POST 246. April 15, 2022. CORONAVIRUS. “State authorities and health care organizations could pay a high price for reinstating SCOPE OF PRACTICE (SOP) restrictions when the pandemic ends.” (e.g. NPs, PAs, PharmDs +++)
for links to POSTS 1-246 in chronological order highlight and click on
At the end of this POST are links to earlier POSTS which together can be used as a CASE STUDY on CRISIS STANDARDS OF CARE/ SCOPE OF PRACTICE
8 Sep 2010
“In a public health emergency involving significant surges in patients and shortages of medical staff, supplies, and space, temporarily expanding scopes of practice of certain healthcare practitioners may help to address heightened population health needs. Scopes of practice, which are defined by state practice acts, set forth the range of services that licensed practitioners are authorized to perform. The U.S. has had limited experience with temporarily expanding scopes of practice during emergencies. However, during the 2009 H1N1 pandemic response, many states took some form of action to expand the practice scopes of certain categories of practitioners in order to authorize them to administer the pandemic vaccine. No standard legal approach for expanding scopes of practice during emergencies exists across states, and scope of practice expansions during routine, nonemergency times have been the subject of professional society debate and legal action. These issues raise the question of how states could effectively implement expansions for health services beyond administering vaccine and ensure consistency in expansions across states during catastrophic events that require a shift to crisis standards of care.” (A)
June 4, 2020
“As hospitals and nursing homes gear up for expected increases in critically ill patients, they should examine all opportunities to expand their workforce capacity. Where the threat of postpandemic legal consequences hampers action to expand capacity, such barriers could be removed by governors enacting emergency orders that modify or temporarily rescind medical malpractice policies that inhibit health professionals’ ability to expand their scope of practice as required. Most organizations, however, will find that outdated internal policies such as workflows, task-delegation protocols, or union agreements are the main culprits in restricting the shifting of tasks and responsibilities among personnel. These restrictions can be changed to allow health workers to fully use their knowledge and skills. How changes are accomplished will vary among organizations, but it’s essential to involve staff in identifying barriers and implementing strategies to overcome them: no one has all the answers, and engaging frontline workers can be empowering and can facilitate difficult decision making…
There are many other opportunities for creating surge capacity. Dentists, dental hygienists and assistants, dental therapists, optometrists and optometry technicians, chiropractors, and hearing technicians are among those whose practices have closed because of Covid-19. Such health professionals can be trained to conduct screenings, take vital signs, provide telephone follow-up of quarantined people with Covid-19, collect epidemiologic data, and provide community education. Short online courses and training documents could be developed to prepare these workers for such roles and to quickly scale up the capacity of the community workforce…
Finally, governors and state regulators should examine regulations to determine whether health professionals’ scope of practice is being unnecessarily restricted. Nurse practitioners can practice safely without formal physician oversight, and there may be unnecessary restrictions on registered nurses and licensed practical nurses. As more patients require care provided by registered nurses, licensed practical nurses and nursing and home care assistants could be trained and authorized to provide more services to ensure continuity of care, especially for vulnerable and frail older adults.
How well the country handles the Covid-19 crisis depends largely on how effectively our health workforce is used. Much can be done to ensure that the workforce is prepared to defeat the pandemic. Some actions discussed here are temporary, whereas others — such as expanding scopes of practice, cross-state licensure, and allowing greater use of telehealth services — probably make sense in general but are especially critical now. Now is the time for pragmatic steps to expand and sustain the health workforce. Once the pandemic has subsided, workforce changes should be evaluated and the results used to inform wiser use of the workforce and improved responses to future pandemics.” (B)
“Nurse practitioners, physicians assistants and pharmacists are pressing for more autonomy to diagnose patients, recommend treatments and write prescriptions, and doctors’ aren’t pleased.
Why it matters: So-called scope of practice fights have been going on for decades. But certain emergency powers granted during the pandemic allowed advanced practice providers who were not doctors to provide more services than ever before and reignited the battle in many states.
Driving the news: Relaxed laws allowing “unrestricted independent practice” by nurse practitioners exist in 25 states, as well as the District of Columbia and two U.S. territories.
