Tag: #interprofessionalimpact

The Interstate Licensure Compact Imperative

Despite interstate practice being more norm than exception, significant obstacles exist for those persons rendering and accessing care. Learn about the current Interstate Compacts and how you can advance them.

What times we are in! Providing clinical intervention and treatment can happen anywhere courtesy of telephonic platforms, plus virtual, remote, and digital products galore. Rural populations rely on these technologies to engage with their practitioners and even health plan case managers, whether for assessment or monitoring of the care process and resource linkage. Patient with disabilities can now access care with greater ease. Yet, there’s a BIG CATCH! Despite interstate practice being more norm than exception, significant obstacles exist for those persons rendering and accessing care.

The health and behavioral health workforce continues to be held hostage by lack of an inappropriate licensure portability structure. Care for consumers is obstructed amid a regulatory system that fails to account for the reality of our professional practice landscape.

Regulatory Realities Reduce Access to Care and Employment

Technology is only one driver of the need for professionals to practice across state lines. Society is more mobile than ever, both for clients and clinicians alike. Traveling practitioners (e.g., case managers, nurses, social workers) are commonly hired to fill employment gaps for staff on medical or family leave, and to mitigate workforce shortages. Yet, this sector of the workforce and their employers face chronic challenges with licensure delays, which only perpetuate barriers and limits to care for the public.

Throngs of licensed mental health providers are at the ready to provide sorely needed telehealth intervention across the states. However, care is often delayed and waiting lists for treatment grow from an antiquated licensure structure that limits one’s inability to practice across state lines. Military families move their state residence every few years and in doing so deal with financial difficulties imposed by licensure delays, and thus, employment. First responders may find their interventions are limited when disasters occur across state lines.

There are an endless list of challenges for the workforce and the public they serve. With minimal exceptions (e.g., licensed professionals who are military members, employed for military contractors), licensed professionals may only practice in the state(s) where they are licensed in good standing. How can licensed practitioners engage with their ethical and legal due diligence when their practice regulations interfere with their ability to do so?

Licensure Compacts on the Move

Licensure compacts are a viable solution for professionals seeking to be licensed in multiple jurisdictions and the that hire them. Through the compact structure, members of the workforce, such as behavioral health providers, case managers, and others who are licensed in one state can actively practice at that same level in other states which are part of the compact. The presence of a compact also reduces the economic burden faced by licensed individuals in dealing with multiple state licensure applications.

The practice of all licensed professionals is controlled by the law in the state(s) where each individual is licensed, typically by the practice act of each state. Scope of practice even supersedes academic degrees. For example, one might presume that as a Doctor of Behavioral Health, I am licensed to prescribe psychopharmacological agents to patients. However, prescribing medications is not included under the scope of practice for my licensure as an LCSW in the Commonwealth of Virginia. The scope of practice for any practitioner extends only to those activities that a person who is licensed to practice as a health professional is permitted to perform.

A change in the traditional licensure structure is mandated: one that allows health and behavioral health professionals to intervene across state and jurisdictional lines. Several professions have engaged in rigorous efforts to advocate for licensure portability through formal regulation.

Nursing

Nurses are required to be licensed in any state where they practice and where the recipient of nursing practice is located at the time service is provided. This fact is a common point of confusion for most licensed professionals—and especially tricky for those my case management colleagues. In contrast, many employers believe licensure must be held in the professional’s state of residence only, instead of where a patient may reside or is receiving care. The Nurse Licensure Compact is actively on the move, and now covers 41 states. More information is accessible on the NCSBN website.

Social Work

The lack of licensure portability has been identified as a public
safety, workforce, and technology issue. The mandate is clear that the workforce responsible for providing the bulk of mental health services to society must be able to practice across geographic state borders. The formal language for the Social Work Licensure Compact was released in February 2023, with legislation actively being introduced across state legislatures; 24 states have done so at the time of blog post with a current map viewable on the official compact website. 4 states have fully approved the legislation: Missouri, S. Dakota, Utah, and Washington State. The Model Compact Bill must be approved by 7 states to be enacted in its entirety before its necessary infrastructure can be implemented, which is expected to happen in the coming months. After verifying eligibility, individual social workers will then be granted a multistate license, which authorizes their ability to practice in all other compact member states, and removes those longstanding barriers to interstate practice.

