Improving Access to Health Care in California: C A L I FOR N I A Testing New Roles for Providers H EALTH C ARE F OU NDATION Introduction ◾◾ Teach new roles to people with no health care Many Californians, along with Americans in most training. other parts of the nation, do not have access to a regular source of health care. While much of Finally, the authors propose possible avenues to the current policy debate focuses on improving further California’s explorations of workforce Issue Brief or expanding insurance coverage, addressing the innovation by drawing on HWPP’s experience, ability to pay for health care only removes one with particular focus on a demonstration project roadblock. Attention must also be paid to the to expand the role of some registered dental health care workforce, such as ensuring adequate hygienists in treating underserved populations. supplies of doctors, nurses, and other health workers. Policies and Practice Models The American health care system is witnessing Recent years have seen a small but growing an explosion of interest in finding new and number of efforts to examine this aspect of the better ways to deliver care — particularly those problem. Some are part of a big picture approach innovations that promise to improve access while to rethink strategies, systems, and the practice advancing quality and controlling costs. Examples models in which professionals deliver care. Others of recent legislation, conferences, and high profile are happening at the point of care itself via new policy recommendations that target the health ways to connect providers and patients, such as workforce include: retail health clinics staffed by nurse practitioners, ◾◾ The California Health Professions or physician offices that offer dental work. Workforce Taskforce. California law now requires the Office of Statewide Health In addition to an overview of workforce Planning and Development to work with innovation initiatives taking place in California the Workforce Investment Board to establish and elsewhere, this issue brief provides a detailed a Health Professions Workforce Taskforce, look at a unique program: the California Health which will assist in the development of a Workforce Pilot Project (HWPP). Administered health professions workforce master plan for by the Office of Statewide Health Planning and the state.1 Development (OSHPD), the project offers the opportunity to safely assess new approaches to the ◾◾ Specialty Care Access Initiative. Begun in delivery of care, including programs that: 2006, the Specialty Care Access Initiative is a partnership of several organizations and ◾◾ Allow health care workers to acquire new sponsors designed to better understand access skills; to specialty care in California and support ◾◾ Seek to develop new health care job categories efforts in the safety net to address access or speed training in existing categories; and problems.2 D ecember 2009 ◾◾ Prescription for Pennsylvania. Governor dental services to patients who would not otherwise Ed Rendell’s comprehensive 2007 overhaul have access to oral health care.4 of Pennsylvania’s health care system included ◾◾ Physician assistants and nurse practitioners prominent attention to increasing access to health delivering specialty medical care. A growing care professionals – particularly non-physician number of high-demand medical specialty providers — and expanding practice laws to allow practices — particularly in orthopedics, dermatology, them to perform to the fullest extent of their and gastroenterology — have incorporated physician training and ability.3 assistants and nurse practitioners as colleague ◾◾ Retooling for an Aging America: Building the clinicians who provide timely and comprehensive Health Care Workforce. This report, produced specialty services to patients, thus reducing wait times by the national Institute of Medicine’s Committee without compromising safety or quality of care.5 on the Future Health Care Workforce for Older ◾◾ Nurse practitioners offer primary care in retail Americans, found that the nation’s health care clinics. Retail health clinics, which are staffed workforce is woefully unprepared to meet the needs primarily by nurse practitioners, are now found of the country’s aging population and outlined throughout the United States. A recent study found policy and financing reform solutions. that retail clinics provide less costly treatment than ◾◾ The U.S. Oral Health Workforce in the Coming physician offices or urgent care centers for three Decade. This report resulted from a workshop common illnesses (otitis media, pharyngitis, urinary convened by the Institute of Medicine. It found that tract infection) “with no apparent adverse effect on the current oral health workforce fails to meet the quality of care or delivery of preventive care.”6 needs of