The establishment of our new Government seemed to be the last great experiment for promoting human happiness.
—George Washington, January 9, 17901
Public policy work—also known as political activism—is a crucially important activity for any professional organization in the United States. In many circles, it is difficult to discuss or even mention “political” issues. However, the United States is one of the best examples of democracy the world has ever known, and we are proud of our accomplishments. If we are going to continue the “great American experiment” in democratic self-governance, we will have to continue our growth toward speaking about politics in civilized and productive ways. One way to accomplish this important challenge is for our professional organizations to model and demonstrate the ways we can be politically active that allow for civil and pleasant disagreement, resulting in productive conversation and reasonable compromise. We must recognize that this level of active, civil engagement is the only way to preserve our democratic system.
Despite any personal aversion we may have to engaging in public policy work, we must remember that at any given moment our careers and professions are being shaped by the democratic processes of our governments and communities. There is always federal- and state-level legislation being introduced that has something to do with case management. Examples include the PPACA (which used the term “case manager” more than 200 times); current legislation such as Senate Bill 1292 (Non-Opioid Directive Act) and House Bill 19 (Lower Costs, More Cures Act of 2021). State-level bills include Colorado (House Bill 21-1187: Long Term Services and Support Case Management Redesign) and New York Assembly Bill A114 (amends the social service law to include accountable care organizations/managed care providers) as just a few examples.
Another legislative issue to be aware of is Case Management Title Protection. The Case Management Model Act has been written and used by Case Management Society of America (CMSA) to help build title protection for case managers and to ensure that our patients/clients/members are protected and are receiving services from or overseen by a professional case manager (CMSA, 2017). This will also ensure that the local Jeep dealer and bank cannot use the term “case manager” when providing a contact person to manage non-health care affairs.
The Case Management Model Act is sample legislative language that CMSA uses to promote the proper definition and use of the term “case manager” in legislation about health care. It provides clear examples and definitions of the work done by case managers to help codify our work and protect us in the same way the other legislation protects the practice of nursing, social work, and medicine by RNs (registered nurses), LSWs (licensed social workers), and MDs.
What a novel concept having a say in our own profession! Whatever your particular passion in our profession is, there is probably a piece of legislation out there that will impact it. Educate yourself, advocate for yourself, your profession and your patients in whatever way you feel comfortable. As the ANA-IL lobbyist Sue Clark often says, “If you're not at the table, you're on the menu.”
The Nurse Licensure Compact (NLC) is a major issue for nurses to pay attention to and one that both of us have spent many years working to promote and pass. The very first article Dr. Morley ever wrote for an association publication was in July 2002. She wrote a piece on the NLC and its importance to the practice of case management, with a focus on managed care case management for the American Association of Managed Care Nurses newsletter. At that time, her home state of Illinois was working toward becoming the 25th state to join the NLC. Fast forward, 19 years and alas, Illinois is still working on joining the NLC, with hopes of becoming the 39th state to join. Mr. Bergman has spent much of the past 8 years working with CMSA, both nationally and in Illinois, to promote the passage of the NLC.
Currently, the law states that a nurse must be licensed in any state where the nurse practices. The location of the nursing practice is defined by the physical location of the patient receiving the care of the nurse, not the state where the nurse is physically located. Therefore, a telemedicine encounter requires the nurse to be licensed in any state where they call or contact patients. The NLC is an initiative aimed at increasing access to patient care across state lines by streamlining multistate licensure requirements. Nurses in all 50 states already must pass the same certifying examination (NCLEX) for state licensure. If the nurse resides in a state that has adopted the NLC, that nurse can treat patients in other Compact States either electronically or in person without having to apply for separate state licensure. The nurse, however, must abide by the nurse practice act of the state in which the patient being treating is located. Licensure and disciplinary information on nurses are shared among the Compact States and the public through a comprehensive database called NURSYS.
Early in the COVID-19 pandemic, individual states used emergency orders to waive state licensure requirements and telehealth usage surged as consumers and providers sought ways to safely access and deliver healthcare. NCSBN complied with an exhaustive chart, detailing the emergency actions by state and territory, including American Samoa, Guam and Puerto Rico (https://www.ncsbn.org/State_COVID-19_Response.pdf). In April 2020, overall telehealth utilization for office visits and outpatient care was 78 times higher than in February 2020. (Bestsennyy, Gilbert, Harris, & Rost, 2021)
Telemedicine has continued to grow in part fueled by the pandemic and in part just because of the efficiency and rapidly improving quality of electronic conferencing. The NLC provides a tremendous step forward in improving all patients' access to quality health care through the enhanced use of electronic health services. By rolling back many unnecessary nurse licensing barriers that currently restrict effective telehealth and e-care, non-Compact States can join 38 other states in bringing their health care system into the 21st century and providing nurses with greater flexibility in treating patients remotely. States that have not enacted the NLC need to catch up with the rest of the nation and adopt the NLC, as the majority of our states have done so.
