Aligning Nurse Practitioner Statutes in California JULY 2021 AUTHORS Garrett K. Chan, Karen G. Duderstadt, and Catherine Dower Contents About the Authors 3 Executive Summary Garrett K. Chan, PhD, RN, NP, is president and Introduction and Background CEO of HealthImpact. Karen G. Duderstadt, Methodology PhD, RN, is clinical professor emerita in the Department of Family Health Care Nursing, 4 Findings and Discussion School of Nursing at UCSF. Catherine Dower, List of Statutes for Review and Action JD, is a health policy consultant. Access to Care Opioid Crisis Acknowledgment The authors would like to thank Dr. Susanne J. Care of Vulnerable Adults Phillips, DNP, RN, FNP-BC, FAANP, FAAN, for 6Conclusion her significant contribution to this publication. 7Appendices About the Foundation A. Aligning Existing California Statutes and Regulations The California Health Care Foundation is with AB 890 dedicated to advancing meaningful, measur- B. 103 and 104 Nurse Practitioners able improvements in the way the health care C. States with Global Signature Laws delivery system provides care to the people of California, particularly those with low incomes 16 Endnotes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. DESIGN BY DANA KAY HERRICK 2837.104. Currently, nurse practitioners are authorized Executive Summary to practice via standardized procedures developed by C alifornia legislation (Assembly Bill 890, or the NP, supervising physician, and health care organi- AB 890) enacted in September 2020 authorizes zation pursuant to BPC § 2725(c), BPC § 2836.1, and certain nurse practitioners to practice without Title 16 of the California Code of Regulations (CCR) §§ physician supervision and standardized procedures.1 1470 –1474. Additionally, the standardized procedure Implementation of this statute holds significant prom- must define physician supervision requirements. (See ise to expand access to high-quality care, particularly Cal. Code Regs. tit. 16, § 1474(b)(7)). Simultaneously, for underserved places and populations. The Board of AB 890 defines eligibility requirements for NPs to Registered Nursing (BRN) is tasked with appointing practice without physician supervision, including cer- a Nurse Practitioner Advisory Committee, reviewing tification from a nationally accredited certifying entity current nursing regulations, and promulgating regula- and completion of postgraduate transition-to-practice tions and guidelines to implement AB 890.2 To meet (TTP) requirements in California.3 AB 890 also requires the access to care needs in California, it is essential the Board of Registered Nursing to appoint a Nurse that the BRN complete this work with expediency Practitioner Advisory Committee, review current nurs- since nurse practitioners cannot practice without phy- ing regulations, and promulgate regulations and sician supervision before the BRN work is completed. guidelines to implement AB 890. To realize the intent of AB 890 and provide maximum benefit to Californians, action is also required to align The passage of AB 890 represents an important step existing, related statutes, including provisions of to meet the pressing health care needs in the state California's Education, Health and Safety, and Labor by expanding the independent practice of nurse Codes. This report offers an analysis of existing stat- practitioners. The legislation also elevates the need utes that, without review and action, may inhibit full to reexamine intersecting statutes, regulations, payer realization of the promise of AB 890. policies, clinical agency operations, interprofessional team structures, health care finance, and employment relationships and align them to fully realize the goals Introduction and Background and intent of AB 890. In 2020, California enacted legislation (Assembly Bill 890) to expand the practice authority for nurse This report examines existing statutes and regulations practitioners (NPs). This legislation holds promise to that could be updated to align with AB 890. The report increase access to primary care and other services by uses three priority policy issues - increasing access to allowing NPs to offer care within a defined scope of care, especially in underserved communities of color; practice without physician supervision requirements. managing the opioid crisis; and caring for vulnerable With this statute, California joins 28 other states that older adults - to illustrate how statutory and regula- previously expanded NPs' scope of practice. tory alignment could enhance the state's capacity to meet community health care needs. Solutions to these The law promotes NPs as important providers of health policy issues are multifactorial. However, research care for underserved and vulnerable populations, par- points to expanded NP practice as one meaningful ticularly in rural areas with limited access to primary solution. States that removed physician supervision of care services. AB 890 creates two new categories of NPs experienced a growth in the number of routine nurse practitioners allowed to practice without physi- checkups, increased access for rural and vulnerable cian supervision, as detailed in Appendix A. For ease of populations, decreases in emergency department nomenclature, these two categories are often referred use, and reductions in health care costs.4 Evidence to as "103 NPs" and "104 NPs" to correspond to indicates that NP services ensure quality of care for the respective statutory sections defining each under chronic illnesses and improvement in functional status Business and Professions Code (BPC) §§ 2837.103 and for patients in long-term care facilities.5 Also, access to Aligning Nurse Practitioner Statutes in California www.chcf.org 3 treatment for opioid use disorder increased in states $ Insurance Code (INS) where there was no physician oversight of NPs com- $ Labor Code (LAB) pared with states that required NP supervision.6 $ Probate Code (PROB) $ Unemployment Insurance Code (UIC) Methodology Research for this report included a review of the $ Welfare and Institutions Code (WIC) California laws related to NP practice that could be updated to be in greater alignment with AB 890. NP Appendix A provides detail on these statutes and experts in