many segments of the U.S. population. The These innovations are changing the way care is delivered workshop examined promising workforce strategies and are being watched and studied for lessons that can be to improve access, as well as ways to improve the used in other, similar settings. Because health professions’ regulatory framework and structure of oral health laws and practice patterns may vary by state, the ease with care delivery. which adaptations can be made may also differ. Questions may arise as to whether practice act authority for a Amid all the exploration of legal and policy changes, particular profession may need to be updated to allow another much larger and wide-ranging set of innovations the provision of specific services or whether practitioners has taken place at the point of contact between health need additional education and training to provide those care professional and patient. Across the country, health services. care providers are testing how practice model changes might make access to clinicians easier. California Health Workforce Pilot ◾◾ Physicians providing dental care. A program Projects Program sponsored by the American Dental Association As California explores new ways to make the best use of and the American Academy of Pediatrics trains health care workers, the state is able to draw upon the pediatricians to look for dental decay and apply resources of the Health Workforce Pilot Project (HWPP). fluoride to their young patients’ teeth. In another Established in 1972, HWPP permits temporary legal example, in a state with notable shortages of dentists waivers of certain practice restrictions or educational in rural areas, primary care doctors who do their requirements to test expanded roles and accelerated residency training in Maine learn and provide basic training programs for health care professionals.7, 8 2  |  California HealthCare Foundation HWPP staff has since processed over 170 applications. ◾◾ Implications of the project for existing licensure The majority were approved and have been completed. laws, with suggestions for changes in the law where Approved projects are educational or training programs appropriate; that do any of the following: ◾◾ Implications of the project for health services ◾◾ Teach new skills to existing categories of health care curricula and health care delivery systems; personnel; ◾◾ Teaching methods used in the project; ◾◾ Develop new categories of health care personnel; ◾◾ Quality of care and degree of patient acceptance; ◾◾ Accelerate training within existing categories of health ◾◾ Extent that those who acquire the new skills could care personnel; or find employment in the health care system, assuming ◾◾ Teach new health care roles to people with no prior laws were changed to accommodate them; and training. ◾◾ Cost of the care provided in the project, the likely cost of such care if performed by the trainees after the Demonstration projects, which typically last from one to conclusion of the project, and the cost of the same three years, consist of a teaching phase, a clinical training care when delivered by current providers. phase, and an employment phase in which trainees provide a specific health care service. State regulations The project director’s closing report for any project may mandate that each project comply with or provide: be provided to the California legislature.11 The value ◾◾ Minimum safety, quality, and feasibility standards; of these evaluations to lawmakers considering statutes that would affect the practice of medicine, nursing, ◾◾ Requirements for sponsor, trainee, and supervisor pharmacy, and dentistry has been clearly demonstrated. selection; Many — though far from all — of the projects appear to ◾◾ Curriculum, evaluation, and monitoring plans; have contributed at least in part to legislative decisions regarding the regulation of health care professionals ◾◾ Provision of informed consent; in California. This outcome is consistent with the original HWPP legislative purpose. As noted in the law ◾◾ An application review process; establishing the HWPP, “it is the intent of this legislation ◾◾ Recordkeeping and continuing approval; and that existing health arts licensure laws incorporate innovations developed in approved projects that are ◾◾ Regular OSHPD HWPP site visits.9 likely to improve the effectiveness of health care delivery systems.”12 Through the site visits and any data submitted to the HWPP office, OSHPD staff prepares an evaluation of Although a long list of health professions can participate each project. These evaluations, which are written as final in HWPP demonstrations (see shaded box on page 4), or “closing” reports for each project, assess:10 a handful of professions make up the majority of ◾◾ New health skills taught or extent to which existing participants. From 1972 