New York became the latest to join that list when Gov. Kathy Hochul signed legislation into law over the weekend to allow “NPs” to practice without supervision from a medical doctor.
Massachusetts Gov. Charlie Baker signed similar legislation earlier this year expanding the independent practice of physician assistants.
In Maryland, the state legislature overturned a veto over the weekend by Gov. Larry Hogan so nurse practitioners, midwives and physician’s assistants could perform abortions.
The Biden administration’s test-to-treat initiative would allow pharmacists to administer antiviral drugs on the spot to patients who’ve tested positive for COVID, spurring that industry to push for regulatory changes to cement its enhanced role in patient care, Axios’ Caitlin Owens wrote last month.
Between the lines: The pandemic allowed certain advanced providers, like nurse practitioners, to demonstrate they were able to fill critical gaps in the strained health care system by being allowed to exercise the entire “scope” of their license, proponents argue.
“We’re not seeking to work beyond our education and training,” American Association of Nurse Practitioners president April Kapu told Axios. “We’re only asking to work to the extent and education of the training we have.”
She pointed to data that found improved access in rural areas and improved outcomes among patients when nurse practitioners were able to practice without limits often placed by state laws.
But, but, but: Doctors call this “scope-of-practice creep,” and they say the non-physician providers are jeopardizing patient safety without expanding access or saving money the way proponents claim.
The American Medical Association has been fighting this battle for years and helped defeat scope of practice expansion bills in Florida, Kansas, Kentucky, Louisiana, Maine, Mississippi, Tennessee and Texas last year.
“The American Medical Association strongly supports physician-led team-based care where all members of the team use their unique knowledge and valuable contributions to enhance patient outcomes,” the organization said in an emailed statement.
“Nurse practitioners are valuable members of this team, but they are not a replacement for physicians,” they said, pointing to an AMA-sponsored poll of 1,000 U.S. voters between Jan. 27–Feb. 1. In the poll, 95% of respondents said it was important for a physician to be involved in their diagnosis and treatment.
What to watch: State-by-state legislative fights will continue with both sides making arguments for improved patient outcomes and access. (C)
“Pharmacists have made significant authority gains over the past year, as many regulations went into effect that expanded pharmacists’ scope of practice amid the COVID-19 pandemic.
However, because these authorities were enacted under the Public Readiness and Emergency Preparedness (PREP) Act, many of them are temporary and only in effect during the public health emergency.
In a session held during the American Pharmacists Association (APhA) 2021 Annual Meeting and Exposition, which is held virtually March 12-15, policy experts discussed key advocacy efforts and legislative enhancements for pharmacy practice during and beyond the pandemic.
“From the start of the pandemic, it was clear that pharmacists had and will have a significant role in patient care and pandemic response,” Ilisa Bernstein, PharmD, JD, senior vice president of pharmacy practice and government affairs at APhA, said in the presentation.
Bernstein pointed to key advocacy areas that APhA is focusing on right now:
Authority to test/treat/immunize for COVID-19 and childhood vaccinations
Reimbursement for pharmacist services
Pharmacists as frontline providers, to ensure adequate personal protective equipment, workplace conditions and protections, and policies and procedures
Pharmacies as essential vaccine access points for distribution, vaccine-confidence, and information
“The AMA House of Delegates has come out against the effort to rebrand the health-professional role of physician assistant as “physician associate,” saying the move taken recently by the American Academy of PAs (AAPA) will perplex patients seeking the benefit of physicians’ team leadership and superior training.
During the June 2021 AMA Special Meeting, delegates directed the AMA to “actively oppose” the name change. In addition, the AMA will “actively advocate that the stand-alone title ‘physician’ be used only to refer to doctors of allopathic medicine (MDs) and doctors of osteopathic medicine (DOs), and not be used in ways that have the potential to mislead patients about the level of training and credentials of nonphysician health care workers.”
AMA Immediate Past President Susan R. Bailey, MD, explained the name change’s likely negative impact.
“Changing the title of ‘physician assistants’ will only serve to further confuse patients about who is providing their care, especially since AAPA sought a different title change in recent years, preferring to only use the term ‘PA,’” Dr. Bailey said in a written statement.
