Hospitals will face a major dilemma if the current federal administration repeals the Affordable Care Act (ACA) without a suitable replacement. The ACA offers millions of Americans affordable health insurance, and hospitals have seen their revenues, and their quality of care, rise as those newly insured citizens access their services. If the ACA goes away, those health care patients and their accompanying insurance payments disappear, putting even more stress on today’s health care labor force. With profit decline comes employee decline, both in number and quality. This will first and foremost affect nursing staff, putting some out of work and others in-over-their-heads.
An Uncertain Health Care Future
Before enactment of the ACA, existing law required (and still requires) that health care facilities provide “stabilizing care” to any person who requests services, regardless of their ability to pay. Medicaid covered these costs. Without ACA coverage, many patients will be forced back to receiving only the substandard “stabilizing care,” and will not receive the services they need to regain their health.
In that circumstance, the medical facility will be forced to balance the volume of unsubsidized, stabilizing care offered against the revenues generated by paying patients, cost reductions, or staff workload increases. If they offer excessive unsubsidized care, they risk declining income levels, staff numbers and possible bankruptcy. If they provide too little, they risk losing their Medicaid/Medicare funding. In both cases, the facility, its staff, and America’s uninsured patients will suffer.
Unpaid Care Is Expensive for the Medical Office …
Every medical consultation generates a series of cost-creating actions, from those of the scheduling secretary to the attending medical professional, and all the way through to the deposits made by the final billing clerk. According to the American Hospital Association, hospitals provided $35.7 billion in uncompensated care to their patients in 2015 alone. When a hospital absorbs these losses, it is also forced to reduce the services it can afford to provide.
Consequently, it is not unheard of for doctors to reduce the size of their bills by limiting the services they provide or the number of recommendations they make, based on their perception of what the patient can afford. Other studies confirm that uninsured patients are checked into a hospital for shorter stays, and they are offered fewer interventions for their condition. For the health professionals, these painful decisions are in direct conflict with their oath to provide the best care possible for every patient.
… And Hard on the Staff
One group of hospital workers that will certainly absorb a significant percentage of additional work due to funding cuts are the nurses. Reduced funding often leads to reduced staff numbers; remaining staff end up working longer, harder shifts, with more responsibility and less break time. And nursing is already a challenging job, with a high demand for significant physical labor that also takes an emotional toll. In fact, between 2002 and 2012, nurses have reported the highest stress levels of all health care professionals.
Additionally, long hours may not allow nurses to get the sleep they need. Inefficient sleep has been associated with a deficit in performance, caused by cognitive problems, mood alterations, reduced motivation, increased safety risk, and physiological changes. These effects only get worse with total sleep deprivation, common among nurses who work consecutive shifts.
Additional Stress Factors
Research reveals that the changes in the nursing profession in particular and the health care system in general, contribute significantly to the problem:
Sophisticated technology offers immense benefits but adds additional layers of responsibility on already overloaded schedules;
Burnout is common, too. Protocols can change as resources ebb; nurses are compelled to follow evolving practices without the opportunity to add input regarding their patient’s care. A 2012 study published by the Canadian Federation of Nurses Unions found high levels of burnout correlated to lower ratings for quality of care.
Reduced staff numbers also drive nurses to work even when they are sick. Many choose to potentially infect their patients rather than leave their colleagues unsupported on shift.
The reality for America is that, before the ACA, unpaid hospital bills were often eventually born by other elements of the system, including taxpayers and patients who incurred higher medical care costs. Repealing it won’t save the country money, but instead will add extra stress to the system and further erode the health of millions of its citizens.
With all the upheaval surrounding the Affordable Care Act (also known as ObamaCare), there is great news for Latinos. In the past year, significant numbers of Latinos have obtained health insurance coverage. The trend is a marked improvement as Latinos are traditionally among the least-insured populations.
According to the Commonwealth Fund Affordable Care Act Tracking Survey and as reported in the Journal of the American Medical Association, rates of Latinos without health insurance dropped a full 13 percentage points – from 36 to 23 percent. The Commonwealth Fund is a private research group focused on health care issues.
The numbers still represent a higher number than the general American adult population which stands at 15 percent uninsured (12 percent for non-Hispanic white adults), but the improvement is welcome.
