Summary - Expanded Scope of Practice
In anticipation of this growing demand for COVID-19 care, the federal government and states are rapidly enacting policies to expand and increase health workforce capacity, both by increasing the pipeline of healthcare workers and by shifting or expanding the ways the current workforce is utilized. This latter approach is often constrained by state scope of practice (SOP) regulations, which address how, where, and to whom healthcare workers can provide care.
Session #3 of the Fitzhugh Mullan Institute for Health Workforce Equity’s mini-webinar series Emergency Health Workforce Policies to Address COVID-19, describes opportunities and challenges with regard to emergency measures states can take to relax SOP restrictions as one way to maximize the current workforce capacity and efficiency.
Moderated by Dr. Patricia Pittman, Director of the Mullan Institute, the webinar features two national experts in health workforce policy, Dr. Joann Spetz and Dr. Bianca Frogner, as panelists. Both panelists are currently working with their respective state governments (CA and WA) on emergency workforce policies to address the COVID-19 pandemic.
Dr. Spetz (minute 02:42) explains that regulations are usually first established through legislation and then implemented by the appropriate state licensing board or agency. SOP regulations may dictate who can work in certain professions, the tasks they are permitted to undertake, and under what circumstances work is permitted to be performed. For example, SOP regulations may place restrictions on the extent to which certain health workers, like physicians’ assistants (PAs), are able to practice autonomously, as opposed to under the supervision of a physician.
While scope of practice restrictions has long been an issue for most of the health professions, in the current situation, they are particularly burdensome for subsets of health workers. Dr. Frogner provides insight (minute 04:30) on SOP implications for an often-overlooked group of front-line health care workers: paramedics. Typically limited in scope to providing transport to the ER, SOP waivers can be enacted allowing them to triage and screen patients for COVID-19 in additional care settings, such as skilled nursing facilities. Dr. Frogner also examines implications for PAs (minute 05:30). She explains that states are increasingly removing restrictions around supervisory requirements, ability to diagnose, and care delivery via telemedicine for this sector of the health workforce, pointing out that removal of these restrictions serves the dual purpose of increasing access to health care services while freeing up physicians to focus on the most severely ill patients.
Dr. Spetz, (minute 06:25) goes on to explain that SOP waivers at all levels of nursing – from those pertaining to licensed vocational nurses to advanced practice nurses like nurse practitioners (NPs) and nurse midwives - can be used to increase the provision of care and expand workforce capacity. For example, states can put waivers in place allowing vocational nurses and nursing assistants to deliver some medications, while waivers for nurses with advanced degrees may remove restrictions around physician supervision or provide them with hospital admitting privileges (the latter of which is especially relevant for certified nurse midwives, as the number of deliveries taking place in non-hospital settings is expected to increase during the pandemic). These provisions, among others, can contribute to the efficient use of scare workforce resources.
Dr. Frogner (minute 09:05) adds that SOP waivers can assist in keeping non-COVID patients out of the hospital during the pandemic. Pharmacists, for example, can divert patients from hospital settings by providing them with clinical consult, while laboratory technicians can perform diagnostic testing in the home care setting, when SOP waivers allow. Scope of practice for respiratory therapists can also be expanded by permitting them to provide non-COVID-19 care in the home setting.
States have taken varied approaches to addressing health worker SOP in the wake of COVID-19 in terms of type of the mechanism used to establish them (minute 12:30). Dr. Frogner explains that the most commonly used approach has been an executive order issued by governors. However, she notes that it is up to state boards to then make SOP changes a reality in practice. Dr. Spetz provides examples of two states using alternative measures to promulgate SOP waivers: emergency legislation (Ohio) and an executive proclamation authorizing state agencies to implement a waiver request and approval process (California). Dr. Frogner points out that payers, like CMS, must also authorize provisions allowing for reimbursement that aligns with SOP changes. “It has to be a simultaneous set of moves that are made to make sure that there is congruency between what state leaders expect and want and what our insurance payers are actually doing”, she states.