The latest PA branding effort—which follows years of study by an international marketing and communications firm—“will undoubtedly confuse patients and is clearly an attempt to advance their pursuit toward independent practice,” Dr. Bailey said.
Scope of practice: How the AMA fights for patient safety
She added that the AMA believes the name change is incompatible with state laws. The AMA, Dr. Bailey said, is “prepared to work with interested state and specialty medical societies to address any efforts to implement this title change in state or federal policy.”
Survey: Many patients unclear on PAs
PAs are a pivotal part of many physician-led health care teams, but confusion about their role is long-standing. About one-quarter of patients wrongly believe that physician assistants are physicians or are unsure, according to AMA survey research on truth in advertising. Meanwhile, 45% of patients say it’s hard to identify who’s a licensed physician or that they don’t know.
“We are strongly committed to supporting physician-led health care teams that use the unique knowledge and valuable contributions of all health care professionals to enhance patient outcomes,” Dr. Bailey said. “It is also what patients want, which is why clarity in health care titles is so important. That is why the AMA has advocated in support of truth-in-advertising laws and stands in strong opposition to AAPA’s title change.”
Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety.
4 tips for physician advocates to protect the doctor-led care team
In 37 states, PAs are supervised by physicians. In 11 other states, PAs must have a collaborative agreement with physicians. In Michigan, PAs must work with a participating physician according to the terms in a written practice agreement.
In nearly all states, PA scope of practice is determined with the supervising or collaborating physician at the practice site. Legislation that would have replaced physician supervision with a weakened definition of collaboration were defeated in Colorado, South Dakota and Texas. In two other states, legislation was favorably amended to retain physician supervision (Florida) or collaboration (Tennessee) of physician assistants. “ (E)
“Changes to state SOP regulations were intended to be temporary; however, the time lines for these changes were not firmly established. The timing of recovery from the pandemic is uncertain and will likely vary among states. When the health care system is able to go back to a “new normal,” many HCPs may not wish to return to their pre-pandemic roles or to the limits placed on their SOP. Concerns about HCPs’ job satisfaction, burnout, and professional well-being—defined as the quality of work-life based on physical, cognitive, emotional, and social aspects of work activities and environments—were widespread before COVID-19. Any changes to SOP regulations will directly affect what HCPs can and cannot do at work, as well as how they structure their workflows. Hasty reversal of SOP expansions would likely have adverse effects on HCPs’ job satisfaction and professional well-being. Therefore, any roll-back of changes to SOP regulations when a pandemic workforce response is no longer necessary will require careful deliberation among state authorities.
Urgency often is a force for change, and changes to SOP regulations were justified in the face of COVID-19, given the surge in case volume and concerns about hospital capacity. What happens when the pandemic subsides and we transition to a post-pandemic normal, although this time without the same urgency?…
State authorities and health care organizations could pay a high price for reinstating SOP restrictions when the pandemic ends. Such decisions could seriously damage relationships with HCPs who perceive lack of reciprocity from institutions for which they have risked their health and sacrificed their personal needs. If SOP changes are suddenly or even gradually reversed when the pandemic subsides, many HCPs may feel that they were treated unfairly. Based on the literature on organizational justice, we know that this sense of unfairness is profoundly dissatisfying and detrimental to professional well-being.
Justifying SOP reinstatements because they are “business as usual” will not be sufficient. If reinstatement occurs, policy makers and regulators should make decisions based on empirical evidence that indicates why SOP expansion was warranted only during the pandemic; whether health care delivery, quality, and patient safety differed under expanded versus usual SOP; and why it would not be appropriate to integrate improvements in care delivery discovered during the pandemic into HCP practice and workflows in the future.
A Focus On Evidence And Gratitude
Regardless of whether temporary relaxation of SOP policies are continued, modified, or discontinued, public- and private-sector health care leadership should clearly communicate the evidence base for these decisions, including any research findings on the clinical impact of changes to SOP policy. To address perceptions of unfairness and avoid compromising professional well-being, these communications should consistently acknowledge the tremendous contributions and sacrifices HCPs have made during the pandemic.” (F)
“Practice at the top of your license.