practice, administration, education, and regulations. policy were queried about statutes that codify NP practice in California. Subsequently, the research team To illustrate how existing statutes and identified areas conducted a search of California code sections via the of misalignment play out in practice, three priority California Legislative Information website (leginfo.leg- health challenges confronting California are described islature.ca.gov) and Westlaw or LexisNexis using the in the next sections: access to care, the opioid crisis, search terms "nurse practitioner," "advanced practice and care of vulnerable adults. Aligning existing statutes registered nurse," "scope of practice," and "stan- to reflect the policy enacted in AB 890 has the poten- dardized procedures" to generate a list of statutes for tial to advance progress on these important issues. analysis. For each statute, the research team identified the issue and the background of the statute, analyzed the statute's alignment with AB 890, and made rec- Access to Care ommendations regarding any misalignment with the One of the biggest challenges in California is ensur- policy enacted in AB 890 or its underlying goals. ing access to high-quality care, particularly primary care, in all parts of the state. Many communities - from rural areas to low-income urban neighbor- hoods - face barriers to accessing care. In part, these Findings and Discussion barriers are driven by an inadequate supply of pro- viders to provide high-quality, culturally inclusive care. List of Statutes for Review and According to the California Future Health Workforce Action Commission, in just 10 years, California is projected The research team reviewed a comprehensive, but not to face a shortfall of more than 4,100 primary care exhaustive, list of California statutes that govern heal- clinicians.7 The commission also found that seven ing arts practitioners and identified opportunities for million Californians - with the vast majority being better alignment between existing laws and new leg- Latino, Black, and Native American - live in Health islation or regulatory action. Specifically, the analysis Professional Shortage Areas, a federal designation for included a review of how newly authorized practice counties experiencing shortfalls of primary care, den- authority for NPs under AB 890 may affect and inter- tal care, or mental health care providers. AB 890 is, at act with sections of the Business and Professions Code its core, a health care access intervention, and while (BPC) as well as other California codes, including but the legislation largely supports this intent, a few statu- not limited to the following: tory considerations would benefit from consideration in order to advance the expansion of access to care. $ Education Code (EDC) $ Evidence Code (EVID) In addition, although nurses may legally form nursing corporations in California pursuant to Corporations $ Health and Safety Code (HSC) Code § 13401.5(f), NPs have historically faced California Health Care Foundation www.chcf.org 4 administrative and bureaucratic barriers to making resources - from hospitals to the workforce - does these corporations financially and practically viable. not meet the demand from individuals ready to seek Updates are needed to statutes, rules, and regulations treatment for substance abuse disorders. The number associated with laws that define owning or operating a of chemical dependency beds decreased in California business or employing healing arts licensees in order by 26.2% between 2005 and 2014, while the rate of to ensure that nurses may form and run corporations addiction to opioids was increasing.10 to provide a full range of clinical services with quali- fied personnel. For NPs, additional legal and practice In states or situations where physician supervision barriers to the types of groups and corporations with of NPs is required, the supervising physician must which managed care entities contract may require fur- also be qualified to prescribe buprenorphine. When ther analysis. AB 890 is implemented, NPs will have full authority pursuant to BPC §§ 2837.103(c)(4) and 2837.104(a)(1) Another hurdle to realizing the potential of NPs' to prescribe buprenorphine and to treat individuals practicing to the full extent of their education is the seeking help for opioid addiction, which will increase disconnect between AB 890's authorization of NPs' access options, particularly for the homeless and other practicing without physician supervision and other vulnerable populations in California affected by sub- laws, such as California's laws regarding managed stance use disorders. health care plans. Known as the Knox-Keene Act of 1975, HSC § 1340 et seq. is a nearly 50-year-old set of Two regulations related to chemical dependency laws designed to ensure that managed health care is treatment that were not addressed in AB 890 con- regulated appropriately and that physicians' and other cern medical staff privileges in chemical dependency health professionals' decisions about patient care are hospitals and the care provider list for psychiatric and not unduly affected by managed care companies. mental health services. Although AB 890 authorizes For example, HSC § 1375.9 requires that there be at 103 NPs to serve on medical staff and hospital com- least one full-time equivalent primary care physician mittees and 104 NPs to be eligible for medical staff for every 2,000 enrollees of a managed health care membership, chemical dependency facilities were not plan. NPs with their own primary care clinic practices specifically considered in the legislation. To align with may not satisfy this requirement. Permitting health AB 890, the California Code of Regulations could be plans to consider NPs when demonstrating that the updated to explicitly authorize NPs to serve on medi- plans have met network adequacy standards would be cal staff committees or be eligible for medical staff consistent with the policy enacted in AB 890. A com- membership of chemical dependency recovery hos- prehensive review of all nuances of the Knox-Keene pitals (Cal. Code Regs. tit. 22, § 79303) and include Act will need to be conducted to evaluate any poten- psychiatric mental