1. Affordable Care Act: What It Means and Why It Matters to Nurses Susan E. King MS, RN, CEN, FAAN

2. ACA Why it Matters “America's health care system is neither healthy, caring, nor a system.” - Walter CronkiteWalter Cronkite “There are more than 9,000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.” - Clayton M. Christensen, The Innovator's Prescription: A Disruptive Solution for Health CareClayton M. ChristensenThe Innovator's Prescription: A Disruptive Solution for Health Care

3. ACA Why it Matters Consumer Reports, July 1992

4. How we practice What we practice Where we practice ACA Why it Matters

5. Florence Nightingale’s Notes on Nursing: “I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet -all at the least expense of vital power to the patient.”

6. Where We Practice

7. Where Will or Should We Practice? Primary care homes Community based settings Schools Patient home Assisted Living/ Long term care Anywhere

8. How Will We Practice? Team based care “top of our license” Unlicensed workers Partnership with patient Increased emphasis on cost and quality outcomes

9. How Will We Practice? “Top of our license” –Carving out vs Full Scope –Authority for recommendations –Supervision and oversight of others –Seat at the table

10. How Will We Practice? New Unlicensed Workers Community Health Workers Community Health Workers: An ONA Position Statement April 2013 by Connie Miyao, RN, BSN; Sue B. Davidson, PhD, RN, CNS Position Oregon Nurses Association supports the development and utilization of the Community Health Worker (CHW) in Oregon's evolving health care delivery system.

11. What Will We Practice? Health Promotion Prevention Transitional Care Care Coordination Case Management Health coaching Direct care

12. What Will We Practice? Attending Registered Nurse: An Innovative Role to Manage Between the Spaces (Nursing Economics, Vol. 30, No. 5) Role: coordinating the work of the interdisciplinary team in improving relationship based care and addressing overuse, underuse, and misuse of services from pre-admission to post discharge care

13. How Will We Practice? Improving value for patients Organize care around the patient’s goals over time –Needed skills motivational interviewing, supporting patient self management, education techniques for patients at all levels of literacy, team communication, data management and usage

14. What Will We Practice? Transitional care –Medicare pilot program bundled payment for acute inpatient, outpatient, physician services and post acute services for one episode of care –BIG ROLE FOR RNs

15. What Will We Practice? Nursing! –Example: Sylvia Pishioneri RN –RN Care Manager Florence, Oregon

16. What Will We Practice? Pishioneri –Care Management includes face to face visits and phone contacts –First 16 months total savings $1,585,266.89 –ED visits for 16 frequent users dropped 42% –Top diagnoses: Chronic pain, Diabetes, CHF and Depression

17. Where, How and What What actions should we take? –Look beyond hospital practice –Protect our scope of practice Keep it and take it back –Improve our skill at demonstrating cost and quality outcomes –Engage and advocate