According to the report, the past year has seen a definite improvement in rates of Latinos covered by health insurance, especially in the young adult population of those between the ages of 19 and 34 and in those with the lowest incomes. And whether the dominant language was English or Spanish, both groups showed gains in coverage, with primarily Spanish-speaking adults showing a larger gain in insurance coverage, although they still lag in overall coverage by more than 10 percentage points.
With affordable health insurance coverage comes many benefits. Personal health treatment and care – from chronic illness care to maternity care to overall family health care – could potentially reap tremendous gains in both physical and mental health and wellness. But, as the report points out, the benefits extend far beyond personal health. With health care coverage, individuals and families have less chance of accumulating insurmountable debt from a health crisis. Once the worry over lack of health care coverage and all the health and financial ramifications of not being covered is lifted, quality of life improves.
There are still many improvements that need to happen so that all Latinos and Hispanic Americans not only have access to coverage but can access it in either English or Spanish and can get help signing up for a health plan, if needed, when first visiting the marketplaces.
And, the report cautions, states that have not expanded their Medicaid eligibility have higher rates of uninsured Latinos, with the statistics of uninsured Latinos remaining virtually unchanged from before the Affordable Care Act was implemented. Despite the positive gains in many other states, the lack of expanding coverage in many states affects millions of people.
The countdown to the institution of the historic Affordable Care Act (also known as Obamacare) has started. October 1st is the first day for enrollment through each state’s Health Insurance Marketplace; coverage won’t actually kick in until January 1, 2014.
Leading the charge to ensure nurses take an active role in educating patients about coverage is Dr. Mary Wakefield, RN, PhD, FAAN, Administrator of the Health Resources and Services Administration (HRSA).
She recently wrote to Sigma Theta Tau International, the Honor Society of Nursing, encouraging nurses to get the word out about the Affordable Care Act. Read her letter, Nurses and the Affordable Care Act: A call to lead, here.
Wakefield’s call for nurses to champion coverage is inspiring, especially for those who provide nursing care to underserved communities, as she did in her home state of North Dakota.
Why Should Nurses Champion Coverage?
>Millions of uninsured and underinsured Americans need to learn about their options for affordable coverage under the new plan. For many people, this will the first time they have access to private insurance, whether because to high premium costs or pre-existing conditons.
>There is much confusion, misinformation, and fear about these changes. Unfortunately, the current political wrangling on Capital Hill over the budget and funding of the health care overhaul isn’t helping matters.
>Some Hispanic Americans (and other minorities) strongly prefer to get health info from sources they know personally, and that they trust. Preferrably in their native language.
>Nurses are trusted sources, plus they’re practiced at educating about health care, and relating to patients as whole people. The latest Gallup Poll of Honesty and Ethics in Professions shows that nurses are the #1 most trusted professionals. When Americans were asked: “Please tell me how you would rate the honesty and ethical standards of people in these different fields,” 85% gave nurses “high” or “very high” marks.
>Nurses must play a pivotal role in improving their community’s health by helping as many patients as possible to sign up for health insurance coverage. (That’s especially crucial in under-served geographic areas and minority populations).
>Best of all, nurses can help give peace of mind to the many uninsured or barely insured people who constantly worry: What will I do in the event of a serious illness or hospitalization?
How are you taking the charge in alerting un-insured or underinsured patients coverage? Let us know!
JebraTurner is a health reporter and former H.R. director, where she oversaw workplace health and safety training programs for staff and clients. She lives in Portland, Oregon, but you can visit her online at www.jebra.com.
Today, October 1st, is the beginning of enrollment in online health insurance marketplaces nationwide. The exchanges are at the center of the Affordable Care Act (or Obamacare), the largest healthcare expansion this country has seen in nearly half a century.
Demand in this first day of the six-month open-enrollment period has been incredible, overwhelming some systems, inspite of the battle on Capital Hill over the debt ceiling and implementaion of the health care overhaul.
Nurses have a major role to play in educating patients about coverage options and enrollment. Though you may not have much experience talking to patients and community members about insurance, think of it as another aspect of health care education.