health NPs on the list of Medi-Cal tial discrepancies or inconsistencies between AB 890 providers recognized for psychiatric and mental health and Knox-Keene. services with county mental health plans (Cal. Code Regs. tit. 9, § 1810.240). These two updates would reduce discrepancies between laws and regulations, Opioid Crisis facilitating the implementation of AB 890 and thereby California continues to experience an opioid abuse cri- increasing the potential to expand chemical depen- sis and increases in opioid-related deaths. California's dency services in California. opioid overdose death rate in 2019 was 7.9 deaths per 100,000, up 2.3 deaths per 100,000 since 2017.8 A recent report on buprenorphine, a treatment for Care of Vulnerable Adults opioid addiction, indicated a nearly fourfold increase Skilled nursing facilities (SNFs) and long-term care in buprenorphine prescriptions in the state between facilities have been particularly vulnerable during 2014 and 2018.9 The supply of chemical dependency the COVID-19 pandemic. Long-term care facility Aligning Nurse Practitioner Statutes in California www.chcf.org 5 residents represented about 3.5% of the COVID-19 the pandemic. A recent study focused on ADHCs cases in 2020 but represented 64.9% of deaths due to in California and the impact of the closures found COVID-19.11 SNFs and long-term care facilities often declines in physical, cognitive, and mental health users care for populations with complex chronic health of ADHCs and increased caregiver strain.12 Expanding conditions, including hypertension, cardiac disease, mental health services in ADHCs has the potential to diabetes, and cognitive impairment, which increase improve treatment management among this vulner- vulnerability to infections. able, underserved population in California. In 1973, the California Legislature passed the Long- Welfare and Institutions Code § 14550(e), which gov- Term Care, Health, Safety, and Security Act (HSC § erns the services and standards provided in ADHCs, 1417 et seq.). This law was created to ensure the qual- lists the health care professionals permitted to provide ity of care in long-term health facilities by delineating psychiatric or psychological services: a psychiatrist, a minimum standards of care and by creating a licens- clinical psychologist, or a psychiatric social worker. ing, inspection, and reporting system and a citation Psychiatric/mental health NPs (PMHNPs) are educated system for a wide variety of long-term care facilities. and qualified to provide psychiatric and psycho- Some long-term care facilities, such as skilled nurs- logical services to older adults who need individual ing facilities, are regulated by both the state and the assessments and/or group or individual treatment for Medicare Conditions of Participation. Other long-term persons with diagnosed mental, emotional, or behav- care facilities, such as congregant living health facili- ioral problems. Amending this section of the Welfare ties, are regulated by the state. and Institutions Code to include NPs would provide clarity to the list of qualified psychiatric/mental health Under AB 890, NPs could independently treat providers authorized to provide care in ADHCs and patients in long-term care facilities. However, existing could have a positive impact on access to mental language in the Health and Safety Code limits their health services in ADHCs. contributions. Specifically, the long-term care code sections related to patient admission and treatment (HSC § 1417 et seq.) could be updated to allow NPs to practice in these facilities, improving continuity of care Conclusion and eliminating gaps in care. Such changes have the In a review of the California codes, many statutes potential to improve management of complex chronic were found to be misaligned with the newly enacted health care conditions in long-term care facilities and AB 890. This misalignment may limit the opportunity to decrease public health costs in California over time. and intent of the legislation. Concerted effort will be required through a variety of interventions, includ- Further, statutes governing respite care services in ing legislation, administrative action, and change in intermediate care and skilled nursing facilities (HSC practice and operations, to realize the full benefit of § 1418.1) could be updated to allow an NP who is the scope of practice reform for nurse practitioners in treating a person being admitted to respite care the improving access to and quality of care. authority to issue advance orders for care and treat- ment for that person, thus providing continuity of care This report has focused predominantly on the incon- and better oversight of the various aspects of care for sistencies in clinical care and practice operations that patient while addressing gaps in care in vulner- described in the various California codes. Further able and underserved populations. analyses of the intersection of AB 890 with health plans, health care financing, and the business aspects Adult day health care centers (ADHCs) support of a practice are needed. the health and social needs of vulnerable older adults. Many ADHCs were forced to close during California Health Care Foundation www.chcf.org 6 Appendix A. Aligning Existing California Statutes and Regulations with AB 890 The statutes cited in Table A1 are presented in two Also, many of the laws in the first category already categories. The first category contains statutes that confer authority to NPs who practice under standard- are inconsistent with the intent and policy of AB 890, ized procedures. AB 890 authorizes 103 NPs and 104 including statutes that predate the passage of AB 890 NPs to practice without physician supervision and and reflect a pre-AB 890 physician supervision of NP without the use of standardized procedures.13 Each of practice. In many cases, these laws do not expressly these code sections could be clarified to include refer- exclude 103 NPs and 104 NPs; rather, the laws do not ence to 103 NPs and 104 NPs to ensure that they can include these NPs, and therefore the inconsistent stat- practice without standardized procedures, so that the utes could be seen as restricting the practice of 103 intent