The NLC is modeled on the driver's license compact, which allows drivers to use a valid license from their home state to legally drive in any other of the 50 states. The compact offers RNs licensure and employment in a participating state, with the caveat that the RN must comply with the “remote” state's nurse practice act and other state and local nursing legislation, mandates, and rules. Taking the driver's license comparison, if the law in the state that issued a driver's license says the speed limit is 65 mph and the driver is driving in a state with a 55-mph law, that driver must abide by the local law or expect to be ticketed.
In this modern age of technology, telehealth, and the lessons learned from the COVID-19 pandemic, interstate practice compacts are a vital piece of the healthcare continuum. Puente and Bieniek (2021) state,
Increased demand for medical professionals has brought the healthcare delivery system to the front line of the pandemic, and the emergent need for healthcare providers required states to take immediate action such as gubernatorial emergency orders related to licensing processes to deal with the crisis.
In addition, we know that telehealth services can bridge the access gap created by health disparities, location, and other factors. Bergman (2021) asserts that:
While there remain inequities such as access to technology to drive telehealth, telehealth has proven to be viable and important in providing primary care and health support during the pandemic. We must learn from these experiences as we strive to improve access to care and meet our clients where they are, so we can provide them the best possible healthcare support.
Managed care case managers have been doing exactly this for years, effectively and efficiently. Bommakanti (2021) notes that during the pandemic,
Telehealth has become a mode of service delivery for people with chronic conditions. Case managers/coaches have adopted this practice transformation, moving from regular weekly home check-ins and collaborative meetings to working remotely; methods include videoconferencing, phone calls and texting. Patient care continued, and patients knew that they were not alone.
Centers for Disease Control and Prevention (2020) guidance reflects that “while telehealth technology and its use are not new, widespread adoption among healthcare providers and patients beyond simple telephone correspondence has been relatively slow prior to the COVID-19 pandemic.” The 1135 Waiver allowances enacted by the Centers for Medicare & Medicaid Services during the pandemic have reduced barriers to telehealth access and expedited adoption of the use of telehealth as a way to deliver all types of health care services: acute, chronic, primary and specialty care, therapies, and others.
The website www.telehealth.hhs.gov reports that the following professions have active compacts:
- Physicians: Interstate Medical Licensure Compact
- Nurses: Nurse Licensure Compact
- Psychologists: Psychology Interjurisdictional Compact
- Physical; therapists: PT Compact
- Emergency Medical Services (EMS) Workers: EMS Compact
- Audiologists/speech–language pathology therapists: Audiology and Speech-Language Pathology Interstate Compact. (Telehealth.HHS.gov, 2021)
And the work continues to include more professions in compact licensure. Earlier this year, the Association of Social Work Boards (ASWB), the National Association of Social Workers (NASW, 2021), and the Clinical Social Work Association (CSWA) jointly received a $500,000 grant to develop an interstate licensure compact for social workers from the Department of Defense as part of an initiative to promote licensure portability for military spouses.
Of course, the NLC is only one example of public policy/advocacy that can impact case management professionals directly or indirectly, but it offers a wonderful example of the importance of active engagement in public policy. Currently, the states that have not yet joined the compact are generally not moving on the compact due to strong influence and active public policy engagement by national nurse unions. The opposition from the unions is based on the worry that allowing nurses to easily cross state lines will weaken the unions' ability to protect their members during negotiations and lead to a decrease in overall nursing pay. It can be argued that the unions are wrong for many reasons, but from the perspective of case managers, many of us are suffering significant injury by not getting all states into the compact, but much of our work, and some of the highest paid most desirable case management work, involves telemedicine that crosses state lines. Many of us are at risk of, if not already suffering from, job loss or degradation based on our residence in a non-Compact State.
The example of the NLC journey demonstrates the impact individuals and organizations can have. In 2021 alone, Ohio, Pennsylvania, and Vermont each passed the NLC in states that historically did not garner much support for it. So, our ask of you is simple. Think differently about the legislative process while you do what you already do.
- What issues do you care about?
- What groups do you support?
- What social problems and issues weigh on your heart?
Make a list of issues and situations you care about. Now consider what laws, regulations, and political bodies influence those things. Choose one issue to investigate: Is there anything you can do to support an organization, influence a leader, or make others aware of the need you perceive? And “just do it.” For inspiration, visit the National Council of State Boards of Nursing (NCSBN) website https://www.ncsbn.org or www.NLCYes.com.