How Nurses Can Champion Coverage
Educate yourself first by downloading a “fast facts” toolkit that includes handouts, fact sheets, and brochures. Or you can watch videos or view PowerPoint presentations until you feel comfortable answering patient questions about enrolling for coverage.
For the ACA Toolkit, click here.
For Marketplace Training Resources, click here.
Share what you find out with others – most of these resources are available online, through text messages, emails, and toll-free phone calls. (In English and Spanish, too.) You can also help patients sign up for coverage. And don’t forget to spread the word to others at work, during nursing rounds, say, or other types of educational sessions.
Online: Healthcare.gov or CuidadoDeSalud.gov (texts and emails available, too)
24/7 Consumer Call Center: 800-318-2596 (available in 150 languages!)
Social Media in English and Spanish:
Facebook.com/HealthCare.gov
Facebook.com/CuidadoDeSalud.gov
@HealthCareGov
@CuidadoDeSalud
How are you taking the charge in alerting uninsured or underinsured patients about coverage under the Affordable Care Act? We’d love to hear what’s working for you!
Jebra Turner is a health reporter and former H.R. director, where she oversaw workplace health and safety training programs for staff and clients. She lives in Portland, Oregon, but you can visit her online at www.jebra.com.
The pace is picking up in the movement of hospitals toward automated tracking of health records, medications, and patient care. Who better than nurses—with their intimate, on-the-ground expertise—to lead the way?
Hospitals are tapping into a variety of computer and telecommunications technologies to help improve the efficiency and outcomes of patient care. The success of these high-tech systems depends greatly on how readily the staffs adapt to them and how easily they fit into the existing workflow. Nurses with training in informatics are playing a vital role in tailoring health information technology (HIT) to meet the needs and goals of their workplaces, as well as educating fellow clinicians in how to use it.
Speedier information access
The Affordable Care Act is giving many hospitals the nudge to trade the traditional hand-scribbled chart notations for electronic records.
“It’s going to be mandated by the federal government, so the hospitals cannot be sustained without medical information systems,” notes Eun-Shim Nahm, PhD, RN, FAAN, who is an associate professor and Program Director of Nursing Informatics at the University of Maryland School of Nursing.
Hospital nurses who have been leaders in the early adoption of electronic health records (EHR) say the new systems save time and make it easier for health care providers to share information with each other and their patients.
As Chief Nursing Officer for NorthShore University HealthSystem in Illinois, Nancy T. Semerdjian, MBA, RN, CNA-BC, FACHE, was in charge of implementing the hospital’s electronic medical records system. One of the most welcome improvements to come from the system, which she and her team began installing 10 years ago, was the automatic reporting of data from doctor visits, laboratory tests, and other patient encounters throughout the hospital.
“You didn’t have to wait for a paper to print somewhere or get a fax sent to the unit,” says Semerdjian, who adds that authorized clinicians can access patient records remotely using a key fob.
At Ann and Robert H. Lurie Children’s Hospital of Chicago, families of patients can apply for access to an online portal that lets them view their records online, including their latest test results and upcoming appointments, says Karen Carroll, PhD, RN, NEA-BC, Director of Nursing Informatics and Innovations.
The EHR system at Fletcher Allen Health Care in Burlington, Vermont, has enabled the oncology department to create a seamless patient care record that includes visits to doctors’ offices, ambulatory centers, and the hospital, saysAnne Ireland,MSN, RN, AOCN, CENP, Director of Clinical Practice and Innovation.
“What we had before were disparate systems in all of those locations,” says Ireland, whopreviously led the EHR implementation across all departments at the hospital.“One place didn’t know what the other knew, because they all kept their own records.”
Medical device integration (MDI) is a technology helping to speed up and enhance the safety of data sharing. MDI systems capture information from the medical instrumentation hooked up to patients and automatically send updates to the patients’ electronic records.
“We’re automating that clinical documentation piece, so the nurse no longer has to manually transcribe the device data—therefore eliminating the risk of transcription error,” says Mary Carr, RN, Chief Nursing Officer for iSirona, a medical device integration software company headquartered in Panama City, Florida. “As a clinician, you gain more time for direct care and ultimately improve patient outcomes.”