It’s an expression you hear a lot these days as healthcare organizations seek to improve the work experience of their employees and raise the quality of patient care, all while lowering costs.
What does it mean to “practice at the top of your license?”
It usually means someone with less training is enlisted to do work that was previously done by someone with more training.
On the face of it, this notion is irrefutable….
In the same way, highly experienced healthcare professionals trained to diagnose and manage complex illness should not be burdened with routine tasks and documentation requirements whose fulfillment don’t require their skills and intellects.
This work can be done by others. Using this logic, many healthcare organizations have added positions to care teams, enabling people with advanced clinical training to focus on work that makes use of that training.
Initially, medical practices supplemented physicians with nurse practitioners (NPs) and physician assistants (PAs).
Before long, this practice led the business people who often drive the structure and organization of care began to ask a series of provocative questions:
If some of a physician’s work can be safely handed off to NPs and PAs, can some of the NPs and PAs work be handed off to registered nurses (RNs)?
If some of a NP or PA’s work can be safely handed off to RNs, can some of the RN’s work be handed off to licensed vocational nurses or medical assistants?
And if some of the RNs job can safely be handed off to licensed vocational nurses (LVN) or medical assistants (MA)—can some of their work be handed off to community health workers or, even, lay people with no medical training?…
This leads to an insidious equivalence being developed in which healthcare professionals are seen as potential substitutes for one another.
Significant differences in training length and intensity are casually being washed away.
But is there a natural limit to how much task-shifting can occur?
At a high-level, those in charge of health systems and allocating resources will say that complex patients should see clinicians with more training.
Seems simple enough—but it is precisely the undefinable nature of a patient’s condition that often makes it hard to know which patient is best suited to what kind of patient care.
Put another way, what defines what is complex or simple? How much do we know upfront whether a patient will require deep expertise?
A patient with a history of a brain tumor who presents with a headache might be triaged and cared for differently than a patient who presents with a headache in the setting of a traumatic injury.
Ultimately, it is often left to an unsupervised clinician to decide themselves whether something is complex or simple.
Dedicated and motivated clinicians of all types get it wrong, not out of willful incompetence, but often out of ignorance, inexperience or just error.
Complexity often lies in subtleties invisible to the untrained eye—and not all health professionals across and within professional groups are trained equally well to see those subtleties (in itself a controversial statement in some organizations).
Which is what is so vexing about healthcare’s great labor arbitrage.
Patient care is being moved around to individuals with different levels of professional training without any clearly defined architecture delineating where and how patients are best served (other than cost).
Systems that rely heavily on task shifting (including ones that I have led) often invest insufficiently in defining the boundaries of roles and fail to invest in other training and resources that enable clinicians to ask for help when they need it.
In the absence of such definition and training, many organizations are pushing on the upper bounds of what falls at the “top of one’s license” without any clear or definable limit…
But it does mean that organizations and advocates who push for new roles in patient care should be hyper-vigilant to ensure that—in the rush to lower the cost of care and allow people to practice at the “top of their license”—we are not irreparably degrading the quality of care through a cascade of false equivalences across professional lines.
To the extent possible, there should be clear boundaries delineating what level and type of care is appropriate for an individual to provide depending on their level of training.
Because these boundaries are so difficult to define, there should be clear systematic supervision protocols through which patients are seen by and presented to more experienced, more highly-trained clinicians at every step of the clinical process (not just by chart review) to ensure that clinical situations are appropriately sized up at the outset.
Some organizations excel at this kind of sorting—but others have yet to take on the hard work for economic reasons and, also, because it is increasingly a topic of sensitivity.
Many professional groups have increasingly focused on their ability to practice and deliver care “independently”—which is to say, without supervision or oversight from another clinician…
Our focus should be on designing systems that allow different professionals with different levels of training to collaborate with others and leverage their distinct expertise to contribute meaningfully to patient care—not exclusively on driving costs down by pushing work around that may or may not belong in the hands of another.” (G)
“The evidence is clear that NPs deliver high-quality, safe care, and scope-of-practice restrictions only limit NPs’ ability to do so. Many NPs find themselves unable to do their jobs from one day to the next if their collaborating physician retires, dies or loses their license. In our work, we have shown that many physicians in New York state find the unnecessary restrictions burdensome. One physician said, “I’ve asked that many times, ‘Why am I signing for a nurse practitioner who has a Ph.D. and has been working with me since 1998?’ I have absolutely no clue.” These restrictions also prevent patients from quickly accessing health care services.