of AB 890 is not diminished. NPs and 104 NPs even after the passage of AB 890. Table A1. Category 1: Laws That Conflict with Policy Established in AB 890, continued ISSUE PRE-AB 890 CALIFORNIA STATUTE AB 890 CALIFORNIA STATUTE Medical assistant BPC § 2069(a)(2)(A). This law authorizes NPs 103 NPs and 104 NPs may delegate tasks to supervision to delegate tasks to medical assistants pursuant medical assistants under AB 890 pursuant to BPC to standardized procedures. § 2837.103(c)(6) and BPC § 2837.104(a)(1). Pre-AB 890 statute could be updated accordingly. Dispensing drugs to BPC § 4056(f). This law authorizes physicians BPC § 2837.103(c)(4)(B) authorizes 103 NPs and outpatients in hospitals to dispense drugs to outpatient patients in rural 104 NPs to dispense drugs. Pre-AB 890 statute that do not employ hospitals and licensed hospitals that contain could be updated accordingly. full-time pharmacists 100 beds or fewer and that do not employ a full-time pharmacist. Furnishing nonprescrip- BPC § 4057(b)(1). This law specifies the healing 103 NPs and 104 NPs are able to procure, tion drugs and devices arts professionals to whom a person can sell dispense, and furnish over-the-counter, nonpre- to NPs or furnish specific nonprescription drugs and scription drugs and devices pursuant to BPC devices. NPs are not listed as being able to buy § 2837.103(c)(4)(B). Pre-AB 890 statute could be nonprescription drugs and devices. updated accordingly. Furnishing prescription BPC § 4059(a). This law specifies the healing 103 NPs and 104 NPs are able to procure and drugs and devices arts professionals to whom a person can sell or prescribe over-the-counter, legend, and controlled furnish prescription drugs and devices. NPs are substances pursuant to BPC § 2837.103(c)(4)(B). not listed as being able to buy nonprescription Pre-AB 890 statute could be updated accordingly. drugs and devices. Possessing and BPC § 4060. This statute limits the possession Pursuant to BPC §§ 2837.103(c)(4) et seq., 103 stocking of drugs of any controlled substance to NPs functioning NPs and 104 NPs are authorized to prescribe and and devices pursuant to standardized procedures. Additionally, procure drugs and devices. Pre-AB 890 statute this section does not authorize an NP to order his could be updated accordingly. or her own stock of drugs and devices. Protection from EVID § 1157. The Evidence Code does not With the passage of AB 890, NPs are part of BPC discovery include NPs as a healing arts professional for § 805 peer review. Therefore, the peer review whom proceedings or records of organized proceedings and discussions for organized committees or peer review bodies are protected committees that include committees composed from discovery. These protections are conferred of NPs should be protected from discovery, and to other healing arts professionals such as, NP meeting attendees should be protected from but not limited to, physicians and surgeons, testifying during a hearing. Pre-AB 890 statute psychologists, dieticians, pharmacists, and could be updated accordingly. licensed clinical social workers. Aligning Nurse Practitioner Statutes in California www.chcf.org 7 Table A1. Category 1: Laws That Conflict with Policy Established in AB 890, continued ISSUE PRE-AB 890 CALIFORNIA STATUTE AB 890 CALIFORNIA STATUTE Prescriptions BPC § 4040. This law allows NPs who are Pursuant to BPC § 2837.103(c)(4)(B), 103 NPs and functioning under standardized procedures 104 NPs may prescribe drugs and devices. Pre-AB to prescribe or order drugs and devices. 890 statute could be updated accordingly. Manufacturer BPC § 4061. This law limits a manufacturer's sales Pursuant to BPC § 2837.103(c)(4)(B), 103 NPs and complimentary representative in distributing complimentary 104 NPs may procure drugs and devices. Pre-AB sample of drugs samples to NPs functioning under standardized 890 statute could be updated accordingly. and devices procedures. Dispensing drugs BPC § 4170(a)(8). This law permits an NP pursuant Pursuant to BPC 2837.103(c)(4) et seq., 103 NPs and devices in place to standardized procedures to dispense drugs and 104 NPs may dispense drugs and devices. of practice and devices in his or her place of practice. Pre-AB 890 statute could be updated accordingly. Dispensing drugs BPC § 4174. This law authorizes only pharmacists Pursuant to BPC 2837.103(c)(4) et seq., 103 NPs and devices by to dispense drugs and devices upon an order and 104 NPs may dispense drugs and devices. pharmacists from an NP functioning pursuant to standardized Pre-AB 890 statute could be updated accordingly. procedures. Cardiac clearance for EDC § 33479.5(c). Students who have experi- BPC 2837.103(c) et seq. authorizes 103 NPs and interscholastic sports enced symptoms of sudden cardiac arrest and 104 NPs to evaluate and manage the care of have been removed from participation by a coach patients. Pre-AB 890 statute could be updated or athletic trainer need to be evaluated and accordingly. cleared to return to participate in interscholastic sports with a written note from a physician and surgeon, a nurse practitioner or physician assis- tant practicing in accordance with standardized procedures or protocols End-of-life care HSC § 442(c). NPs are authorized to provide BPC §§ 2837.103(c)(4) et seq. authorizes 103 NPs counseling and comprehensive information and counseling and 104 NPs to plan a therapeutic regimen that options regarding legal end-of-life options when a could encompass end-of-life care. Pre-AB 890 patient is diagnosed as being terminally ill statute could be updated accordingly. pursuant to standardized procedures. Uniform Controlled HSC § 11026(a). This law authorizes NPs BPC § 2837.103(c)(4)(B) authorizes 103 NPs and Substances Act functioning under standardized procedures 104 NPs to prescribe, administer, dispense, and to furnish or prescribe controlled substances. furnish controlled substances. Pre-AB 890 statute could be updated accordingly. Prescription HSC § 11150. NPs can write or issue a prescrip- BPC § 2837.103(c)(4) authorizes 103 NPs and 104 requirements tion pursuant to standardized procedures. NPs to write prescriptions. Pre-AB 890 statute could be updated accordingly. Health care service HSC § 1375.9(a)-(d). This