The Affordable Care Act (ACA) was the most consequential piece of legislation for the medical field in the last half-century. Ten years later, every aspect of the American medical infrastructure has been affected.

Below, Dr. Catherine Garner—former Executive Director of Nursing Practice for the Greenville Health System in South Carolina and current Assistant Professor in ACU Online’s Doctor of Nursing Practice program—reflects on how the ACA has particularly impacted the nursing field. 

The Affordable Care Act was an effort by American policymakers to rein in healthcare costs that had been unsustainably increasing for 30 years. Alongside the massive bloat in cost, the American healthcare system was experiencing startling irregularities in quality of care from hospital to hospital.

To counter both this increase in cost and irregularity in care—the ACA targeted four main areas of healthcare: establishing reward systems for best practices, measuring in-hospital quality of care, collecting patient-centered feedback, and tracking transition of care out of the hospital. Each of these four improvement targets impacted the daily life of the average nurse, and has spurred a tremendous amount of nursing innovation. Let’s take a closer look at how the ACA has reshaped nursing practice and the American healthcare system.

Establishing Reward System Through Value-Based Purchasing

Following the enactment of the ACA, the Centers for Medicare and Medicaid Services (CMS) announced new strategies for how hospitals would receive federal funding—aimed at improving healthcare quality and reducing cost. This would be accomplished through the Value-Based Purchasing (VBP) system—perhaps the most impactful policy change on health service delivery systems in the last 25 years.

Using the VBP system, the federal government moved from offering passive fees to healthcare servicers and towards being an active purchaser of high-quality, high-value healthcare. Basically, if a hospital did not meet enough quality indicators or patient satisfaction quotas, they would not receive full federal funding (like Medicare). This large system change by the ACA reshaped how hospitals and other medical facilities measure their success.

A decade after the implementation of the ACA, all long-term care and skilled nursing facilities, home health agencies, and rehabilitation agencies report specific standardized data on quality data that is publicly available to consumers. And in 2020, new payment methodology rewards physicians either for quality improvement or the adoption of alternative value-based payment models. 

In this values-based model, nurses need to be more familiar with tracking and managing the measurement of their care. For nurses who want to be leaders in their hospitals or to charter new nursing programs, learning to ‘talk finance’ and understand the benchmarks for receiving federal funds is essential.

This type of financial savvy, measurement competency, and leadership development is absolutely necessary in the new values-based nursing world.

Measuring In-Hospital Quality of Care

The ACA’s creation of value-based purchasing systems led to financial incentives for increasing trackable quality of care on the systemic level. But, day-to-day, how has that changed nursing practice in the last decade?

It caused a spotlight to be placed on morbidity and mortality rates that were caused by poor clinical practice, especially that of non-physicians like nurses. As a result, the nursing world saw a dramatic shift in: 

• Practice guidelines for a variety of hospital-incurred infections (like catheter-associated UTIs and surgical site infections);
• Safety checks in the operating rooms (changing nurse’s pre-operation training);
• Redundancy and ‘succession plans’ for leadership change (implementing nurses more directly in the chain of command than they have been historically);
• Focused event reviews (drawing day-to-day nursing practices into more consistent review);
• Hospital nursing processes for sepsis bundles, stroke teams, and on-call rescue teams; and
• Home health agencies’ standards for medication reconciliation, home fall prevention, and infection control.

All of these practical shifts are measured and contribute to quality of care data published on Medicare Compare for nursing homes and for hospitals. 

Because so many of these quality metrics are directly linked to individual nursing practice, healthcare providers are recognizing the massive value nurses add to the healthcare system. So, while the ACA placed immense pressure on hospitals to increase their performance, it also created a renewal of appreciation for nursing as a practice. 

Emphasizing Patient-Centered Feedback

One of the most important metrics in evaluating a hospital’s quality of care (for reimbursement calculation under the ACA) is tracking patient-centered feedback. With the increase in feedback over the last 10 years, hospitals have adjusted many daily practices affecting nursing such as:

• Improving patient satisfaction with noise levels—hospitals have increased “quiet times” practices, such as discouraging visitors, minimizing staff interruptions, and implementing noise-cancelling headphones in intensive care units. 
• Improving dissatisfaction with nurse reaction times to call lights—many hospitals introduced new technology like Voicera, which allowed nurses to call patients directly. 
• Improving nurse communication scores—the healthcare industry has implemented widespread strategies like bedside shift reports, regular nurse and leader rounding, and focused communication training for new nurses.
• Improving a perceived lack of emotional support from nurses among patients—it’s become common practice for orthopedic nurses to run pain management classes as well as oncologic nurses to function as “nurse navigators” who support patients through multiple touchpoints associated with cancer care and run survivorship clinics. 

All of these changes to the nursing field have been driven by the patient-centered care emphasis of the ACA’s quality indicators. 

Tracking Transition of Care

Finally, a significant change to the nursing profession motivated by the ACA involved tracking transition of care out of the hospital.

Following the ACA’s implementation, the large-scale increase in measuring quality indicators at hospitals and other healthcare providers revealed an unacceptably high rate of avoidable readmissions. An unofficial philosophy of “treat ‘em and street ‘em” was unfortunately pervasive in many hospitals—prioritizing quick treatment over long-term success, often leading to readmission later.

To lower these avoidable readmissions, new roles began to emerge for nurses such as transitional care managers, who oversee patients’ transition from hospitals back into the community. Palliative care teams were formed to address end-of-life options for those dying slowly of chronic diseases beyond just at-hospital hospice. 

These services have been popular with patients and caregivers and have been cost-effective for the system. Long-term disease care management programs are now routinely offered through private insurance companies—often coordinated by experienced nurses and nurse practitioners. Public-private partnerships have emerged in many communities for management of high-risk, high-volume populations—seeking to preemptively prevent hospital admission or readmission. 

In one notable example, a public and private health system in South Carolina partnered with two local clinics to create a new emergency department liaison position in the nursing department. This position allows hospitals and clinics to more easily divert to lower-level care using referrals from the discharging nurses. In this same hospital system, a nurse-led program was started using text messaging and group classes to educate and support patients with hypertension and obesity, aimed at reducing repetitive hospitalization. This example demonstrates that nurses have been, and continue to be, essential to lowering the rate of hospital readmission and tracking transition of care out into the patient’s communities.

The Next Generation of Nursing Innovation

Clearly, a lot has changed since the inception of the Affordable Care Act. New reward systems that track quality indicators, new ways of measuring in-hospital quality of care, increased collection of patient-centered feedback, and new methods of care transition for patients have reshaped the nursing field. Our society needs nurses who are leaders and innovators, those willing to think and dream big about how to bring the best care to their patients while creating and leading sustainable, effective, successful healthcare systems.

Fortunately, ACU Online’s Doctor of Nursing Program (DNP) is doing just that. We focus on equipping nurses with leadership, analytical, and clinical skills, so they’re set up for success in this new data-driven world of nursing. Our nursing programs also prioritize and teach the best practices in population-based, patient-centered care to produce nursing professionals whose work extends beyond the hospital—ensuring holistic patient healing and systemic success! 

Want to know how ACU Online is training the next generation of nursing leaders? Learn more about our DNP program and other online nursing programs at acu.edu/online or call us at 855-219-7300.