Counseling

The American Counseling Association Counseling Compact calls for counselors licensed in one state who have no disciplinary record, to be eligible for licensure in any state or U.S. jurisdiction where they seek residence. Like other disciplines, laws that impact counselors (e.g., mandated reporting statutes) vary from state to state, so the compact recognizes how jurisdictions may require a state jurisprudence exam. At the time of this writing, over 32 states have approved the Counseling Compact with the interactive map viewable on the compact site.

Compacts on the Move

In addition to the compacts listed, further information is available for those covering:

Individual practitioners must engage in advocacy efforts through their respective professional associations. Many of these entities have fierce public policy committees that work diligently to support interstate practice. In addition, contact local legislators to provide individual support for those licensure compacts of interest to you. Access your elected legislators through USA.gov. Remember, support for one interstate compact, leverages them all!

What to find out more on Interstate Compacts, and the Do’s and Don’ts of practice across state lines?? Read Chapter 8 in The Ethical Case Manager: Tools and Tactics, available on Amazon.

The U.S. Playbook to Address the SDoH: Launchpad vs. Final Comprehensive Strategy

The White House released the inaugural U.S. Playbook to Address the Social Determinants of Health. The document serves as an important cross-sector guidepost for application, implementation, and action by all involved stakeholders to best serve their patients and communities. But, does the Playbook go far enough to fully address the SDoH? What other opportunities loom?

It’s been another exciting week for those of us taking our daily walk down Social Determinants of Health Lane. The White House released their U.S. Playbook to Address the Social Determinants of Health. The document has captured the industry’s attention, though also yielded some scrutiny.

The Lowdown

The Playbook is a bold undertaking. The document level-sets the massive work engaged in so far to address the health disparities and barriers to care engaged in across the industry. It quotes research and seminal reports citing the clinical and fiscal impact of health inequities faced by society’s minoritized and marginalized populations and providers. This vital foundation also highlights the importance of patient- and family- centric care that heeds the Quintuple and Quintile Aims at micro, meso, and macro levels, and across involved sectors.

For those who want the Cliff Notes version, here you go. Pages 1-18 provide critical information for persons and organizations who seek foundational information on SDoH (e.g., research, definitions, models) and context for them. This is especially valuable knowledge for students, as well as those who might not be as informed on this topic.

For my colleagues who have been in these trenches, pages 18-35 detail the three Playbook pillars with numbered strategic actions to advance each pillar. There is a candid and comprehensive review of the context for each pillar and potential challenges for implementation. Opportunities for Congressional Action are also detailed.

1. Expand data gathering and sharing: Advance data collection and interoperability among health care, public health, social care services, and other data systems to better address SDOH with federal, state, local, tribal, and territorial support.

2. Support flexible funding for social needs: Identify how flexible use of funds could align investments across sectors to finance community infrastructure, offer grants to empower communities to address HRSNs, and encourage coordinated use of resources to improve health outcomes.

3. Support backbone organizations: Support the development of community backbone organizations and other infrastructure to link health care systems to community-based organizations

The Appendics (pages 36-46) discuss how aspects of the Playbook are currently being operationalized using the Whole of Government approach. This section is a ‘must read’ for it provides specific examples to operationalize each action, with further guidance and information for readers on funding opportunities, toolkits with existing screening and assessment resources, and other critical community activities.

To Be Clear

Like most Federal reports and position papers, the Playbook was not developed as a ‘be all to end all’ document. This valuable resource highlights the mandate for all stakeholders and sectors of health and behavioral health services to ensure the most robust and sustainable approach to inclusive care for all populations possible.