States granting NPs a greater practice authority experience expanded health care utilization, especially among rural and vulnerable populations. States such as New York have traditionally faced uneven access to primary care providers. In 2019, the ratio of population to primary care physicians across New York state counties ranged from 700:1 to 13,780:1. Millions of New Yorkers, particularly those living in rural, low-income, and minority communities, are without access to primary care. Almost 5 million New Yorkers live in areas that are designated Primary Care Health Professional Shortage Areas. Federally qualified health centers in the state that mostly serve low-income and minority patients are unable to recruit primary care physicians and NPs. And NPs cannot practice in areas without physicians if the state requires agreements between these two health professionals.
NPs can help to meet the growing demand for chronic care services. Evidence shows that NPs are well-suited and uniquely qualified to deliver care to chronically ill patients given their nursing training and a background that focuses on the overall health and well-being of the patient and not on the disease alone. Consider the fact that more than 40 percent of New York adults suffer from a chronic disease. These individuals need timely access to primary care services to manage their conditions. We know that those who suffer chronic health conditions are most at risk for COVID-19; 91.6% percent of all COVID-19 deaths in New York were among people who had underlying chronic illnesses, such as hypertension and diabetes. We are also learning that minorities, who suffer disproportionately from chronic illnesses, have been dying at a disproportionally higher rate from COVID-19.
Governors’ willingness to temporarily lift scope of practice restrictions to begin with demonstrates that such restrictions are arbitrary rather than evidence-based. Even in a crisis, no governor would risk the public’s safety by allowing unqualified clinicians to care for patients without oversight. If NPs are qualified to care for the sickest patients during the most challenging times of crisis and chaos without a physician’s supervision, then they should certainly be able to operate autonomously in normal times.
There is no need to go back to outdated, artificial restrictions as these executive orders expire. Post-COVID-19, more than ever, we will need to optimally use all health care resources, including the growing NP workforce, whose numbers almost doubled from 2010 to 2017 and continue to grow rapidly.
Many more states are considering permanent expansion of the NP scope-of-practice regulations. On January 1, Massachusetts Governor Charlie Baker signed a new law titled “An Act Promoting a Resilient Health Care System That Puts Patients First.” The law enables NPs to practice independently, provided that they meet educational and training requirements. Allowing NPs to deliver care to Americans without restrictions will assure that when disasters happen, Americans will be healthier and more ready to weather them, and our health care system will be prepared.” (H)
“Here are five ways pharmacy has expanded its scope during COVID-19 – and how pharmacists and technicians will play an essential role moving forward.
1. Administering COVID-19 Tests and Vaccines
New guidance issued in April 2020 under the Public Readiness and Emergency Preparedness Act authorized pharmacists to order and administer COVID-19 tests. This guidance from the U.S. Department of Health and Human Services (HHS) has positioned pharmacists to practice at the top of their license and provides them opportunities to add greater value on the frontlines, servicing patients from diagnosis to follow-up.
In certain states, pharmacy technicians can perform rapid point of care testing (POCT) to help enable greater preventative and supportive care for COVID-19 as well as help to reduce emergency department visits.
Pharmacists, as well as pharmacy technicians and students, have also played a key role in COVID-19 vaccine administration. Additional guidance from HHS announced in the fall of 2020 authorizes state-licensed pharmacists – and state-licensed, registered pharmacy interns acting under the supervision of a qualified pharmacist – to order and administer COVID-19 vaccinations to individuals 3 years of age and older.
Enabling pharmacists and technicians to administer COVID-19 tests and vaccines recognizes these vital roles as front-line healthcare workers who make a meaningful difference in combating the pandemic.
2. Digital Access to Care…
Through telepharmacy visits, pharmacists have been working collaboratively with their patients’ providers, making recommendations to care plans and providing vital education and medication counseling throughout various disease states.
