The Expert View
Expert View - Fall 2011 - Mary K. Wakefield
Mary K. Wakefield
Health Resources and
Services Administration

Mary K. Wakefield, PhD, RN
Building the Primary Care Team

By Sandy Graham

EDITOR'S NOTE: A noted advocate for rural health care, Mary K. Wakefield, PhD, RN, became head of the Health Resources and Services Administration (HRSA) in the U.S. Department of Health and Human Services in 2009. Before going to Washington, she was associate dean for rural health at the University of North Dakota School of Medicine and Health Sciences. She served on the committees that produced two landmark reports for the Institute of Medicine: "To Err is Human" and "Crossing the Quality Chasm." At HRSA, Wakefield oversees the $9.6 billion agency and its efforts to expand access to quality health care in partnership for people who are uninsured, isolated or medically vulnerable.

For many decades in America, "going to the doctor" meant a one-to-one visit with a primary care physician. Is that changing?

Americans will continue to have a primary care provider in the future and providers will continue to see patients face to face, but providers are more likely to function as part of a health care team that better coordinates patient care and manages chronic conditions. And they are more likely to include nurse practitioners and physician assistants. With the increasing rate of chronic illness, there is a variety of health professionals, such as nutritionists and health educators, who can work with primary care providers to assist patients in achieving improved health outcomes. People also are more likely to communicate with providers electronically.

How has the country's primary care workforce been evolving?

We've already seen a move to team-oriented and prevention-focused care. The Affordable Care Act includes a number of initiatives to advance this movement. For example, the law supports new pilots intended to better organize and coordinate care delivery.

We know, however, that redesigning the delivery system alone will not get us to our goal. We must educate professionals to work effectively in teams with a sharp focus on care transitions – such as moving from hospital to rehabilitation center – and care coordination.

Working with states, universities and health care systems, HRSA plays a key role in health professions training. In the past fiscal year, we invested $39 million in programs that will improve primary care medical residency training, develop primary care faculty, create innovative primary care training curricula and support the development of new primary care physician assistants. We also put $64 million into advanced nursing education programs, which includes, among other initiatives, investments in developing primary care nurse practitioners.

What benefits arise from a more integrated, team-oriented primary care system?

An integrated, team-oriented approach is critical to improving both the quality and cost of care. For certain conditions, particularly chronic diseases, a team approach ensures not only that the patient is seen by the right provider at the right time, but also that we are best leveraging the available workforce to meet patient needs. [The patient] will benefit from better communication among their providers; providers will benefit from more information and collaboration with other members of the patient's care team; and the health system will benefit when we reduce medical errors, duplication of tests and other inefficiencies that are too frequently the byproducts of poor communication and coordination.

While the Affordable Care Act funds some important initiatives, its implementation is going to swell the rolls of insured Americans and exacerbate provider shortages. What do we do, especially when financial resources are so scarce?

The Affordable Care Act creates new tools and resources to address primary care needs. In addition to investing in education for physicians, nurses and other professionals, the law also funds nurse-managed clinics, which provide health services and training sites for advanced practice nurses, and creates a new training model called the Teaching Health Center Graduate Medical Education (THC GME) program. The THC GME program is a five-year, $230 million investment in increasing the number of primary care medical and dental residents trained in community-based settings across the country. The Affordable Care Act also provided initial funding for the State Health Care Workforce Development Program to support better analysis of state health workforce needs and to help states best target available resources. We're working closely with a variety of stakeholders to ensure access to primary care providers.

The Institute of Medicine's "Future of Nursing Report" (2010) advocates an expanded role for nurses as the Affordable Care Act is implemented. What's your reaction to this recommendation?

Nurses, including nurse practitioners, are a vital part of our health care workforce, and their effective use is pivotal to providing primary care to an aging and expanding U.S. population and to the Americans who will be joining the ranks of the insured through the Affordable Care Act. Our investments in developing a well-trained, robust nursing workforce, combined with the new tools and strategies to improve health care quality included in the Affordable Care Act, are important steps. In fiscal year 2011, HRSA invested nearly $150 million in nursing workforce development.

Colorado's primary care shortages are especially serious in rural areas. How do we delivery quality primary care in those areas when we don't have the personnel we need?

Through scholarship and loan repayment programs, the National Health Service Corps helps health professional shortage areas in the U.S. attract the medical, dental and mental health providers necessary to meet these communities' tremendous health care needs. The dramatic increase in funding for the program through the Recovery Act and the Affordable Care Act already has more than doubled the number of providers serving underserved communities since fiscal year 2008. Other tools to address rural health needs include the Rural Health Clinics (RHC) program, which is intended to increase primary care services for Medicaid and Medicare patients in rural communities. RHC status allows for enhanced reimbursement rates for providing Medicaid and Medicare services in rural areas.

Looking at funding that Colorado entities have gotten through HRSA, it appears just as we are approaching a time of great need, we are seeing serious cuts in fiscal year 2011 compared with 2010.

Final fiscal year 2011 awards will have been made by the time this article appears. These include tens of millions in funding for the Health Careers Opportunity Program, the Area Health Education Centers program, physician training and nursing education programs. Nonetheless, it remains true that these are difficult budget times.

What would you say are HRSA's major accomplishments in supporting the primary care workforce since you joined the agency?

In my time at HRSA, the agency has made substantial investments in training new primary care physicians, nurse practitioners and physician assistants. We have stood up completely new models for training primary care clinicians in the community and fostered dramatic growth in the reach of the National Health Service Corps to help direct primary care clinicians to the communities that need them most acutely. We have put the National Center for Health Workforce Analysis in place to build our analytic capacity on health workforce policy.

However, we know we have much more to do. We recognize that building the primary care workforce for the 21st century takes both continued effort and substantial partnerships with states, universities, hospitals, communities and the whole cadre of individuals and organizations with a stake in the future of the nation's health and health care delivery. The team at HRSA is committed to continuing this very important work.