Currently, states are taking varied approaches to the types of SOP waivers being authorized, although replication across states is starting to be observed. Three states presented in the webinar: Indiana (EO 20-12, 20-05); New York (EO 202-10); and Pennsylvania (EO Waiver Under Disaster Declaration) have emerged as early leaders in SOP regulation in response to COVID-19 (minute 18:15). Although these states vary in terms of political climate, previous SOP regulations, and severity of COVID at this time, Dr. Spetz points out that they represent early enactors of SOP waivers that are both comprehensive in the provisions and professions they cover and responsive to workforce needs.
Although SOP waivers can be an effective tool for expanding workforce capacity, they remain relatively scarce across the landscape of state legislative and executive responses to COVID-19 (minute 20:15). Drs. Frogner and Spetz provide context for this discrepancy, explaining that SOP has always been a politically contentious issue and an area not well understood by the public. Dr. Frogner emphasizes here is a popular misconception that SOP restrictions are in place to protect patient safety and, that by relaxing restrictions, patients will receive sub-par care. Studies, however, demonstrate this not to be the case. “When you relax SOP laws to allow people to work at the top of what they’re licensed to do…that does not provide any less quality of care to the patients”, she affirms.
Dr. Frogner (minute 21:40) indicates that an additional complexity inherent in SOP policy discussions is that SOP is not well defined for many allied health workers. Additionally, SOPs vary across states, and their implementation also varies across health care organizations. Dr. Frogner acknowledges that there is limited understanding of how many health workers are being used across settings and best practices for deploying them. These factors, she points out, make SOP legislation difficult.
Dr. Spetz (minute 23:00) notes the broader question is which SOP waivers states will make temporary as an emergency response to COVID-19 and which will be sustained in the long-term through codified legislation. She points out that some states, such as California, already had SOP legislation in the pipeline prior to the US being hit by COVID-19, and only time will tell if these temporary waivers will complicate or facilitate their passage. When it comes to the lasting policy implications of emergency SOP waivers, “It’s too early to say how this is going to play out”, concludes Dr. Spetz.
Session #3 of the Fitzhugh Mullan Institute for Health Workforce Equity’s mini-webinar series Emergency Health Workforce Policies to Address COVID-19, describes opportunities and challenges with regard to emergency measures states can take to relax SOP restrictions as one way to maximize the current workforce capacity and efficiency.
Moderated by Dr. Patricia Pittman, Director of the Mullan Institute, the webinar features two national experts in health workforce policy, Dr. Joann Spetz and Dr. Bianca Frogner, as panelists. Both panelists are currently working with their respective state governments (CA and WA) on emergency workforce policies to address the COVID-19 pandemic.
Dr. Spetz (minute 02:42) explains that regulations are usually first established through legislation and then implemented by the appropriate state licensing board or agency. SOP regulations may dictate who can work in certain professions, the tasks they are permitted to undertake, and under what circumstances work is permitted to be performed. For example, SOP regulations may place restrictions on the extent to which certain health workers, like physicians’ assistants (PAs), are able to practice autonomously, as opposed to under the supervision of a physician.
While scope of practice restrictions has long been an issue for most of the health professions, in the current situation, they are particularly burdensome for subsets of health workers. Dr. Frogner provides insight (minute 04:30) on SOP implications for an often-overlooked group of front-line health care workers: paramedics. Typically limited in scope to providing transport to the ER, SOP waivers can be enacted allowing them to triage and screen patients for COVID-19 in additional care settings, such as skilled nursing facilities. Dr. Frogner also examines implications for PAs (minute 05:30). She explains that states are increasingly removing restrictions around supervisory requirements, ability to diagnose, and care delivery via telemedicine for this sector of the health workforce, pointing out that removal of these restrictions serves the dual purpose of increasing access to health care services while freeing up physicians to focus on the most severely ill patients.