During these virtual pharmacist-patient connections, pharmacists provide reliable drug information and awareness to patients’ disease management – which, in turn, helps free up provider time and instill greater trust in pharmacists. Additional benefits of pharmacy telehealth services include:
Scheduling flexibility for both pharmacy staff and patients.
Reducing the need for on-site patient visits.
Pharmacists’ ability to assess patient awareness and understanding of medications as well as visualize all patient medications…
3. Conducting Remote Order Verification and Overseeing Compounding
During the pandemic, some health system pharmacists have transitioned from hospital-based functions to remote order entry and verification as well as telepharmacy services. Remote order verification is a process that allows pharmacies to expand services without having to add new pharmacists – and can expand medical care in rural or underserved communities.
Remote order verification has helped providers optimize staffing as well as supplement staffing at facilities where 24/7 pharmacy support is not present on-site. Given social distancing guidance, the use of remote order verification has increased, as have considerations to centralize remote order verification in multi-hospital organizations. In responding to rapidly evolving situations, since mid-March, many states have issued waivers or otherwise amended regulations to permit the use of remote processing or telepharmacy to oversee a wide range of pharmacy operations…
4. Reimbursement of Pharmacy Services
Through crisis comes opportunity for pharmacists to be recognized as providers. ASHP states that while pharmacists can provide telehealth services as an “incident to” a Medicare-eligible provider, they cannot directly bill Medicare for these services.
It is imperative that the Centers for Medicare and Medicaid Services (CMS) recognize front-line pharmacists as providers during these unprecedented times as pharmacists and technicians are valuable sources of information and treatment to serve patients and support a strained system at its most critical time…
5. Pharmacy Technicians as Extenders and Technology Experts
The expansion of telepharmacy services has provided opportunities for pharmacy technicians to practice at the top of their licenses and act as extenders for pharmacists.
Traditionally, pharmacy technicians have facilitated the day-to-day functions of the medication use process – from order entry and drug product preparation to dispensation, allowing pharmacists to focus on direct patient care and medication therapy management. With the implementation of a variety of pharmacy technologies deployed throughout the medication use process, pharmacy technicians trained in information technology have become experts in day-to-day telepharmacy operations…” (I)
“In each state, scope of practice (SOP) regulations primarily define the services a health professional is legally allowed to perform. The pandemic has highlighted how these regulations affect public health, equity, and patient care. In response to emergency needs, some states have modified their regulations, with questions now arising about whether to make the changes permanent. To set the stage for the conference discussions, Penn Nursing Dean Antonia Villarruel, PhD, RN pointed out four key considerations in SOP reform:
• Health professional practice is constantly changing and innovating due to changes in supply, technology, and demands for care. Retail clinics and telehealth are just two examples of recent changes in health care delivery. State regulation must evolve to meet the needs of these changes in practice and policy.
• The scope of health professional activities could and should overlap. While different health professional groups have unique capabilities and functions, many activities can cross professions. For example, should a dentist, dental hygienist, or veterinarian provide a flu shot? Should a home care nurse or physical therapist order durable medical equipment for a patient at home? Should a hospice nurse legally declare someone dead? Should a pharmacist manage some aspects of chronic illness?
• We should assume and promote collaboration between health care providers, rather than oversight of one profession over another. Competent providers will refer to others to manage issues that require different expertise; the fundamental question is whether a proposed service can be provided safely and effectively, given a professional’s education and training.
• We should transcend “turf” battles and payment issues and focus instead on access, safety, and equity. Debates about state regulation should center around the patient and the public’s health, rather than on competition and reimbursement issues between health care professions.” (J)
“The strongest opponents to APP scope of practice expansion are medical associations and physician groups, which argue that loosening supervision requirements may negatively impact quality of care and patient safety. These groups emphasize that APPs receive less technical and clinical training than physicians and argue that “the education and training really matters.” Michaela Sternstein, Vice President of the American Medical Association State Advocacy Resource Center, emphasizes the importance of “[t]he level, the depth, the intensity, the time commitment.”