to 2005, the HWPP office skills have been reallocated; estimated that roles in the nursing field (including nurse practitioners) represented the largest number of projects, followed by dental auxiliaries (including dental hygienists) and medical auxiliaries.13 Improving Access to Health Care in California: Testing New Roles for Providers  |  3 HWPP Demonstration Projects OSHPD submits. In addition, many of the approved HWPP demonstration projects may be in any of the projects found that the sponsors’ original objectives following fields:14 to educate and train professionals were not feasible or • Expanded-role medical auxiliaries affordable. Each of these experiences also provided lessons • Expanded-role nursing to members of the profession as well as the respective • Expanded-role dental auxiliaries project sponsors. • Maternal child care personnel • Pharmacy personnel Illustrative examples of HWPP projects include: • Mental health personnel Nurse Practitioners. Several dozen nursing projects were • Other health care personnel including, but not limited approved in the early-to-mid 1970s, shortly after the to, veterinary personnel, chiropractic personnel, podiatric personnel, geriatric care personnel, therapy HWPP program was established. Under these projects, personnel, and health care technicians. over 2,000 nurse practitioners and nurse midwives were Projects must be sponsored by a community hospital prepared to practice under proposed expanded nursing or clinic, a nonprofit educational institution, or a practice act authority, which was progressing through government agency engaged in health or educational the legislature at the same time. By the time the Nurse activities. Projects operating in rural and Central Valley Practice Act took effect in 1975, a workforce of nurses areas are given priority. with advanced training was equipped with the skills needed under the new law and ready for employment.16 Pharmacy. From the mid-1970s through the early Some subsets of professions are noteworthy. From 1974 1980s, a number of HWPP projects were approved that to 1984, the nurse practitioner profession was involved focused on pharmacists prescribing and administering in 40 pilot projects. At least six legal expansions are medications. While some ended in early termination, attributable in part to demonstration outcomes. The the projects likely contributed to the passage of AB 502 physician assistant profession was involved in four pilot (1983, Maddy), which permitted pharmacists to initiate projects, leading to the passage of expanded scopes of drugs based on a physician’s diagnosis. practice in 1981 and 1983.15 Paramedics. One HWPP project focused on testing Practical challenges to successful HWPP projects include and demonstrating that paramedics (EMT-P) can inherent risk to patient safety, significant project costs, administer selected vaccines and immunizations at and opposition from other professions. In addition, outreach clinics sponsored by a county fire department. trainees do not have absolute immunity against The project was approved in 1998; 14 paramedics were malpractice claims, although they are protected for trained, and five vaccination clinics were held over four services rendered under the delegation of project directors. months by 11 paramedics at fire stations in Alameda As noted above, most of the HWPP demonstrations County. OSHPD found that “…the main value of the undertaken over the past three decades have overcome paramedic-based program is not in cost savings but in any challenges and succeeded in meeting their training use of fire stations and paramedics as a way of reaching objectives. This is not to say however, that all projects out into the community to enhance overall efforts to were effective in changing laws to the extent desired by achieve immunization of all children.” In its evaluation, project sponsors. Legislative decisions remain in the hands the OSHPD HWPP office determined there was “…no of the state legislature, which is in no way bound by need for statewide changes in existing law governing the the outcomes of the HWPP projects or the evaluations scope of practice for paramedics.” This finding was based 4  |  California HealthCare Foundation on its analysis that while paramedics could safely provide by state, setting, and patient population. However, a childhood immunizations (which would necessitate national, if incremental, trend towards expanding and a change in the practice act), “with only one year of overlapping scopes of practice among non-physician experience in one community with paramedics providing clinicians is occurring. States leading in broader practice immunizations to 184 children, a change in the scope of authorities do not tend to revert to earlier restrictions, and practice for paramedics statewide is not warranted.” other