Introduction

Accountable care organization (ACO) according to Pollock and Roderick (2018) is a group of specific care providers with who offer special services to a particular patient population and make accountability assessment of the quality of services they deliver and cost incurred in the process. The group of trained health professionals could include nurses, doctors, primary care givers, special health professionals, and at times hospitals. The health program began in the United States (US) under the regime of the immediate former president Barrack Obama. Working is an ACO group ensures shared responsibilities geared towards improved patient experience. In the US, the pioneer ACOs include the Group Health Cooperative of Puget Sound formed in Washington State, the Intermountain Healthcare in Salt Lake City, and the Geisinger Health System in western Pennsylvania (Moberly, 2017). ACOs are responsible for delivering quality services that meet quality metrics and at the costs set by funders through a capitation-funding model.

ACO is important health care program for nurse leaders because their insights on planning and delivering healthcare. According to Bagwell, Bushy and Ortiz (2017), nurses working in the rural set ups take the functions of care providers and administration. As such, they should be well informed on the risks and benefits of taking part in ACO. Nurse leaders should be knowledgeable enough on ACO initiatives that deliver quality service, prevent illness health, and manage chronic diseases. Nurses also play a pivotal role in entering data into electronic health records (EHRs) that are helpful in determining the quality of services rendered in all spheres of practice. On the administrative front, nurses should understand the basic financial incentives and their associated risks when participating in an ACO to determine the risks and cost-benefits of any partnership. The immense roles of nurses in managing successful ACO warrant an exploration in influencing key policies and procedures in the health program.

Importance of ACOs for Nurse Leaders

The role of nurse leaders in ACO in this review of literature is threefold: Resource allocation, protecting professional ethical obligation, and the delivery of fair decisions. To begin with, ACO leaders should make decisions on resource allocation especially when not all the health issues can achieve the quality metrics then exclusion of others would be a priority. A nurse leader facing such a situation is in a distributive justice dilemma to choose whether to make a choice to manage diseases affecting many or to focus on a rare disease affecting a few. At this point ACO leader should determine how best to share savings made such us whether to use them to improve quality or to give clinicians bonuses for their services. Another determination by a nurse leader would be to give bonuses based on performance of nurses. Patient incentive programs in ACO should be considerate of ethical design such as the avoidance of giving large incentives to coerce patients (DeCamp et al., 2014).

Secondly, ACO nurse leader should have control over quality improvement strategies that consider ethical obligations of clinicians such as beneficence. Moreover, a nurse leader develops ACO program with financial and non-financial incentives to ensure that ethical obligations of involved professionals are intact. A nurse leader intervenes to help professionals model their ethical behavior in an environment that is conducive in managing arising ethical issues. A nurse leader should engage in practices geared towards the achievement of ACO mission. While funders may be monitoring the behaviors, the role of a nurse leader is preventive and fosters an ethical culture (DeCamp et al., 2014).

Lastly, a nurse leader in ACO program solves disagreements in resource allocation by making key decisions. The decisions made depend on the processes followed along ethical principles on issues such as relevance, transparency, and enforcement. To make a fair decision requires a leader to devise ways of actively engaging clinicians. Besides, attention should also be on the choice of community beneficiaries with a good representation of a community (DeCamp et al., 2014).

Application, Impacts, Implications, and Consequences ACO on Nurse Leaders

The US’ health sector via the Patient Protection and Affordable Care Act that took effect in 2010 led to the initiation of the ACO model to spark imagination in the entire industry. To forge forward paths, professionals must set guidelines and regulations, as the terrain is still rough. Nurses will make impact in the successful implementation of ACO; hence, the massive roles of registered nurses (RNs) in making the patient-centered approach a success. ACO reminds a nurse leader to carry out their typical roles beyond the conventional care delivery systems. Best practices in the ACO for a nurse leader expands their roles to be care coordinators, disease manager, resource coordinator, supporter of psycho-social needs, a health coach, information analysts, data analysis, transition planner, and a community outreach vessel (Jones, 2011). The models for accountable care are still evolving; hence, the need to have standard of practices. The National Committee for Quality Assurance (NCQA) sets the criteria for evaluating ACO best practices. On the other hand, nurse leaders should know their resource strength, care gaps, and redesign processes. They are at the center of making sure nurses augment their skills to run successful projects (Jones, 2011).

The America population is aging, which increases the challenges of delivering health care services to the population. The number of RNs required to manage the health issue is high; hence, the need to come up with care models that would meet future demands. As such, an innovative work management program such as ACO is a step in the right direction. The available nurses have to increase their work performance with natural desire to learn, overcome job challenges, and socially integrate with other professionals in the sector (Bernard, & Oster, 2018). However, there are practice implications of ACO especially in enhancing quality of care at low cost. According to Chukmaitov, Harless, Bazzoli, Carretta and Siangphoe (2015), improving health care delivery at low costs calls for additional changes such as pay approaches and a centralized care delivery strategy. The latter change process would be difficult to attain due to the multidisciplinary nature of the ACO. Another implication for nurse leaders in ACO is establishing the merits of a program so that the proposed benefits are achieved in the end.

Summary of Main Points

ACO programs are innovative ways of managing the overwhelming health care demands in the US brought about by aging population. At the same time, the uncertain economic situation makes the predictability of the future very fragile. As such, the health care sector needs the affordable health care plans such as ACO. The multidisciplinary nature of the program calls on leadership to be astute and deliver the objectives of the program including low cost and quality services. The roles of a nurse leader in ACO programs are immense. A nurse leader should bring a team that understands the vision, mission, and objectives of a particular ACO program and leads it to success. In the process, there are ethical obligations to observe when handling the clinicians and patients. In ACO programs, adhering to nursing principles should be the foundation of care delivery and a nurse leader ensures the compliance by all clinicians. Another role of a nurse leader is to ensure nurses get job satisfaction in their care delivery paths even though there is increased responsibility. Allocation of bonuses should be a calculated move from leaders considering the dynamics of service delivery. One may opt to reward bonuses on performance while another may opt to reduce and give incentives to patients. Nonetheless, incentives should not coerce them into engage in ACO program. In the multidisciplinary nature of ACO programs, it is vital to coordinate inter-professional roles and adaptive changes that could lead to success. At the center of these is a nurse leader. Generally, the responsibilities of a leader fall in the three categories: resource allocation, ensuring ethical practices, and making fair decisions. If all these responsibilities are met, then a successful ACO program ensures:

• Delivery of medical services to patients backed by an institutional set up,
• developed comprehensive financial plans coined from available resources from funders, and
• offer of sustainable, reliable, and inclusive inter-professional services that are measurable at all levels of a project.