Allied Health Workshop Institute Of Medicine

Scope of Practice andthe Future of Team Based CareAllied Health WorkshopInstitute of MedicineMay 9 and 10, 2011Jean MooreCenter for Health Workforce StudiesUniversity at Albany, School of Public Healthhttp://chws.albany.edu

What is Scope of Practice (SOP)? oBased in state licensing laws and rulesSets legal framework for service delivery by aspecific health profession in a state Defines parameters of practice for aprofession Limits practice to people who successfullycomplete specified education and/or training Restricts use of title and/or credential tolicense holders in the professionDesigned to provide consumer protection

SOP Is Just One Aspect of HealthProfessional Regulation in a StateState ucation andTrainingSOP IncludingLimitations ocessAppealsProcess

There is Wide Variation in SOPRules Between Stateso Medical physicists are only licensed inFlorida, Texas, New York, and Hawaiio Clinical psychologists have prescriptiveauthority in New Mexico, Louisiana, andOregono About half of states license nuclearmedical technologists

There is Wide Variation in SOPRules Within Stateso Paramedics in San Francisco are allowed tomonitor and adjust potassium IV solutions,while paramedics in Sacramento cannoto Requirements for dental hygienists in Missourito place dental sealants varies by setting andinsurance statuso The supervisory plan required for PAs in Ohiodepends on practice setting

Variation in In-State SOP MayDepend on a Number of Factors Setting, typeof patient,requiredprofessionaloversight,and priorauthorizationcontributesto in-stateSOPvariationSettings inwhich care isprovidedAuthorizationor PrescriptionPermissibleSOPLevel ofrequiredsupervisionType orclass ofpatient

In Some Instances, Federal Rules SupersedeState Rules for Some Health Professionso Under the federal Mammography QualityStandards Act (MQSA) medical physicists whocertify mammography equipment must meetcertain training and experience standardso Dialysis technicians must be certified within 18months of initial employment in a dialysis centero Health professionals employed by federalagencies and facilities fall under federal rules

Substantial Inconsistencies in SOP Interpreted broadly for some professions, narrowly forothersDefined in state statute or regulations for some professions(e.g. pharmacists, physical therapists),Sometimes not well-defined SOP for auxiliary personnel is allowed under delegationauthority of other health professionalsNot all states have SOP rules for all health professionsThese variations have implications for cost, quality andaccess to health care services

Changing SOP: Barriers and Facilitators Restrictive SOP rules can create a mismatch between whathealth professional are trained to do compared to what they canlegally doSOP rules have evolved considerably for many professions overthe last decade (e.g. prescriptive authority for physicianassistants and nurse practitioners)Forces for change include: Health workforce shortages Limited access to needed services Emerging technologies Concerns about costForces of resistance include: Concerns about qualityConcerns about costTurf issues

SOP Rules and Inter-professionalCompetitiono Podiatrists vs. orthopedists about whetherpodiatrists should treat ankles or connectivetissues of the footo Physical therapists vs. athletic trainers aboutwhether athletic trainers can provide manualtherapy techniques without the supervision ofa physical therapisto RNs vs. radiologic technologists on whetherradiologic technologists can safely injectcontrast agents during imaging studies

Change in SOP: What Is Needed? EducationProgramBody ofKnowledgeCertificationProcess PracticeRedesignSOPLegislationChangein eptancePatientAcceptance Evolutionary, notrevolutionaryThere are manypieces that needto be in place toeffect SOP changeThere are manystakeholdersinvolved inimplementing thischange

Steps in the Process of Changing SOP:Prescriptive Authority of NPs and PAs Prescribing privileges for NPs and PAs required: Regulatory/ statutory changeDidactic education in pharmacy and pharmacokineticsCertification process/ competency testingGeneral acceptance of NP and PA prescriptive authorityChanges in hospital agreements related to responsibility forstanding medical ordersFederal permission/ DEA numbersReimbursement for pharmacies relied on the acceptance ofinsurance companies of NP or PA as legitimate prescribersOften a lag between passage of a SOP change and actualimplementation of the change

Team-Based Care and SOPooooooIncreasing use of teams in health care deliveryPatient-centered medical homes typically useinterdisciplinary teams in the provision of health careservicesCare is coordinated among multiple providers andtransitionsTeam configurations vary depending on patient needsTeam members actively communicate and collaboratewith each in the delivery of careGreater team cohesiveness is associated with betterclinical outcome measures

SOP Effects onTeam-Based CareoooooEfficiency is a priorityTeam members are encouraged to work totheir full SOPTask sharing and role overlap is common inteam-based careRole overlap can sometimes mean SOPoverlap Physicians-NPs-PAs CDEs-other members of the DSME teamOverly restrictive SOPs more likely to berecognized

Certified Diabetes Educators (CDEs) andTeam Based Diabetes Self-ManagementEducation Services (DSME) Team based chronic disease managementmodels typically include a focus on patient selfmanagementDSME helps people with or at risk for diabetesmanage their disease and prevent complicationsCDEs often lead DSME chronic diseasemanagement teamsTeam members include: DietitiansRegistered nursesCommunity health workers

CDEs and SOP OverlapCDEs are drawn from a variety of health professions:RNs, registered dietitians, NPs, PAs, pharmacists, etc.CDE requirementsoo two years of experience in their health profession1,000 hours of practical experience providing DSMEpass a certification examCDEs have broad based knowledge of diabetes but arelimited to some extent by their professional SOP RN CDEs can counsel broadly on nutrition but refer toa dietitian on their team for detailed dietary planningo The interdisciplinary approach to DSME supports teamcollaboration with some overlap in professional SOPso

Restrictive SOPfor Medical Assistants Medical assistants typically work in ambulatoryhealth care settingsNot licensed in NY, but fall under delegationauthority of licensed health professionalsMedical assistant are considered valuablemembers of teams in patient-centered medicalhomesAmbulatory health care providers haveexpressed interest in expanding the list ofapproved tasks for medical assistants in NY

Planning for the Future:State Strategies “Sunrise” reporting requirements Used by policymakers to systematically assessSOP proposalsScope of practice review committees Assess SOP changes based on objectivecriteria Composition of committees vary by state, butnot limited to the health professions affectedby the proposal Offer recommendations to legislature

Planning for the Future:National Strategies Consistency, Accuracy, Responsibility and Excellence(CARE) in Medical Imaging and Radiation Therapy Bill Would provide a uniform standard for education and certificationfor health care professionals who administer ionizing and nonionizing radiationA number of health professions have developed ‘modelpractice acts’ that include national uniform SOPs toguide state legislaturesThe Nurse Licensure Compact standardizes licensurerequirements for RNs and LPNs across states Allows license portabilityPractice is subject to the laws and regulations that governprofessional practice in each state

Closing Thoughts Emerging models of care emphasize teambased approachesThe success of these models requires acommitment to team-based education andtrainingThere will be a greater need for regulatoryflexibility related to SOPIt is critical to develop impact measures ofSOP changes on CostQualityAccess

Would provide a uniform standard for education and certification for health care professionals who administer ionizing and non-ionizing radiation A number of health professions have developed 'model practice acts' that include national uniform SOPs to guide state legislatures The Nurse Licensure Compact standardizes licensure