states often follow in legal expansions. Dental Hygienists. In 1990, an HWPP project was Several developments are driving the evolution of practice approved to test and demonstrate that dental hygienists acts. First are the changes in demographics and disease could provide preventive oral health care independent burden — with increased demands to care for the aging of dentist supervision. The project ran for eight years, and chronically ill — that translate into tremendous by which time legislation had passed to establish a new stress being placed upon primary care clinicians. With category of dental auxiliary — the registered dental appropriate changes in practice acts, for example, nurse hygienist in alternative practice (Chapter 753, Statutes practitioners and physician assistants could more fully of 1997). The dental hygienists who had completed their complement the physician workforce. In contrast to a training and established independent practices under the declining number of primary care physician trainees in HWPP project were considered to have satisfied state California, enrollment in nurse practitioner and physician licensing requirements for this new category and the assistant training programs has increased.18 Second, change in law authorized them to continue their practice. research and practice have clarified that collaboration between physicians and other clinicians improves delivery From Pilot Projects to Policy of care.19 Models are being tested and implemented California’s HWPP program is flexible, making it to promote interdependent and complementary useful for professionals to either respond to changing relationships among health professions, while minimizing laws by accelerating educational programs to meet new competition.20 Third, it is important to acknowledge that requirements, or help inform discussion about proposed practice acts which prohibit professionals from applying new scope of practice laws. By their nature, state practice their full range of skills inhibit the efficient delivery of acts are variable and evolving (see shaded box). Similarly, care. Because many professional education programs now regulatory, research, and policy publications on health train students to high, national standards, state practice care professions’ practice acts have evolved over the past acts that fail to recognize those advanced authorities create two decades.17 Many health professions in the United an artificial gap between a professional’s competence and States are still subject to practice acts that vary widely the care they are permitted to deliver.21 Scopes of Practice The full impact of practice act revisions is difficult to State practice acts define legal scopes of practice, which measure, but studies largely report positive outcomes. describe the services a health profession may provide, Findings include reduced costs, increased access to the settings in which the services may be provided, and the minimum levels of supervision required. These care for underserved populations, and similar, if not three factors constitute scope of practice laws, which higher, quality of care.22 – 24 Some of the evidence for the vary widely within professions across the United States. value of expanded practice acts comes from legislative For example, some states require nurse practitioners to grants of more permissive practice authority to health work under direct physician supervision. Other states professionals treating certain populations. Historically, permit independent practice by nurse practitioners. both in California and the nation, barriers to fuller Improving Access to Health Care in California: Testing New Roles for Providers  |  5 scopes of practice have been less prominent under certain Candidates must complete an additional 150 hours of conditions: in safety-net institutions, such as community coursework in clinical practice and practice management. clinics and public hospitals, where loss of income is less of They are not permitted to place permanent restorations, a risk; in rural areas that have greater difficulty attracting devise comprehensive treatment plans, or make a providers; and for low-reimbursement procedures that diagnosis beyond a hygiene assessment. RDHAPs may threaten to overwhelm clinicians.25 Lawmakers and render services in: residences of the homebound; schools; professionals can look to these successful experiments to residential facilities and other institutions; and certified better ensure that all Californians have equal access to dental health professional shortage areas. They are a wide range of competent providers governed by one prevention specialists who provide community-based case evidence-based practice act per profession. management, behavioral management, desensitization, and health promotion (all currently unreimbursed) in