than it did a few years ago."
Advice for Other Chapters
What advice would Meyers and Pheifer have for other chapters that might want to consider a workforce summit?
"Make sure you have 100 percent focus and commitment on the part of your board," says Pheifer. "Expect that the effort will take more planning, time and resources than you think it will. It also should be an obvious next step for your chapter, as it was for us."
Pheifer also suggests having a procedure in place to periodically assess progress. "Our executive committee met every month and asked about progress, and they kept the board up to speed," he says.
For his part, Meyers suggests the use of improvisational theater's "yes and" concept in situations in which participants have differing viewpoints. At the second Wisconsin summit, "I told them to build on each other's ideas with a 'yes and' instead of denying the idea with a 'yes but' -- to accept what has been said, and then tweak it until it's better," Meyers says. "Participants seemed to buy into that, and I think it helped."
Meyers also says he would like to see some type of national forum on the workforce issue. "I would like to see us have a summit rather than a turf war," he says.