Dr. Spetz, (minute 06:25) goes on to explain that SOP waivers at all levels of nursing – from those pertaining to licensed vocational nurses to advanced practice nurses like nurse practitioners (NPs) and nurse midwives - can be used to increase the provision of care and expand workforce capacity. For example, states can put waivers in place allowing vocational nurses and nursing assistants to deliver some medications, while waivers for nurses with advanced degrees may remove restrictions around physician supervision or provide them with hospital admitting privileges (the latter of which is especially relevant for certified nurse midwives, as the number of deliveries taking place in non-hospital settings is expected to increase during the pandemic). These provisions, among others, can contribute to the efficient use of scare workforce resources.
Dr. Frogner (minute 09:05) adds that SOP waivers can assist in keeping non-COVID patients out of the hospital during the pandemic. Pharmacists, for example, can divert patients from hospital settings by providing them with clinical consult, while laboratory technicians can perform diagnostic testing in the home care setting, when SOP waivers allow. Scope of practice for respiratory therapists can also be expanded by permitting them to provide non-COVID-19 care in the home setting.
States have taken varied approaches to addressing health worker SOP in the wake of COVID-19 in terms of type of the mechanism used to establish them (minute 12:30). Dr. Frogner explains that the most commonly used approach has been an executive order issued by governors. However, she notes that it is up to state boards to then make SOP changes a reality in practice. Dr. Spetz provides examples of two states using alternative measures to promulgate SOP waivers: emergency legislation (Ohio) and an executive proclamation authorizing state agencies to implement a waiver request and approval process (California). Dr. Frogner points out that payers, like CMS, must also authorize provisions allowing for reimbursement that aligns with SOP changes. “It has to be a simultaneous set of moves that are made to make sure that there is congruency between what state leaders expect and want and what our insurance payers are actually doing”, she states.
Currently, states are taking varied approaches to the types of SOP waivers being authorized, although replication across states is starting to be observed. Three states presented in the webinar: Indiana (EO 20-12, 20-05); New York (EO 202-10); and Pennsylvania (EO Waiver Under Disaster Declaration) have emerged as early leaders in SOP regulation in response to COVID-19 (minute 18:15). Although these states vary in terms of political climate, previous SOP regulations, and severity of COVID at this time, Dr. Spetz points out that they represent early enactors of SOP waivers that are both comprehensive in the provisions and professions they cover and responsive to workforce needs.
Although SOP waivers can be an effective tool for expanding workforce capacity, they remain relatively scarce across the landscape of state legislative and executive responses to COVID-19 (minute 20:15). Drs. Frogner and Spetz provide context for this discrepancy, explaining that SOP has always been a politically contentious issue and an area not well understood by the public. Dr. Frogner emphasizes here is a popular misconception that SOP restrictions are in place to protect patient safety and, that by relaxing restrictions, patients will receive sub-par care. Studies, however, demonstrate this not to be the case. “When you relax SOP laws to allow people to work at the top of what they’re licensed to do…that does not provide any less quality of care to the patients”, she affirms.
Dr. Frogner (minute 21:40) indicates that an additional complexity inherent in SOP policy discussions is that SOP is not well defined for many allied health workers. Additionally, SOPs vary across states, and their implementation also varies across health care organizations. Dr. Frogner acknowledges that there is limited understanding of how many health workers are being used across settings and best practices for deploying them. These factors, she points out, make SOP legislation difficult.
Dr. Spetz (minute 23:00) notes the broader question is which SOP waivers states will make temporary as an emergency response to COVID-19 and which will be sustained in the long-term through codified legislation. She points out that some states, such as California, already had SOP legislation in the pipeline prior to the US being hit by COVID-19, and only time will tell if these temporary waivers will complicate or facilitate their passage. When it comes to the lasting policy implications of emergency SOP waivers, “It’s too early to say how this is going to play out”, concludes Dr. Spetz.