Nurses will find their skills in far greater demand under many of the provisions of the Patient Protection and Affordable Care Act, but much of the new activity will take place outside the walls of the hospital as efficiency efforts drive more routine care into the home.
Nurses in demand
Reform law seeks to distribute primary resources
The law puts an emphasis on distributing highly educated nurses closer to medically underserved populations. Lawmakers also wanted to encourage lesser-trained nurses to go back to school so they can provide primary care or become faculty at the many nursing colleges that still turn away qualified students because of a lack of instructors.
“I would say the nursing organizations are unanimous in support of healthcare reform,” said Susan Reinhard, the chief strategist with the Center to Champion Nursing in America, an initiative of the AARP and the Robert Wood Johnson Foundation.
Nurse leaders say they were gratified to see how the law recognizes a point they've long been arguing—that one of the best ways to make the healthcare system more efficient is to shift away from episodic, crisis-driven healthcare and toward a system that relies on primary care and preventive health maintenance to keep people healthier before they become hospital patients. In many cases, that means having more highly trained nurses directly deliver care to patients.
For example, Section 5208 of the law will pump cash into the hundreds of nurse-managed community care clinics already operating across the country. “The support that the bill provided to these programs really shined a light on nursing,” said Rose Gonzalez, director of government affairs for the American Nurses Association. “The movement away from acute care, into more primary care, prevention and wellness is something that has been nurses' mantra for years.”
The law adds “nurse-managed health clinics” to the group of health centers eligible to receive up to $50 million in grants in fiscal 2010. The clinics must be managed by advanced practice nurses, provide services to underserved or vulnerable populations without regard for insurance or income, and be affiliated with a university of another qualified health center.
Many of the approximately 250 nurse-managed clinics that exist today are affiliated with local schools of nursing, Gonzalez said.
Elsewhere in the law, Section 5316 sets up a $600,000 demonstration program to provide one-year training programs for recently graduated nurse practitioners who agree to work in nurse-managed health clinics.
“The clarity and the emphasis that's in the legislation about health promotion, disease prevention, maintaining and maximizing optimal health—this is huge for the nursing profession,” said Beverly Malone, CEO of the National League for Nursing, which represents nurse faculty and nursing education leaders. “Healthcare is going to have to move from the hospital into the community.”
The law also adds $200 million over four years in funding for a five-hospital pilot program for Medicare graduate nursing education, paying hospitals with community-based clinics to train advanced practice nurses in direct patient care for Medicare beneficiaries. Section 5509 of the law says the grants will be based on how much growth is seen in advanced practice nurse-training programs, which teach nurses to provide primary care, preventive care, transitional care and chronic care management.
Nurses are also celebrating a provision that creates an expansive grant program to fund maternal, infant and early childhood visitation programs, in which nurses conduct regular home visits with low-income women on their first pregnancy to counsel them on maternal and childhood health. Supporters say academic studies have shown that such programs reduce criminal justice costs and give moms and kids better clinical outcomes.
“Over the years, we've been able to document that a woman of very little means who gets home visits has better outcomes, they are able to seek employment, their kids get better outcomes, there is less abuse and neglect,” said Susan Hassmiller, the senior adviser for nursing with the Robert Wood Johnson Foundation, which has funded maternal home-visit programs for years. Section 2951 of the law appropriates at least $1.5 billion to the program between 2010 and 2014.
But if demographic factors were already converging to create a huge nursing shortage before reform even became law, where will all of the nurses for these new and expanded programs come from?
The reform law addresses that need as well, nursing advocates say. Tucked away in the 906-page final legislation was the long-awaited complete reauthorization of Title VIII of the Public Health Service Act. Among other changes, the amped-up law provides for greater tuition loans for nurses under Section 5202, and more opportunities for loan forgiveness and scholarships for nurses who agree to work as faculty in accredited colleges of nursing for at least two years, in Section 5310.
Section 5311 expands loan repayment programs for higher education tuition for nurses who become full-time faculty at nursing schools. The American Association of Colleges of Nursing said the law removes the cap that formerly limited grantmaking to doctoral of nursing degree students to 10% of the overall funds available through the program.
Outside of Title VIII, several different sections of the law reauthorized and expanded nurse funding for the National Health Service Corps, run by the Health Resources and Services Administration, including larger tuition repayment and scholarship programs for nurses who agree to work in “health professional shortage areas” for at least two years.
“We need to have a highly trained workforce to care for the population,” said Suzanne Begeny, director of government affairs for the American Association of Colleges of Nursing. “Today, if you are in the hospital, you are darn sick. And we need to make sure the nurses have what they need to practice in this new healthcare system.”
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