law requires a health HSC § 1375.9(a)–(d) could be amended to align plans operations care service plan to ensure that there is at least with AB 890 and to ensure that 103 NPs and and renewal one full-time equivalent primary care physician 104 NPs who are contracted with a health care for every 2,000 enrollees of the plan. After service plan can provide care independently of the initial 2,000 enrollees are empaneled, a physician. another 1,000 enrollees can be added for each "nonphysician medical practitioner," which is defined to include an NP performing services in collaboration with a physician. California Health Care Foundation www.chcf.org 8 Table A1. Category 1: Laws That Conflict with Policy Established in AB 890, continued ISSUE PRE-AB 890 CALIFORNIA STATUTE AB 890 CALIFORNIA STATUTE Contracting with INS § 10133.4. This law allows for NPs function- Pursuant to BPC §§ 2837.104 et seq., NPs in their life and disability ing in collaboration with a physician to be own primary care practices should be eligible to insurance primary care providers who contract with life be recognized as primary care providers. Pre-AB and disability insurance for alternative rates. 890 statute could be updated accordingly. Long-term care WIC § 14111(c). This law allows NPs functioning NPs with their own practices pursuant to BPC facility services under the supervision of a physician and surgeon §§ 2837.103 et seq. and §§ 2837.104 et seq. and pursuant to a standardized procedure to should be authorized to provide health care provide health services in a long-term care services that are delegated to the NP without a facility that is reimbursed by Medicare. standardized procedure. Pre-AB 890 statute could be updated accordingly. Occupational BPC § 2571(a). This law permits an occupational Occupational therapists should be authorized to therapy and topical therapist to apply topical medications prescribed apply topical medications prescribed by 103 NPs medications by an NP pursuant to standardized procedures. and 104 NPs without needing to practice under standardized procedures. Pre-AB 890 statute could be updated accordingly. Risk factor screening BPC § 2242.2. This law permits an NP pursuant The law could authorize 103 NPs and 104 NPs to for hormonal to standardized procedures to use a self-screen- use self-screening tools to identify patient risk contraceptives ing tool to identify patient risk factors for the factors of self-administered hormonal contra- use of self-administered hormonal contraceptives ceptives without needing to practice under by a patient and, after an appropriate prior standardized procedures. Pre-AB 890 statute examination, prescribe, furnish, or dispense, could be updated accordingly. as applicable, self-administered hormonal contraceptives to the patient. Workers' compensation LAB § 3209.10 (a). This law authorizes NPs The law could authorize 103 NPs and 104 NPs - medical treatment functioning pursuant to standardized procedures to provide medical treatment in the workers' to provide medical treatment in the workers' compensation insurance program without needing compensation insurance program. to practice under standardized procedures. Pre-AB 890 statute could be updated accordingly. Medi-Cal primary WIC § 14088(c). Within Medi-Cal managed care The law could authorize 103 NPs and 104 NPs care provider case plans, NPs are considered to be "nonphysician to independently perform primary care case management medical practitioners" and may perform primary management in the Medi-Cal program. Pre-AB care case management in the Medi-Cal program 890 statute could be updated accordingly. only in collaboration with a physician and surgeon. Aligning Nurse Practitioner Statutes in California www.chcf.org 9 The second category lists laws that are not in conflict In addressing the statutes that could interfere with with AB 890 but that do not reflect the intent or spirit NP clinical practice, one solution is to adopt stat- of the policy enacted in AB 890 (see Table A2). Many utes or agency rules that authorize an NP to sign, of the laws in this category restrict NPs' ability to pro- attest, certify, stamp, verify, endorse, or provide an vide a full range of evidence-based clinical services, affidavit for any form for patient care within the NP's to establish and run a practice efficiently, or to com- scope of practice.14 These laws are generally known plete forms related to patient care. Alignment of these as "global signature" laws. A list of states with model statutes with the policy established in AB 890 would, global signature authority legislation can be found in therefore, facilitate the delivery of safe, high-quality, Appendix C. seamless patient care. Table A2. Category 2: Statutory Changes to Facilitate Evidence-Based Patient Care and Continuity of Care, continued ISSUE PRE-AB 890 CALIFORNIA STATUTE AB 890 CALIFORNIA STATUTE Blood transfusions HSC § 1645(a). This statute restricts the Independently practicing nurse practitioners determination of need for a blood transfusion will need to order blood transfusions based on to a physician and surgeon and a doctor of evidence-based clinical guidelines. There are podiatric medicine. many health conditions that may require a patient to need a blood transfusion. HSC 1645(a) could be amended to authorize 103 NPs and 104 NPs to provide blood transfusions. Respiratory therapy BPC §§ 3700 et seq. "Respiratory care as Current statutes allow only physicians and services a practice means a health care profession surgeons to order respiratory care services. NPs employed under the supervision of a are educated and qualified to evaluate patients medical director." for respiratory therapy needs and will need to order respiratory care services for patients. These statutes could be amended to include 103 NPs and 104 NPs as being eligible to order respira- tory care services and supervise respiratory care practitioners. Treating sexual HSC § 120582 (a)–(b). An important public health This statute could be amended to allow 103 NPs, partners of patients initiative in California has been surveillance and 104 NPs, and NPs functioning under standard- diagnosed with treatment of sexually transmitted infections (STIs). ized procedures