How each organization accomplishes this critical priority is on them. Some might have preferred a greater Playbook focus on expanded funding and reimbursement, and that’s one clear opportunity. My take for ensuring organizational success in addressing the SDoH involves ten elements:

1. Take an honest and critical look at their current SDoH priorities.

2. Identify their target populations most impacted and develop means to ensure equitable and accessible care for all persons. This also includes incorporation of quality metrics and relevant outcomes that go beyond length of stay and readmissions to population-specific health priorities (e.g Patient-reported Outcomes Measures).

3. Align all existing inter- and intra-organizational resources and community partners.

4. Utilize and partner on funding access and opportunities; this includes ongoing investment in their communities served, advocacy for appropriate reimbursement (yup, those ICD-10-CM Z codes), and other fiscal imperatives.

5. Ensure appropriate mechanisms for data-gathering, interoperability, and use.

6. Heed industry compliance requirements (e.g., CMS, the Joint Commission, NCQA, NQF) to implement formal patient assessment (or Health-related Social Needs (HRSNs)) intervention, and direct referral linkage.

7. Ensure diverse and sufficient interprofessional staffing who can provide concordant and respectful whole-person care to all populations, which leverages integrated care frameworks and integrated behavioral health models of treatment.

8. Prioritize workforce training on trauma-informed approaches to care, eliminating implicit and explicit biases and microaggressions, and maximizing ethical engagement to enhance patient engagement and treatment adherence versus compliance and resistance.

9. Ensure the alignment and application of Diversity, Equity, Inclusion, and Belonging (DEIB) policies, whereby all patients and the industry workforce feel safe, seen, heard, and valued.

10. Commit to long-term strategic solutioning of the SDoH rather than short-term reactive response.

In Closing

“The Playbook is a launchpad, and not a final comprehensive strategy for addressing the SDoH”. It may not go as far as all stakeholders would like. Yet, the Playbook serves as an important guidepost for necessary cross-sector application, implementation, and action by all entities and individuals to best serve their patients and communities. I trust readers of this post will weigh in with other suggestions, and that input is encouraged. Just remember, final accountability for advancing these efforts is on us all.

The Ethical Conundrum of Healthcare Ethics Committees

Ethics committees have been a condition of Joint Commission accreditation since 1992, yet there is massive variation in their implementation and use. They should not replace the dialogues of interprofessional team members with patients, families, or each other.

There’s been a recent uptick by case managers of their patient referrals to hospital ethics committees. This topic is near and dear to me, especially having served as the chair or co-chair of several acute care-based ethics committees over the years. The industry demand for decreased hospital utilization and length of stay has meant a shift in how ethics committees are viewed and often utilized. We’ve gone from traditional referrals, as in defining a treatment plan when practitioners define care as futile or a patient lacks advance directives, to when an individual refuses to accept a discharge plan. I’ve heard of situations where ethics committee consults are tapped should a patient be “non-compliant” with their treatment; this is language that I challenge at every opportunity and my recent blog on this topic reveals just how much. But I digress….

Ethics committees have been a condition of Joint Commission accreditation since 1992, yet there is massive variation in their implementation and use. The Joint Commission standard is clear: “healthcare organizations must have a mechanism in place to develop and implement a process that allows staff, [patients], and families to address ethical issues or issues prone to conflict.” Yet, the details of that mechanism are left to the discretion of each organization and therein lies the conundrum and challenge!

The Power of Ethics Committee 

The requirements for ethics committees were driven by increasing patient situations that involved a lack of clarity between patient and family wishes, expectations for treatment, the provider’s prognosis, and/or the patient’s treatment plan. The case of Karen Ann Quinlan is often viewed as that legal landmark to set the precedent for formalization of bio-ethics and ethics committees in hospitals. In April 1975 at the age of 21, Ms. Quinlan became unconscious after consuming Valium with alcohol while on a crash diet. She lapsed into a coma, followed by a persistent vegetative state. After a lengthy legal battle, the New Jersey Supreme Court allowed Ms. Quinlan’s parents to disconnect the respirator, affirming the choice she would have made; Karen lived until 1985. Other patient situations would follow and continue to appear, Terry Schiavo to Brittany Maynard and David Adox. The real-life experiences of these individuals have bolstered the vital role of ethics committees as one firm pillar of today’s healthcare process, leveraging the industry’s ethical principles of autonomy, beneficence, fidelity, justice, and nonmalfeasance.