The US Department of Veteran Affairs has become a world leader in the application of telehealth technology to improve patient care and education, and the VA aims to double its program’s reach to 825,000 veterans by the end of 2013.At the Michael E. DeBakey VA Medical Center in Houston, telehealth is part of a two-pronged HIT system that also includes secure messaging for patient emails, says Omana Simon, DNP, RN, FNP-BC, the facility telehealth coordinator. Components of the program include home telehealth, clinical video telehealth, and a store-and-forward process for relaying information to providers in remote locations.
Patients participating in home telehealth take home a device called a Health Buddy that enables them to record and send information about their vital signs and symptoms. At the hospital, several nurses and a nurse practitioner regularly review the data, and the patient’s medication can be adjusted accordingly.
The program currently focuses on the treatment of uncontrolled diabetes, uncontrolled hypertension, depression, heart failure, and COPD, and the hospital plans to add telehealth programs for smoking cessation and palliative care, according to Simon.
With clinical video telehealth, patients go to the nearest VA clinic and sit in front of a video monitor. A clinician at the Houston medical center provides long-distance consultation, while a clinical technician at the local site is on hand to assist the patient. Data from the video encounter is automatically added to the patient’s medical record.
Improving patient care
“Many studies have shown that [the telehealth programs] have improved the patients’ quality of life, patient satisfaction, and clinical outcomes,” says Simon, who notes, for example, that blood sugar and blood pressure results have improved, while the number of ER visits and unscheduled clinic visits has decreased.
NorthShore University HealthSystem puts its electronic records system to use in managing chronic illnesses, for example, by generating automatic checklists for patients admitted with congestive heart failure, Semerdjian says.
“When the patient is discharged, we make sure the patient has a follow-up visit with their physician, that they receive instructions in medications, and that they know to weigh themselves every day,” she says. “Those are the kinds of things that, in the paper world, you just didn’t have.”
The Mayo Clinic in Rochester, Minnesota, uses Fair Isaac Corporation’s Blaze Advisor® business rules management system to create pop-up warnings for the prevention of pressure ulcers.
“If certain pressure ulcer conditions are met, the Blaze rule will pick up on it and send a message to a clinical nurse specialist, who will then act upon this message—go out and see the patient and work with the nurses on the floor to come up with the best treatment process,” saysBob Kirchner, RN, MSN, MBA, an informatics nurse specialist at the Mayo Clinic.
Medication delivery is another target area for enhancement through HIT. The Mayo Clinic has been using barcode medicine administration for the past two years, and Kirchner says the evidence shows the system has prevented medication errors.
Nikita Cowan, RN, a charge nurse and the interim manager in the Acute Med Surgical Unit at Texas Health Presbyterian Hospital in Dallas, says barcoding is the most significant automation tool the hospital has implemented in the last few months. Like Kirchner, she touts the system for reducing errors.
“It just builds that extra barrier of protection and safety for the patient and for the nurse,” Cowan says.
Fletcher Allen Health Care employs programmable electronic IV pumps that are connected to the EHR system so records are updated instantly whenever medication is administered. “If I change the infusion rate on a patient’s pump, the computer knows what I’ve done,” Ireland says.
HIT is also improving the efficiency of prescription orders. Semerdjian notes that NorthShore physicians’ medication orders show up simultaneously in the pharmacy department and on the chief nursing officer’s medical administration record, speeding up the time that the medicine gets transported to the hospital unit.
Texas Health Presbyterian recently implemented an early warning score system for monitoring patients’ vital signs. The system features color-coded electronic charts that help clinicians keep track of significant changes in a patient’s condition.
“I think it has a direct impact on the number of RRTs—rapid response team calls or code blues—because the system is picking up on some subtle things that the nurse or staff may not be aware of,” Cowan says.
Nurses at the design table
Not only are nurses often in charge of implementing and managing hospital HIT projects, they also are tapped for their expertise in the planning stages.
Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN, Vice President of Informatics at the Healthcare Information and Management Systems Society (HIMSS), says nurses need to get involved in the process as early as possible.
“It’s really critical to have nursing represented at the table for the decisions that are made about electronic health records and the technology systems around them, because nurses understand what patients need,” says Sensmeier, who is a co-founder andEx-Officio Chair of the Alliance for Nursing Informatics, an organization co-sponsored by HIMSS and the American Medical Informatics Association (AMIA). “They understand the importance of accuracy, consistency, and documentation.”