Potential Demonstration Projects addition to clinical prevention services. in California Today, the state has over 250 RDHAPs. As a prerequisite California, like other states, faces myriad health care for licensure, candidates must provide the California challenges and problems. California also falls roughly in Dental Board with documentation of an existing the middle of the practice continuum of expansive and relationship with a dentist for referral, consultation, and restrictive states for several professions, providing plenty emergency services. If the hygienist provides services to of room for workforce innovation experimentation. With the patient 18 months or more after the first encounter, more than three decades of experience using the HWPP, RDHAPs must obtain written verification (valid for two the state is well-positioned to continue its exploration of years) that a patient has been examined by a dentist or workforce innovations. physician. These requirements are in place to ensure For example, the need for improved access to oral health patient safety and coordination between RDHAPs care services in California might support a demonstration and dentists or physicians. Unfortunately, in practice, project for Registered Dental Hygienists in Alternative the requirements serve only as a time-consuming Practice (RDHAP). The proposed project is presented administrative process with no relationship to safety nor here in rough form and would need to be much more assurance of care coordination. fully developed by members of the profession and interested policy makers, as well as potential sponsors, Need. Low-income children, the elderly, and the disabled educators, employers, and delivery site administrators. have more dental disease and difficulty getting dental treatment than the general population. They often cannot Modification of Documented Relationship travel to dental offices, and those who seek care soon find Requirement and Expansion of Scope of that relatively few dentists accept Denti-Cal coverage.27 Practice for RDHAPs California’s nursing homes and long term care institutions Background. In 1998, California recognized the are mandated to provide or arrange oral health services Registered Dental Hygienist in Alternative Practice for residents.28, 29 However, long term care organizations profession.26 The goal was to improve access to dental have had limited success because of the costs of travel care for underserved populations by permitting dental time, inherent difficulties with providing services hygienists to practice independently in certain settings. outside of a dental office, and the challenge of finding clinicians experienced in treating patients with complex RDHAPs are experienced registered dental hygienists conditions.30 with baccalaureate degrees who work independently. 6  |  California HealthCare Foundation California’s RDHAPs have already expanded access to Rationale. The RDHAP profession was created to dental treatment for underserved patients.31 Compared to expand disease prevention in non-dental office settings. A dentists who rely on office-based equipment, RDHAPs central premise is that the workforce would assist seriously bring their practices to the patient. Many are found underserved areas. However, this legislative intent may be to need restorative care beyond the RDHAP scope of undercut by the weakness of the documented relationship practice. and the inability to stabilize dental disease at the point of contact. A pilot project studying these two changes may Hypothesis. Registered dental hygienists in alternative help to improve the oral health of underserved patients in practice would be more effective if they were able California. to stabilize their patients with certain carious lesions using interim therapeutic restorations (ITRs) and have Conclusion a mechanism for collaborative practice which would California’s Health Workforce Pilot Projects program ensure that there is a dentist willing to accept a referral if offers an extremely useful vehicle for testing workforce necessary. practice and education innovations. With more than thirty years of history and scores of successfully completed Demonstration. A pilot project revising the documented projects, the program has demonstrated its worth. As relationship into a collaborative practice agreement, and health care professionals and policy makers seek better expanding the scope of practice to include ITR, would ways to organize and deliver care, the HWPP continues make it possible to test whether RDHAPs would be more to be a valuable proving ground for California and a effective in providing dental care for their patients. To model other states may wish to consider replicating. evaluate the demonstration project, outcomes for patients receiving the ITR in select sites could be measured, as