Physician groups and medical associations also emphasize the value and long-standing tradition of a team-based approach to providing healthcare, in which one or more physicians leads a team of APPs and other auxiliary personnel. These organizations argue that allowing for independent practice of APPs could lead to a siloed approach, with less collaboration and accountability…
In most states, scope of practice for APPs was expanded on a temporary basis in response to the COVID-19 pandemic, as part of a necessary all-hands-on-deck approach to combating the coronavirus. Some governors who signed executive orders to temporarily permit this scope of practice expansion have now expanded those orders by signing subsequent legislation that permanently allows APPs to practice independently or on a more autonomous basis. For example, following the expiration of his executive order expanding scope of practice for Nurse Practitioners, Optometrists, Nurse Anesthetists and Psychiatric Nurse Mental Health Specialists, Massachusetts Governor, Charlie Baker, signed a comprehensive piece of healthcare legislation, which permanently codified the expanded scope of practice permitted during the pandemic. Similarly, Arkansas Governor, Asa Hutchinson, signed several pieces of legislation in March of this year, which permanently codified his executive orders giving full independent practice authority to certain Nurse Practitioners and Certified Nurse Midwives, and shifting the practice relationship between Anesthesiologists and Nurse Anesthetists from supervisory to collaborative. Further, the scope of practice for pharmacists has also been expanded during the pandemic, in response to the necessity of rolling out COVID-19 vaccines on an expedited timeframe. For example, HHS’ Third Amendment to Declaration under the Public Readiness and Emergency Preparedness Act allows pharmacists, and even pharmacy interns, to administer vaccines to children between the ages of three and eighteen for the duration of the public health emergency. Multiple states have followed suit to codify emergency authority granted during the pandemic, including Virginia, which allows pharmacists to independently prescribe and administer vaccines, and Utah, which grants pharmacists broad independent prescriptive authority...
The majority of states have enacted some expansion of APP scope of practice over the past few decades, and nearly every state legislature deliberated scope of practice bills in 2021. A staggering 280 bills have been introduced in 2021 to modify the scope of practice laws for different APPs.
However, the success of these bills has been inconsistent. For example, while Massachusetts, Delaware, Michigan, Arkansas, and Pennsylvania all passed bills expanding the scope of practice for Nurse Practitioners, similar bills were struck down in Florida, Kansas, Kentucky, Louisiana, Maine, Mississippi, Tennessee, and Texas. In view of these mixed results, it remains to be seen the speed with which scope of practice reform will continue its progression toward independent practice for APPs.” (K)
PREQUELS FOR A CASE STUDY
POST 37. June 8, 2020. CORONAVIRUS. When “crews arrive at a hospital with a patient suspected of having COVID-19, the hospital may have a physical bed open for them, but not enough nurses or doctors to staff it.”
POST 105. January 8, 2021. CORONAVIRUS. POST 105. January 8, 2021. CORONAVIRUS. “Facing a shortage of vaccinators, the Association of Immunization Managers… recommends relaxing regulation or adjusting licensing requirements. At least two states, Massachusetts and New York, have changed their laws in recent weeks to expand those who are eligible to give shots.”
POST 190, August 21, 2021. CORONAVIRUS. “We’re looking, in essence, at running two systems — a COVID system and a non-COVID system of care,”..“Emergency medical technicians (EMTs) and certified paramedics can now care for patients in Mississippi hospitals and emergency rooms under a new health office order issued by the Mississippi State Department of Health on Wednesday.”
POST 197. September 12, 2021. CORONAVIRUS. Idaho officials have instituted “crisis standards of care” to help 10 hospitals and health care systems decide how to allocate personnel and resources to deal with a crush of COVID-19 patients.”… “The Washington Medical Coordination Center oversees facilitating transfers in the state, and it’s warning we could be nearing the point of “Crisis Standards of Care,” just like Idaho.” .. “These crisis models don’t actually save more lives, they just save different lives..”
POST 199. September 19, 2021. CORONAVIRUS. Crisis Standards of Care. “… to his knowledge, no patient in Idaho has been taken off life-support therapy in order to provide that therapy to another patient who has a better prognosis.” “While that has yet to occur, if we continue on this path, it will,”
POST 200. September 23, 2021. CORONAVIRUS. CDC Director overrides a recommendation of its scientific advisors saying “that people can get a booster if they are ages 18 to 64 years and are health-care workers or have another job that puts them at increased risk of being exposed to the virus.”…“In a pandemic, even with uncertainty, we must take actions that we anticipate will do the greatest good.”