Semerdjian notes that when nurses partnered with HIT experts in planning the EHR project at NorthShore University HealthSystem, the working group was divided into teams with specific expertise. For example, one team dealt with an application for scheduling appointments and medical procedures, another with a system for outpatients.
Nurses at Lurie Children’s offered guidance on how to integrate the EHR system into the various hospital units, says Carroll.
“There is no such thing as an isolated system, entity, or department when you’re talking about computer records,” she says. “Everything hinges on another and has to communicate with another system.”
At Texas Health Presbyterian, Cowan has been a designated superuser of the HIT system since 2009. During monthly meetings, she and other superusers get updates on new pilot programs and planned upgrades to existing ones; then they relay the news to the rest of the staff.
Graduate-level nursing informatics studies programs are providing nurses with academic credentials for these leadership roles. For instance, Middle Tennessee State University’s (MTSU) School of Nursing in Murfreesboro offers an MSN with nursing informatics concentration and an MSPS with informatics concentration for other health professionals such as physical and respiratory therapists. A required four-hour practicum gives students hands-on experience in the field. Take, for example, the MTSU nursing student assigned to the VA hospital in Kingston, Tennessee.
“She is working on a really cool project . . . to actually integrate a medical surgical floor into the electronic medical record environment,” says Richard Meeks, MSN, RN, CPHRM, an assistant professor at MTSU.
The project includes creating concept maps and floor diagrams to help guide unit nursing leaders in adapting their workflows to an automated documentation system, Meeks adds.
Nahm, at the University of Maryland, says vendors need nurses trained in informatics to help them build better HIT systems that fit the way hospital staffers work.
“The system should correctly and accurately reflect the clinician’s workflow,” Nahm says. “If the system doesn’t work for them, it can create medical errors.”
HIT: A work in progress
One of Sensmeier’s favorite sessions at the AMIA’s Annual Symposium in Chicago last November was titled “Why is Interoperability Taking So Darn Long?” Sensmeier is a longtime advocate for interoperability in health care IT, which would involve, among other things, standardizing terminology and programming language so that different hospital systems could communicate with one another.
“Every hospital has been pretty much doing its own thing for a long time,” Sensmeier says. “To require them to standardize and begin to integrate is a huge challenge.”
As with any technology, another challenge for HIT users is coping with the glitches that crop up from time to time: sluggish or errant data flow, interpretation flaws, and equipment failures.
“When I first got into nursing informatics, I respected computers and thought that whatever comes out of a computer is probably correct,” Sensmeier recalls. “Well, during my first testing experience with a computer, I could see how easy it was for a system to misinterpret something, or for data to not get to the right place, or for printers to break.”
Nurses at Lurie Children’s continually monitor the EHR system for its efficacy in improving patient outcomes.
“We have a nursing-driven clinical informatics committee that reviews, with the staff on our front lines, what they are seeing in documenting and providing care,” Carroll says. “That is nursing’s opportunity to have input and to bring up issues and their suggestions for improvement.”
Sometimes the toughest job for the nurse informaticist is educating other clinicians about computers and getting them to embrace the technology. NorthShore University HealthSystem provided every physician with 16 hours of computer training, which helped convert a lot of skeptics among them.
“I had a physician say to me [that] he spent his first few days swearing at it,” Carroll says. “Now he swears by it.”
Fletcher Allen Health Care even offered its clinicians free typing classes, though not many signed up, according to Ireland. She notes that some found it easier to make the transition from pad and paper when they viewed the computer as a tool for interacting with patients.
Meeks says the best results come from taking an analytical approach to implementing new technology, thoroughly assessing how it will fit into the way nurses and other health care providers do their jobs.
“When we bring on this type of technology—medical records, electronic scanning of meds—we traditionally dump that stuff into an environment that hasn’t been updated since the ‘70s,” Meeks says. “That causes an imbalance in that environment, and it causes frustration and anxiety in the staff—not only nurses but other clinicians and physicians—because we’ve not done a good job integrating all of that technology into their practice.”