well as the timing and execution of appropriate referrals. Authors Catherine Dower, J.D. and Sharon Christian, J.D. This would be compared to the same measures in a Center for the Health Professions, University of California, practice using the existing model. Finally, the evaluation San Francisco could measure provider opinion and experience using a different collaborative practice model. Alternative Study Option If a scope of practice waiver under the HWPP is not available or approved, alternative studies may be conducted. One potential model is an independent scientific review comparing data on therapeutic pharmaceutical agent-certified optometrists, ophthalmologists, primary care physicians and non-physician clinicians.32 The research, commissioned by the California Optometric Association in 1999 and conducted by a neutral third party, included chart evaluations of the four groups of clinicians’ treatment of common eye conditions based on the American Academy of Ophthalmology’s standard of care. The report concluded that optometrists were at least as cost-effective and competent as each clinician group for each examined condition. The results provided solid responses to evidence-based questions of safety, quality, and cost. The report led to the legislative revision to allow optometrists a broader practice authority. The study design could be used as a model to compare the competence of two professions with overlapping scopes of practice. It might be particularly valuable to begin by focusing on a specific underserved setting, such as long term care facilities or community clinics. Improving Access to Health Care in California: Testing New Roles for Providers  |  7 About the F o u n d at i o n 1 0.California Health and Safety Code §128165. The California HealthCare Foundation is an independent 1 1.Ibid. philanthropy committed to improving the way health care is delivered and financed in California. By promoting 1 2.California Health and Safety Code §128125. innovations in care and broader access to information, our 1 3.Gloria J. Robertson, Health Workforce Pilot Projects goal is to ensure that all Californians can get the care they Program (HWPP) (undated). Presentation available online need, when they need it, at a price they can afford. For more at www.oshpd.ca.gov/hwdd/HWPP.html. information, visit www.chcf.org. 1 4.California Health and Safety Code §128160 (a) Endnotes 1 5.“Health Manpower Pilot Projects: History of Participating 1.California AB 2375 (Hernandez, April 10, 2008); Bill Professions,” California Office of Statewide Health Analysis (April 1, 2008). Planning and Development. 2.Specialty Care Access Initiative, A Partnership of 1 6.Gloria J. Robertson. [OSHPD] Healthcare Workforce and Kaiser Permanente, California Association of Public Community Development Division, Journal of the Health Hospital and Health Systems and California Primary Workforce Pilot Projects Program. Edited 2003. page 8. Care Association. Roundtable Forum #3: Improving 1 7.Safriet, B. 1992. “Health Care Dollars and Regulatory Specialty Care through Scope of Practice. March 6, 2008. Sense: The Role of Advanced Practice Nursing.” Yale See also information at on the SCAI at the Safety Journal on Regulation 9:2; Sekscenski, E., et al. 1994. Net Institute: www.safetynetinstitute.org/content/ “State Practice Environments and the Supply of Physician SpecialtyCareAccessInitiative.htm. Assistants, Nurse Practitioners, and Certified Nurse- 3.Rx for PA. Frequently asked questions. Accessed October 1, Midwives.” New England Journal of Medicine 331: 2009 at www.rxforpa.com/faq.html#11. 1266 –1271; Finocchio, L., et al. Reforming Health Care Workforce Regulation: Policy Considerations for the 21st 4.Zezima, K. “Short of Dentists, Maine Adds Teeth to Century. Pew Health Professions Commission, 1995; Doctors’ Training.” New York Times. March 2, 2009. Cooper, R., T. Henderson, and C. Dietrich. 1998. “Roles Accessed October 1, 2009 at www.nytimes.com/2009/ of Nonphysician Clinicians as Autonomous Providers of 03/03/us/03dentist.html?_r=1. Patient Care.” Journal of the American Medical Association 5.Dower, C and Christian S. (2009) Physician Assistants and 280(9): 795–802; University at Albany of the State Nurse Practitioners in Specialty Care: Six Practices Make It University of New York and Health Research Inc. A Work. California HealthCare Foundation. Comparison of Changes in the Professional Practice of Nurse Practitioners, Physician Assistants, and Certified Nurse 6.Mehrotra, A. et al. Comparing Costs and Quality of Care Midwives: 1992 and 2000. National Center for Health at Retail Clinics with That of Other Medical Settings Workforce Analysis, Bureau of Health Professions, U.S. for 3 Common Illnesses. Annals of Internal Medicine. Health Resources and Services Administration, 2000; Vol. 151:15, pp 321–328 (September 1, 2009), Christian, S., et al. Overview of Nurse Practitioner Scopes www.annals.org/cgi/content/abstract/151/5/321. of Practice in the United StatesDiscussion. University 7.