POST 202. September 30, 2021. CORONAVIRUS. “..NY Governor Hochul signed an executive order expanding healthcare worker eligibility requirements…to head off potential staffing shortages fueled by the state’s new COVID-19 vaccination requirements.” “The.. order allows out-of-state/ out-of-country healthcare workers to practice in New York…”..”It allows EMTs graduates to temporarily pitch in at additional healthcare settings; allows various types of healthcare workers to more easily administer and order COVID-19 vaccinations; enables telemedicine physician visits in nursing homes; permits facilities to more quickly discharge, transfer or receive patients…”
POST 223. December 28, 2021. CORONAVIRUS. Links for a case study of Crisis Standards of Care.
POST 224. December 29, 2021. CORONAVIRUS. “crisis standards of care protocols in Maryland – “It also allows us to slim down documentation,… allows unconventional staffing models such as using nurses that have not been bedside. It also sets the expectations for the community that it’s not business as usual.”
- A.Expanding Practitioner Scopes of Practice During Public Health Emergencies: Experiences from the 2009 H1N1 Pandemic Vaccination Efforts, Brooke Courtney, Ryan Morhard, Nidhi Bouri, and Anita Cicero, https://www.liebertpub.com/doi/10.1089/bsp.2010.0036
- B.Ensuring and Sustaining a Pandemic Workforce, by Erin P. Fraher, Ph.D., M.P.P., Patricia Pittman, Ph.D., Bianca K. Frogner, Ph.D., Joanne Spetz, Ph.D., Jean Moore, Dr.P.H., Angela J. Beck, Ph.D., M.P.H., David Armstrong, Ph.D., and Peter I. Buerhaus, Ph.D., R.N., https://www.nejm.org/doi/full/10.1056/NEJMp2006376
- C.Turf wars heat up after pandemic blurred provider treatment lines, by Tina Reed, https://www.axios.com/turf-wars-heat-up-between-doctors-and-nurse-practitioners-516f6068-e157-4e00-bfdd-60dd8bae5078.html
- D.Expanding Scope of Practice Amid the COVID-19 Pandemic and Beyond, Jennifer Barrett, https://www.drugtopics.com/view/expanding-scope-of-practice-amid-the-covid-19-pandemic-and-beyond
- E.PA rebrand as “physician associates” will deepen patient confusion, by Kevin B. O’Reilly, https://www.ama-assn.org/practice-management/scope-practice/pa-rebrand-physician-associates-will-deepen-patient-confusion
- F.Is It Fair? How To Approach Professional Scope-Of-Practice Policy After The COVID-19 Pandemic, Alden Yuanhong Lai Susan M. Skillman Bianca K. Frogner, https://www.healthaffairs.org/do/10.1377/forefront.20200624.983306/
- G.‘Practicing At The Top Of Your License’ And The ‘Great’ American Healthcare Labor Arbitrage, by Sachin H. Jain, https://www.forbes.com/sites/sachinjain/2022/04/04/the-great-american-healthcare-labor-arbitrage/?sh=1a8ffae66133
- H.We trusted nurse practitioners to handle a pandemic. Why not regular care?, BY LUSINE POGHOSYAN, https://www.niskanencenter.org/we-trusted-nurse-practitioners-to-handle-a-pandemic-why-not-regular-care/
- I.Five Ways Pharmacy Expanded its Role During COVID-19, by James A. Bana, Leila Tibi-Scherl, https://premierinc.com/newsroom/blog/five-ways-pharmacy-expanded-its-role-during-covid-19
- J.EXPANDING SCOPE OF PRACTICE AFTER COVID-19, https://ldi.upenn.edu/wp-content/uploads/2021/06/PennLDI-PennNursing-Expanding-Scope-of-Practice-After-COVID-19-Brief.pdf
- K.Debate Continues Around Scope of Practice Expansion for APPs, By Erica J. Kraus and Theresa E. Thompson, https://www.natlawreview.com/article/debate-continues-around-scope-practice-expansion-apps