Developing Effective Prevention and Wellness Programs

With the enactment of the new Patient Protection and Affordable Care Act (Public Law 111-148), ambulatory care nurses will have opportunities to come to the planning table to develop and enhance programs that anticipate many of the major areas of funding in this act.

In this column, we will address some of the funding for prevention/wellness programs as described in the "Summary of New Health Reform Law" (#8061) on the Kaiser Family Foundation Web site (2010), as well as strategies that ambulatory care nurses might pursue. The document describes three national strategies forPrevention/Wellness:

  1. Establish the National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness, and public health activities. Develop a national strategy to improve the nation’s health (Strategy due one year following enactment). Create a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs (Initial appropriation in fiscal year 2010). Create task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidence-based recommendations on the use of clinical and community prevention services (Effective upon enactment).
  2. Establish a Prevention and Public Health Fund for prevention, wellness, and public health activities including prevention research and health screenings, the Education and Outreach Campaign for preventive benefits, and immunization programs. Appropriate $7 billion in funding for fiscal years 2010 through 2015 and $2 billion for each fiscal year after 2015 (Effective fiscal year 2010).
  3. Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates, and addressing health disparities, especially in rural and frontier areas (Funds appropriated for five years beginning in FY 2010).
        (The Henry J. Kaiser Family Foundation, June 2010)

Regarding the first strategy, ambulatory care nurses should actively seek opportunities to place themselves on task forces that are being established for Preventative Services and Community Preventive services. AAACN members who have fostered use of evidence-based prevention protocols as well as developed successful strategies for use of clinical and community prevention services should have seats at the national table.

Knowing that significant funding will be devoted to prevention and wellness, including health screenings as described in strategy number two, should provide the impetus for ambulatory care nurses to plan to expand existing services in these areas as well as add new offerings. Given funding that should be forthcoming, there may be many new players in this arena also that will add to the competition for new patients and families. Demonstrating proven quality and safety in ambulatory care will be necessary to maintain and expand its position in the new health care prevention and wellness marketplace.

The third strategy sets the stage for ambulatory care organizations to partner with academic institutions to seek grant funding to support, develop, deliver, and evaluate evidence- based and community-based prevention and wellness services (Haas, 2008). The aim of such grant funding will be to strengthen prevention activities, reduce chronic disease, and address health disparities.

Coverage of Preventive Services under the Patient Protection and Affordable Care Act includes:

  1. Provide states that offer Medicaid coverage of and remove cost-sharing for preventive services recommended (rated A or B) by the U.S. Preventive Services Task Force and recommended immunizations with a one percentage point increase in the federal medical assistance percentage (FMAP) for these services (Effective January 1, 2013).
  2. Authorize Medicare coverage of personalized prevention plan services, including a comprehensive health risk assessment, annually. Require the Secretary to publish guidelines for the health risk assessment no later than March 23, 2011, and a health risk assessment model by no later than September 29, 2011. Reimburse providers 100% of the physician fee schedule amount with no adjustment for deductible or coinsurance for personalized prevention plan services when these services are provided in an outpatient setting (Effective January 1, 2011).
  3. Provide incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs (Effective January 1, 2011, or when program criteria is developed, whichever is first). Require Medicaid coverage for tobacco cessation services for pregnant women (Effective October 1, 2010).
  4. Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U.S. Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women (Effective six months following enactment).
        (The Henry J. Kaiser Family Foundation, June 2010)

Obviously, the funding of preventive services will provide incentives to develop well-organized programs to provide such services, including computerized records and follow-up reminders to patients and families to complete a series of immunizations or screenings. Ambulatory care nurses have the expertise to lead planning in these areas. Increased demand should also provide incentives for broader hours (evenings and weekends) of service, walk-ins, and open access. Again, alternative providers may step up and provide these services now that there is insurance coverage for many more people and services, so competition will increase and demonstration of quality, safety, and patient-centered care will be essential to viability in the marketplace.

Ambulatory care nurses and advanced practice nurses should monitor Federal work done on the health risk assessment discussed in #2 above, so that they will be able offer this annual health risk assessment to Medicare patients. Again, planning should include development or expansion of evidence-based behavior modification programs that will now be funded for Medicare and Medicaid beneficiaries.

Funding for Wellness Programs in the Patient Protection and Affordable Care Act includes provisions that may increase roles for nurses working in occupational health and safety positions and for ambulatory care nurses working in organizations that collaborate with major employers:

  1. Provide grants for up to five years to small employers that establish wellness programs (Funds appropriated for five years beginning in fiscal year 2011).
  2. Permit employers to offer employees rewards - in the form of premium discounts, waivers of cost-sharing requirements, or benefits that would otherwise not be provided - of up to 30% of the cost of coverage for participating in a wellness program and meeting certain health-related standards. Employers must offer an alternative standard for individuals for whom it is unreasonably difficult or inadvisable to meet the standard. The reward limit may be increased to 50% of the cost of coverage if deemed appropriate (Effective January 1, 2014).
        (The Henry J. Kaiser Family Foundation, June 2010)

The participation of ambulatory care nurses in the planning, implementation, and evaluation of prevention and wellness initiatives funded by the Patient Protection and Affordable Care Act bodes well for patients, families, and organizations that provide care. Ambulatory care nurses have the expertise and experience necessary to design and implement efficient and effective prevention and wellness programs that are responsive to patient needs. Now is the time to accelerate planning and implementation as well as evaluation.


Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at shaas@luc.edu

References
Haas, S. (2008). Resourcing evidence-based practice in ambulatory care nursing.Nursing Economic$26(5), 319-322.

The Henry J. Kaiser Family Foundation. (2010, June). Summary of new health reform law (#8061). Retrieved from http://www.kff.org/ healthreform/upload/8061.pdf

The information on Prevention/Wellness, Coverage of Preventive Services, and Wellness Programs is reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis and information on health issues.

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