There are four major challenges that are a part of the Affordable Care Act (ACA) (U.S. Department of Health and Human Services [HHS], 2010): a focus on wellness and health promotion, patient-centered care, use of evidencebased practice, and population health management. Each of these is a 180-degree change from the way that health care has been provided in the past. We now must think both in terms of care for acute and chronic disease, as well as provide wellness and disease prevention interventions for all. Instead of waiting the usual 17 years (Baumbusch et al., 2008; Westfall, Mold, & Fagnan, 2007) to use evidence to guide practice, we must now move from provider-preferred practices to implementing evidence-based guidelines as part of population health management while also providing patient-centered care. Although many health care providers like to think they are already doing patientcentered care, they must now elicit patient goals, preferences, and values, as well as engage patients in decisionmaking about their care.
There are incentives to do all of these required initiatives and also penalties if they are not embraced. We are seeing movement to risk stratification for patients with chronic illnesses, especially those with complex chronic illnesses and multiple co-morbidities, so that care can more appropriately be offered to those at highest risk. However, the fee-for-service providers are neophytes with risk stratification. They are not as aware of how social determinants or socioeconomic factors (health literacy, educational and income levels, presence of support of significant others, and community resources) markedly influence risk status and are mistakenly purchasing vendor tools that only use physical and mental status in stratification when these only account for about 50% of risk. Therefore, risk stratification using such computer programs is often flawed.
Organizations are becoming aware of the need for care coordination and transition management (CCTM), but they continue to think in terms of managing the individual patient. What they need to do is use evidence-based guidelines available for populations with complex chronic illnesses — such as congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), and communityacquired pneumonia (CAP) — and make adaptations in such guidelines for individual patients based on patient values, goals, and preferences. Risk stratification has created a need to have providers who can focus on high-risk populations; however, organization senior management seems to be thinking in terms of traditional roles, such as individual case management and disease-focused educators. What is needed is an analysis of staffing within interprofessional teams in both acute and outpatient care that correlates with problems and needs of patient populations. It is likely that different populations will require different configurations of providers. For example, the high-risk COPD population will need pulmonologists, respiratory therapists, pharmacists, dieticians, and both inpatient and ambulatory care nurses in the CCTM role. Social workers would also be needed if there were significant socioeconomic issues in the population being served.
The traditional acute care mentality has made it challenging to put a focus on wellness and health promotion in this new age of health care, and this is exacerbated by traditional education for health care providers where wellness has not been a major focus. Nutrition, exercise, work/life balance, and mental health are not major topics in many health professional curricula and often not addressed in evidence-based guidelines. It was not surprising that the American Medical Association only designated obesity as a disease in 2013. Interprofessional collaboration and teamwork has not, until recently, been a focus in the education of health care providers.
So how can ambulatory care nurse leaders be responsive to incentives for the ACA (HHS, 2010) initiatives? Many wellness and health promotion initiatives can be completely nurse-driven. One requirement is that nurse leaders have accurate data on the demographics of patient populations served; their needs, values, and social determinants, such as education and income levels; as well as employment. Wellness programs can be planned and offered on nutrition, cooking, child wellness, exercise, and more, but they must be geared to education levels and times available given patients' work schedules. Decision support programs should be considered to provide timely reminders of immunizations and routine testing needed so patients can have one-stop visits, where they receive these preventive health services when coming in for a visit with their health care team, no matter what the reason.
Implementation of evidence-based practice begins with strategic selection of evidence-based guidelines for major populations with chronic illnesses such as CHF, hypertension, diabetes, and COPD. The interprofessional team evaluates the strength of evidence-based assessments and interventions recommended and designs protocols for these populations. Individual providers work with their patients to make sure patient goals, values, and preferences are in alignment with these guidelines. The interprofessional team also selects process and outcome indicators for each evidence-based protocol that can be embedded in documentation using standardized coding in the electronic health record (EHR), so effectiveness of care can be tracked and evaluated. Appropriate staffing for each patient population can be tied to longitudinal data generated in the EHR.
Baumbusch, J.L., Kirkham, S.R., Khan, K.B., McDonald, H., Semeniuk, P., Tan, E., & Anderson, J.M. (2008). Pursuing common agendas: A collaborative model for knowledge translation between research and practice in clinical settings. Research in Nursing and Health, 31, 130-140.
U.S. Department of Health & Human Services (HHS). (2010). Read the law: The Affordable Care Act (ACA) section by section. Retrieved from http://www.hhs.gov/healthcare/rights/law
Westfall, J., Mold, J., & Fagnan, L. (2007). Practice-based research — “Blue Highways” on the NIH roadmap. JAMA, 297, 403-406.
Haas, S., & Swan, B.A. (2014). Developing the value proposition for registered nurse care coordination and transition management role in ambulatory care settings. Nursing Economic$, 32(2), 70- 79.
Haas, S.A., Swan, B.A., & Haynes, T.S. (2014). Care coordination and transition management core curriculum. Pitman, NJ: American Academy of Ambulatory Care Nursing.
Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at firstname.lastname@example.org