to prescribe, dispense, furnish, sexually transmitted This care has extended to the partners of those or otherwise provide a prescription to a patient's infections infected. The current statute allows only physi- sexual partner or partners without examination of cians and surgeons to prescribe, dispense, furnish, that patient's partner or partners. or otherwise provide a prescription to a patient's sexual partner or partners without examination of that patient's partner or partners. Child health and HSC § 124030(g)(2)-(3). This law allows for only Children with childhood illnesses such as cystic disability prevention family nurse practitioners and pediatric nurse fibrosis and congenital heart disease are now program practitioners to serve as a Child Health and living longer and being cared for by others Disability Prevention program director. besides just family or pediatric nurse practitioners. This statute could be amended to authorize 103 NPs and 104 NPs to serve as program directors. Intermediate care HSC § 1250(e). This law specifies that physicians NPs are educated and qualified to make the facility or develop- and surgeons are authorized to certify that determination whether a patient needs continuous mentally disabled patients in an intermediate care facility or skilled nursing care or ongoing care in an inter- habilitative facility developmentally disabled habilitative facility mediate facility. HSC § 1250(e) could be amended skilled nursing needs do not require continuous skilled nursing care. to specify that 103 NPs or 104 NPs acting as the certification primary care provider in these settings can deter- mine the appropriate level of care for the patient. California Health Care Foundation www.chcf.org 10 Table A2. Category 2: Statutory Changes to Facilitate Evidence-Based Patient Care and Continuity of Care, continued ISSUE PRE-AB 890 CALIFORNIA STATUTE AB 890 CALIFORNIA STATUTE Congregate living HSC § 1250(i)(2)(B). This statute specifies NPs are educated and qualified to make the health facilities - certification by physicians and surgeons that prognosis, evaluate, and manage the care of life-threatening illness patients who need initial or ongoing care in an patients with life-threatening illness. HSC § 1250(i) intermediate care facility or developmentally (2)(B) could be amended to specify that 103 NPs disabled habilitative facility need 24-hour and 104 NPs acting as the primary care provider personal care but do not need continuous in these settings can determine the appropriate skilled nursing care. level of care for the patient. Diabetes management HSC § 1265.6(a). Blood glucose testing in an NPs are educated and qualified to evaluate in intermediate care intermediate care facility or developmentally and manage the care of patients in intermedi- facilities or devel- disabled habilitative setting is permitted only ate care facilities or developmentally disabled opmentally disabled if a physician orders the testing. habilitative facilities and to determine the need habilitative facility for and cadence of blood glucose testing.. HSC § 1265.6(a) could be amended to allow blood glucose testing orders by 103 NPs, 104 NPs, and NPs functioning under standardized procedures. Long-term health care HSC § 1418.8. Physicians and surgeons are NPs are educated and qualified to make determi- facilities the only authorized healing arts professionals nations about decision-making capacity and the authorized to prescribe or order a medical medical necessity of an intervention. HSC § 1418.8 intervention when the patient lacks decision- could be amended to allow 103 NPs, 104 NPs, and making capacity. NPs functioning under standardized procedures to prescribe or order medical interventions when the patient lacks decision-making capacity. Death registration HSC § 102795, HSC § 102800, HSC § 102825, Patients who die while under the care of a and certificates HSC § 102850(c), HSC § 102875(a)(7). These 103 NP or 104 NP will need their death to be five Health and Safety Code sections address registered and a certificate to be completed. who can complete the death registration and The cited code sections could be updated to death certificate. HSC § 102795 states that only ensure that NPs can complete the death a physician and surgeon or physician assistant registration and death certificate. last in attendance must complete the medical and health section data and time of death. HSC § 102800 states that the medical and health section data shall be completed by a physician or coroner and the death certificate deposited within 15 hours after the death. HSC § 102825 requires the physician, or a physician assistant in the case of a death in a skilled nursing facility or long-term care facility, to state the disease or condition of death and other death certificate requirements. HSC § 102850(c) allows only a physician or physi- cian assistant to state the cause of death. HSC § 102875(a)(7) allows only a physician or coroner to certify the death on the death certificate. Clinical laboratory BPC §§ 1209 et seq. This law lists the definitions To increase available clinical and laboratory director of who may be a laboratory director. Pursuant to services, NPs could be authorized to be labora- BPC § 2837.103(c)(2)(B) and § 2837.104(b)(1), 103 tory directors. BPC § 1209 could be amended to NPs and 104 NPs may perform or interpret clinical authorize 103 NPs and 104 NPs to be laboratory laboratory procedures that they are permitted to directors for both waived and moderate complex- perform under BPC § 1206 and under the federal ity laboratory tests. Clinical Laboratory Improvement Act (CLIA). NPs who own a clinical practice will need to be autho- rized to be a laboratory director for waived and moderate complexity laboratory tests. Aligning Nurse Practitioner Statutes in California www.chcf.org 11 Table A2. Category 2: Statutory Changes to Facilitate Evidence-Based Patient Care and Continuity of Care, continued ISSUE PRE-AB 890 CALIFORNIA STATUTE AB 890 CALIFORNIA STATUTE Interscholastic EDC § 494458. This law authorizes a physician NPs are educated and qualified to conduct athletic programs - and surgeon or a physician assistant to conduct physical and health assessments for students. physical exams a physical exam as a condition of a student's EDC § 494458 could be amended to include participation in interscholastic athletic programs. 