The Opportunity of the Affordable Care Act

To celebrate National Family Caregivers Month, this November the Future of Nursing: Campaign for Action is teaming up with Nurses Improving Care for Healthsystem Elders (NICHE). NICHE is the leading, nurse-driven program designed to help hospitals improve the care of older adults. NICHE knows that family caregivers require support and guidance to help them understand and cope with their loved ones' hospitalization and transitions. NICHE also understands that nurses are uniquely positioned to help support family caregivers. In this series of posts, NICHE staff and others will share their perspectives on health care, caregiving, and the important role nurses play in supporting family caregivers. To learn more about NICHE, visit their website.

In this post, Elizabeth Capezuti, PhD, RN, FAAN, Dr. John W. Rowe Professor in Successful Aging and Director of NICHE, shares her perspective on the Affordable Care Act and its implications for older adults.

This November, during National Family Caregivers Month, I have been thinking a lot about the key role that nurses play in supporting family caregivers. I have also been thinking about the opportunities of the Affordable Care Act (ACA) and how nurses and other clinicians can help patients and their families understand the changes that are happening in our health care system. Many people are worried about health care in the United States. There is so much uncertainty about what the ACA means for individuals, providers, and health care institutions. As the Director of NICHE, a collaborative of nearly 500 hospitals and health care systems working together to focus on care specific to older adults and their families, I’d like to share some of my thoughts on the opportunity of the ACA.

Through Medicare, older adults have had access to hospital care for more than 45 years. But access is only one part of improving health care, especially when access encourages diagnostic and treatment intensity, instead of prevention and supportive services. Research shows that older adults are more likely to experience complications during their hospital stays than younger adults.

Although many great solutions to common problems experienced by older, hospitalized patients exist, many of us know that a more effective and less costly solution is to provide better primary care (including care management and services to prevent acute exacerbation of chronic illnesses) and keep people at home.  Problems like functional decline that occur when an older person stays in bed for most of their hospital stay, or delirium that occurs due to treatments such as medications or anesthesia can be drastically reduced if the person is simply not treated in the hospital environment. These adverse complications then lead to more health problems and longer hospital stays, which often lead to more complications, and often discharge to a nursing home or other post-acute service. And yet, there is so much evidence to demonstrate how to prevent hospitalizations for older adults living in their own home, assisted living facilities, and nursing homes.

Up to this point, our health system has provided financial incentives to hospitalize—and now the ACA will motivate us to refocus to the community. For providers, this will take considerable retooling to shift our health care workforce from an acute to a chronic/preventive care model.  But what about older Americans and their families who have received the message from us that ordering more tests or going to the hospital is a good thing?  This is one of the barriers to Americans developing an advance directive or to accepting palliative care. In the US, a common perspective is “the more care, the better.” The workforce retooling will thus need to help health care providers communicate to patients and families why we are doing this not just that, “we have to.” This also means that we really have to provide another type of care—supportive services in the community that will not just shift more care to family caregivers. Hospitalization cannot be the only form of respite for physically and emotionally stressed caregivers.

The recent study conducted by the AARP Public Policy Institute and the United Hospital Fund, Home Alone: Family Caregivers Providing Complex Chronic Care, reported the intensity of medical/nursing tasks performed by family caregivers at home. By refocusing on community-based care, the ACA will likely lead to nurses providing more physical and emotional support to caregivers.  We know that many family caregivers cherish their role in caring for their loved ones but are often left with feelings of invisibility and isolation. Nurses, in collaboration with social workers and other health care providers, can provide the education, counseling and resources to assist caregivers in their various roles.

We will also need to foster a new level of care management that will emphasize honest dialogue among older persons, their family members, and health care providers. Fear of difficult conversations about making choices regarding health care interventions has been cultivated by a culture that often just does everything, regardless of the futility or the secondary effects.  Younger people now seek answers by searching the web or asking questions via texting, but these are not necessarily good ways that help older adults connect to their health care providers.  We may also need a public awareness campaign to help us talk constructively about changes in the way health care is delivered in this country. But the bottom line is that we all need to learn how to talk to those we care about in our lives, as well as our health care providers, about our health choices and goals. I am so excited about the potential positive effects of the ACA, and I hope that access and quality will be the hallmarks of American health care as we move into this new age.

by Elizabeth Capezuti | November 8, 2013

Tags: leadership, practice

Kerry Gallagher

Great post Dr. Capezuti!
Posted on: November 19, 2013, 12:39 pm

John Jorgensen

Excellent post!
Posted on: December 17, 2013, 11:41 am


Community Guidelines

Be Transparent: Always identify yourself.

Be Responsible: Take ownership of your comments and uploads; respect the opinions of others.

Be Non-Partisan: Reserve all lobbying and/or political endorsements for your personal social network.

Be Responsive: Make your participation a dialogue and not a monologue.

Be Aware: Graphic, obscene, explicit or racial comments or submissions; comments that are abusive, hateful or intended to defame anyone or any organization; third party solicitations or advertisements; comments that suggest or encourage illegal activity, are subject to be removed.

View the full Community Guidelines


about progress in your state