Misconceptions Run Amuck

Despite clear guidelines for ethics committees, organizations can have a varied understanding of their moving parts. Among these points of confusion can be what members of the interprofessional team should be involved, how many persons should serve and for how long, the amount of onboarding required, and scope of each member’s role. Even the amount of work expected can prompt a moment of pause. Ethics committees are too often developed haphazardly and without a formal plan. The consequences of these actions yield an Ethics Committee in name only, which devalues the role of this critical resource for patients, their families, and the interprofessional teams that care for them. 

One of the largest misperceptions of ethics committees lies in their true function. Despite recent popular belief, ethics committees are not used to tell patients, their families, and members of the interprofessional team what to do. Ethics committees review the clinical nuances of individual patient situations and documentation from interprofessional team members to make sure the wishes of the patient and/or their legal representatives are acknowledged. This may be specific to end-of-life decision-making, reviewing futility of care determinations by practitioners, or recognizing the rights of patients to refuse care or treatment.

Ethics committees play a vital role is reviewing that the care rendered is done in accordance with all Federal and State laws and regulations. One of my physician co-chairs used to say, “Ethics Committees step in when the treatment team has employed their due diligence to engage, assess, and communicate with the patient and family, whether through informed consent, shared decision-making, or other collaborative efforts (e.g., team and/or family meetings, care coordination rounds). Anything less reflects incomplete work by the team.”

Functions of Ethics Committees in a Changing Practice Climate

It might seem optimal to involve the ethics committee’s objective lens for review of discharge planning processes, such as when a patient refuses to go to a particular nursing home in deference to another facility or plan. However, that can also be a misuse or critical resources. Ethics committees should not replace the dialogues of interprofessional team members with patients, families or each other.

Ethics Committees have three basic functions:

  • Consultation:
    • Ensure training and support for committee members and consultants.

    • Provide consistent subject matter expertise for cases requiring formal ethics evaluation and recommendations.
    • Develop and implement evaluation metrics to ensure quality improvement, and,
    • Develop appropriate reports, publications, presentations for both internal personnel and external strategic partners.
    • Promote ethical leadership behaviors, such as explaining the values that underlie decisions, stressing the importance of ethics, and promoting transparency in decision making.
  • Education
    • Assure knowledgeable ethics committee members.
    • Provide appropriate education to the organization (e.g., trainings, journal articles, reports, available literature on professional resource trainings and conferences).
  • Policy review and development

In recent years, ethics committees affiliated with academic institutions and large healthcare systems have advanced into comprehensive ethics programs. A growing number of healthcare organizations integrate ethics from the bedside to the boardroom (University of Washington, 2023).Others provide consultations in response to non-clinical ethics questions, such as identifying and remedying systems-level factors that have the potential to induce or exacerbate ethical problems and/or impede their resolution, as in staffing issues from workforce shortages. A valuable article recommends key foundational principles to:

  • Strengthen the position of ethics committees in hospitals, 
  • Ensure continuous supervision over committee formation and meetings, operations and decision-making processes, and
  • Define how committees’ decisions are shared with involved hospital stakeholders and staff.

Case managers can find out more on ethics committees, the seminal cases that drove them, and innovative ways to engage with them in Chapters 2 and 4 of The Ethical Case Manager: Tools and Tactics available on Amazon.

Are Safety Net Programs Losing Their Safety Net?

A far bigger safety net must be in place to support these essential facilities, programs, providers, and the communities who rely on them. More must be done quickly to ensure safety net sustainability.

The nation’s 56 official safety nets strive to provide quality health and mental health to the nation’s most in need populations. Yet, new struggles to do so are endangering the lives of patients and mandate swift action.