103 NPs, 104 NPs, and NPs functioning pursuant to standardized procedures as authorized healing arts professionals who can conduct physical and health exams for interscholastic athletic programs. Workers' compensation LAB § 3209.3. This law defines the authorized This statute could be amended to authorize 103 insurance - definition providers used throughout the workers' NPs and 104 NPs to provide services to workers in of authorized provider compensation insurance statutes as being the workers' compensation insurance program. qualified to provide care. NPs are not listed. Adult day health care WIC § 14550(e). This law requires adult day Psychiatric/mental health NPs (PMHNPs) are centers health care centers (ADHCs) to offer medical educated and qualified to provide psychiatric services including psychiatric services when and psychological services to older adults who indicated and individual or group therapy for need individual assessments and/or group or mental and behavioral health problems. These individual treatment for persons with diagnosed services may be provided only by psychiatrists, mental, emotional, or behavioral problems. NPs clinical psychologists, or psychiatric social are authorized to establish primary and differen- workers. Note that there is a shortage of tial diagnoses, create a plan of care, and initiate mental health providers in California. therapeutic regimens, and so PMHNPs could be included in this statute as authorized providers in ADHCs. California Health Care Foundation www.chcf.org 12 Appendix B. 103 and 104 Nurse Practitioners Business and Professions Code (BPC) § 2837.103 NPs are eligible to practice pursuant to a defined scope of practice without standardized procedures or supervision. In order to be eligible, the NP must (1) work in one of six settings in which one or more physicians practice, and (2) satisfy specific requirements delineated in AB 890. 103 NP SETTINGS BPC § 2837.103(A)(2)(A)–(F) Authorized Settings and Organizations Any of the following settings that has one or more physicians and surgeons: $ A clinic, as defined in Section 1200 of the Health and Safety Code. $ A health facility, as defined in Section 1250 of the Health and Safety Code, except for the following described under Exempted Settings. $ A facility described in Chapter 2.5 (commencing with Section 1440) of Division 2 of the Health and Safety Code. $ A medical group practice, including a professional medical corporation, as defined in Section 2406, another form of corpo- ration controlled by physicians and surgeons, a medical partnership, a medical foundation exempt from licensure, or another lawfully organized group of physicians and surgeons that provides health care services. $ A home health agency, as defined in Section 1727 of the Health and Safety Code. $ A hospice facility licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code. Exempted Settings NPs will still need to practice under standardized procedures in these settings. A correctional treatment center, as defined in paragraph (1) of subdivision (j) of Section 1250 of the Health and Safety Code. A state hospital, as defined in Section 4100 of the Welfare and Institutions Code. 103 NP REQUIREMENTS REQUIREMENT BPC SECTION The NP has passed a national NP board certification examination. 2837.103(a)(1)(A) If applicable, the NP must pass a supplemental examination developed by the 2837.103(a)(1)(A) and 2837.105(a)(1)–(4) Department of Consumer Affairs Office of Professional Examination Services (OPES). The NP holds a certification as an NP from a national certifying body accredited by 2837.103(a)(1)(B) the National Commission for Certifying Agencies or the American Board of Nursing Specialties and recognized by the BRN. The NP provides documentation that the NP education was consistent with already 2837.103(a)(1)(C) existing BRN regulations in BPC § 2836. The NP has completed a transition to practice (TTP) in California of a minimum of 2837.103(a)(1)(D) three full-time equivalent years of practice or 4,600 hours. Aligning Nurse Practitioner Statutes in California www.chcf.org 13 Business and Professions Code (BPC) § 2837. 104 NPs are eligible to practice independently pursuant to a defined scope of practice without standardized procedures in settings outside those listed in BPC § 2837.103(a)(2)(A)–(F) if they meet the criteria in the following table. The Board of Registered Nursing (BRN) will issue a separate NP certificate once the NP completes all of the 104 NP requirements and submits an application to the BRN. With the certification, NPs can open up their own practices and businesses pursuant to already existing laws and structures such as, but not limited to, a nursing corporation. 104 NP REQUIREMENTS REQUIREMENT BPC SECTION The 104 NP must meet all of the same requirements as the 103 NPs: 2837.104(b) $ National certification $ OPES exam, if applicable $ BRN-approved NP education $ TTP Holds a valid and active registered nurse license and a master's degree in nursing or 2837.104(b)(1)(B) other clinical field related to nursing or a doctoral degree in nursing. The NP has practiced as an NP in good standing for at least three years, not inclusive 2837.104(b)(1)(C) of the TTP. The BRN may, at its discretion, lower this requirement for an NP who holds a doctorate of nursing practice (DNP) based on practice experience gained in the course of doctoral education. California Health Care Foundation www.chcf.org 14 Appendix C. States with Global Signature Laws STATE/JURISDICTION CITATION TEXT OF LAW Alabama (a) When any law or rule requires a signature, certification, stamp, verification, affidavit, or endorsement by a Ala. Code § 34-21-93.1 physician, the document shall be deemed to authorize a signature, certification, stamp, verification, affidavit, or endorsement by a certified registered nurse practitioner or certified nurse midwife for the items listed in this section. The authority in this section for a certified registered nurse practitioner and a certified nurse midwife shall be subject to an active collaboration agreement. This