“Healthcare Workforce Development Division,” California of California, San Francisco, Center for the Health Office of Statewide Health Planning and Development Professions, 2007. (www.oshpd.ca.gov/HWDD/HWPP.html). 1 8.“San Joaquin Valley Has Greatest Shortage of Doctors in 8.California Health and Safety Code §§128125–128195. California.” California Healthline, California HealthCare Foundation, November 20, 2007. 9.California Code of Regulations, tit. 22, div. 7, ch. 6 §§92001–92702 (2007) . 8  |  California HealthCare Foundation 1 9.For example, “[O]nly the coordinated efforts of multiple, 2 5.Safriet, B. 1992. “Health Care Dollars and Regulatory diverse health professionals can meet the needs of Sense: The Role of Advanced Practice Nursing.” Yale tomorrow’s patients.” Taillie, J.; foreword by Clyde Journal on Regulation 9:2 H. Evans. Academic Health Centers Take Leading Role 2 6.California Business and Professions Code §§1774–1777; to Advance Interdisciplinary Education and Practice in California Code of Regulations §§1073.3(e), 1090(a)–(c), Prevention. Association of Academic Health Centers, 2003. 1090.1 2 0.Grumbach, K., and J. Coffman. 1998. “Physicians and 2 7.In 2006, the Pacific Center for Special Care at the Nonphysician Clinicians: Complements or Competitors.” University of the Pacific School of Dentistry received Journal of the American Medical Association 280(9): 825– a policy development grant for people with special 826; Taylor, D., and E. Wade. Primary Care Education needs. One workgroup established by Pacific developed and Training at UCSF: An Inventory and Preferred Future. a proposal for a distance collaboration system whereby UCSF Center for Collaborative Primary Care, 2002; oral health professionals working in community settings, Aiken, L. 2003. “Achieving an Interdisciplinary Workforce such as school-based settings, day programs, residential in Health Care.” New England Journal of Medicine care, and long term care facilities, could use electronic 348:164 –166; U.S. Department of Health and Human communication technology to collaborate with dentists in Services, Health Resources and Services Administration, dental schools, offices, and clinics. (Glassman, P. Distance Advisory Committee on Interdisciplinary, Community- Collaboration Concept Paper (Draft). University of the Based Linkages. 2004 Fourth Annual Report to the Secretary Pacific School of Dentistry, August 2007.) The university of the U.S. Department of Health and Human Services is in the process of securing funding to implement and to the Congress, Recommendations: Interdisciplinary, this teledentistry pilot project, which could serve as an Community-Based Linkages Title VII, Part D, Public Health excellent model for dental care delivery. Service Act, 2004. 2 8.“Aging Population Could Push Major Changes to Health 2 1.Dower, C. 2008. “Pulling Regulatory Levers to Improve Care.” California Healthline, California HealthCare Health Care.” From Education to Regulation: Dynamic Foundation, April 21, 2008. Challenges for the Health Workforce, D. Holmes, ed. Association of Academic Health Centers. 2 9.California Code of Regulations §§87575(a)(1), 72301(e); 42 Code of Federal Regulations §483.55. 2 2.The Use of Therapeutic Pharmaceutical Agents by Optometrists in California: A Study of Competence and Cost 3 0.Mertz, E. Registered Dental Hygienists in Alternative Effectiveness. PricewaterhouseCoopers, February 4, 1999. Practice: Increasing Access to Dental Care in California. University of California, San Francisco, Center for the 2 3.University at Albany of the State University of New York Health Professions, May 2008; Glassman, P. Concept and Health Research Inc. A Comparison of Changes in Paper: Oral Health and Long-Term Care Facilities. the Professional Practice of Nurse Practitioners, Physician Statewide Task Force on Oral Health for People with Assistants, and Certified Nurse Midwives: 1992 and 2000. Special Needs and Aging Californians, draft for limited National Center for Health Workforce Analysis, Bureau distribution only, January 30, 2008 (citing Oral Health in of Health Professions, U.S. Health Resources and Services America: A Report of the Surgeon General. U.S. Department Administration, 2000. of Health and Human Services, National Institutes of 2 4.Mundinger, M., et al. 2000. “Primary Care Outcomes Health, 2000). in Patients Treated by Nurse Practitioners or Physicians: 3 1.Mertz, Registered Dental Hygienists in Alternative Practice A Randomized Trial.” Journal of the American Medical Association 283(1): 59 – 68. 3 2.See note 22. Improving Access to Health Care in California: Testing New Roles for Providers  |  9