Safety Net Realities 

A quilt of >14,000 sites comprise the safety net system: disproportionate share hospitals, federally qualified health centers (FQHCs), rural, and community health centers. Location maps and listings are accessible at HRSA’s FQHC with a safety net hospital list at their trade association website (America’s Essential Hospitals). These sites provide care:

  • Independent of patient ability to pay and immigration status
  • To the highest share of Medicaid and uninsured patients: 75% and 60% of the population respectively!
  • Across rural and urban regions and both, public and non-profit entities 

Pandemic-related financial headaches continue for the industry, safety net hospitals shouldering more than their share of this burden. Rural regions have seen a waning hospital presence, adding pressure to remaining FQHCs. The Sheps Center displays >100 closures in the past decade, 50% of 2020 closures for safety net facilities alone.

A recent Kaiser Family Foundation issue brief reviewed COVID’s disproportionate impact on populations covered by Medicaid and Medicare, including people of color and those who use long-term services and supports. Providers serving these patients were less likely to have received monies from the $178 B in pandemic federal provider relief funds; barely $13.1B went to safety net hospitals with a mere $11B to rural providers. This reality contributes to national health expenditures soaring to $4.1 Trillion dollars. The amount accounts for early 2020 through the pandemic’s first wave, which hit safety net facilities hard. Pandemic-related losses for the largest safety net hospitals (e.g., 1000 beds) are as high as 50% of their quarterly revenue. 

Loss of 340B Drug Discounts

Recent loss of 340B drug discounts has meant major fiscal challenges for safety-net programs. The legal battle against drug makers wages in the courts. HRSA has stepped up, imposing fines against drug makers when possible. A study of 510 urban facilities identified losses at 23% of savings from due to loss of 340B, a median of $1 M. Critical access hospitals saw 40% of savings lost, roughly $220,000. While that amount seems small, it is a major hit to these rural hospitals with a max of 25 beds, located 10 miles from other providers. While dollars and losses are relative to each organization, the bottom line is the same; patient endangerment from cuts and closures of needed programs, potentially the only facility or service provider for miles.

How to Save the Safety Nets

7 ideas are posed by experts to strengthen the safety-net foundation: 

  1. Increase federal funding: Target funds to hospitals that qualify for Medicaid disproportionate-share hospital (DSH) payments. Use hospital census data to more equitably distribute payments to facilities that primarily treat uninsured and Medicaid patients (and not Medicare patients). 
  2. Clear Guidance: Federal agencies, as the CDC should use hospital census data to more equitably distribute payments to facilities primarily treating uninsured and Medicaid patients. This action is a sound public health reimbursement strategy moving forward. 
  3. Streamline Regulation: Reduce regulatory burdens to foster reimbursement, such as ongoing expansion of telehealth and virtual requirements and reimbursement, lengthen quality reporting programs, and extend leniency with value-based purchasing programs. These will help hospitals to recover financially from pandemic-related losses.
  4. Loan Forgiveness: Expand programs that incentivize new clinicians to accept positions in safety-net programs. This action will bolster the workforce of providers who accept new Medicaid patients.
  5. Expand Coverage Options: Advance these options to limit growth of uninsured patients and uncompensated care
  6. State And Local Initiatives: Enact policies to mitigate effects of hospital closures. Keep public and surrounding healthcare systems informed so regions can best plan for, and provide necessary outreach to service shortage areas. This will also minimize service gaps, providing safer transitions of care.
  7. Community and Volunteer Efforts: Target corporate and community investing to bridge gaps in care: create grants, fundraising campaigns, horizontal mergers, to build satellite clinics, services, and programs. 

A far bigger safety net must be in place to support these essential facilities, programs, providers, and the communities who rely on them. More must be done quickly to ensure safety net sustainability.

I know there will be other suggestions, so add them in the comment area below.

#safetynet #accesstocare #bridgethosegaps #340B #funding #interprofessionalimpact #interprofessional insights 

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