section applies to all of the following: [a long list of defined actions, including but not limited to certifying disability for parking placards, signing death certificates, and so on] Arkansas (a) When a provision of law or rule requires a signature, certification, stamp, verification, affidavit, or Ark. Code § 17-80-120 endorsement by a physician, the requirement may be fulfilled by an advanced practice registered nurse or a physician assistant in any of the following circumstances: (1) Certification of disability for patients to receive disabled parking permits or placards from the Office of Motor Vehicle; or (2) Signature for: (A) Sports physi- cals to authorize student athletes to participate in athletic activities; (B) Physicals for bus drivers; (C) Forms relating to do-not-resuscitate orders; (D) Forms excusing a potential jury member due to an illness; (E) Death certificates; (F) Workers' compensation forms; (G) Forms relating to absenteeism for employment or school purposes; or (H) Authorizations for durable medical equipment. DC Section 604 of the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 D.C. Law 22-60, (D.C. Law 6–99; D.C. Official Code § 3–1206.04), is amended as follows: . . . (c) A new paragraph (5) is added § 2, 65 D.C. Reg. 5 to read as follows: "(5) Sign, certify, stamp, or endorse all documents that require a signature by a physician, in place of a physician, provided it is within the scope of their authorized practice." Hawaii Notwithstanding any other law to the contrary, advanced practice registered nurses shall be authorized to Haw. Rev. Stat. sign, certify, or endorse all documents relating to health care within their scope of practice provided for § 457-8.8 their patients, including workers' compensation verification documents, verification and evaluation forms of the department of human services and department of education, verification and authorization forms of the department of health, and physical examination forms; provided that nothing in this section shall be construed to expand the scope of practice of advanced practice registered nurses. Idaho When a provision of law or rule requires the signature, certification, stamp, verification, affidavit, or endorse- Idaho Code § 54-1420 ment of a physician, that requirement may be fulfilled by an advanced practice registered nurse (APRN), including a certified nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, or clinical nurse specialist. This section shall not be construed to expand the scope of practice of an APRN. Maine Global signature authority of a certified nurse practitioner or certified nurse midwife. When a provision of Me. Rev. Stat. tit. 32, law or rule requires a signature, certification, stamp, verification, affidavit or endorsement by a physician, § 2205-B(5) that requirement may be fulfilled by a certified nurse practitioner or a certified nurse midwife. This subsec- tion may not be construed to expand the scope of practice of a certified nurse practitioner or a certified nurse midwife. Massachusetts When a law or rule requires a signature, certification, stamp, verification, affidavit or endorsement by a Mass. Gen. Laws physician, when relating to physical or mental health, that requirement may be fulfilled by a nurse practitio- ch. 112, § 801 ner practicing under section 80B. Nothing in this section shall be construed to expand the scope of practice of nurse practitioners. This section shall not be construed to preclude the development of mutually agreed upon guidelines between the nurse practitioner and supervising physician under section 80E. Rhode Island Whenever any provision of the general or public law or regulation requires a signature, certification, stamp, R.I. Gen. Laws verification, affidavit, or endorsement by a physician, it shall be deemed to include a signature, certification, § 5-34-42 stamp, verification, affidavit, or endorsement by a certified registered nurse practitioner; provided, however, that nothing in this section shall be construed to expand the scope of practice of nurse practitioners. Vermont Whenever any provision of Vermont statute or rule or any form provided to any person in this state requires Vt. Stat. Ann. tit. 26, a signature, certification, stamp, verification, affidavit, or other endorsement by a physician, such statute, § 1616 rule, or form shall be deemed to include a signature, certification, stamp, verification, affidavit, or other endorsement by an advanced practice registered nurse (APRN) licensed pursuant to this chapter and certi- fied as a nurse practitioner or a nurse midwife; provided, however, that nothing in this section shall be construed to expand the scope of practice of APRNs. Aligning Nurse Practitioner Statutes in California www.chcf.org 15 Endnotes 1.Assembly Bill 890, "Nurse Practitioners: Scope of Practice: 8."Opioid Overdose Death Rates and All Drug Overdose Practice Without Standardized Procedures," California Death Rates Per 100,000 Population (Age-Adjusted)," Kaiser Legislative Information, September 30, 2020. Family Foundation, 2019. 2.Assembly Bill 890. The relevant legislative language is as 9.H. B. Rowan, "Use of Buprenorphine to Treat Opioid follows: "The bill would authorize a nurse practitioner who Addiction Proliferates in California," California Healthline, meets certain education, experience, and certification May 23, 2019. requirements to perform, in certain settings or organizations, 10.J. L. Chow, M. J. Niedzwiecki, and R. Y. Hsia, "Trends specified functions without standardized procedures, in the Supply of California's Emergency Departments and including ordering, performing, and interpreting diagnostic Inpatient Services, 2005–2014: A Retrospective Analysis," procedures, certifying disability, and prescribing, BMJ Open 7, no. 5 (May 2018): e014721. administering, dispensing, and furnishing controlled substances. The bill, beginning January 1, 2023, would also 11."COVID-19 Nursing Home Data," Centers for Medicare authorize a nurse practitioner to perform those functions & Medicaid Services, accessed May 3, 2021. without standardized procedures outside of specified settings or organizations in accordance with specified conditions 12.T. Sandarangani et al., "'Advocating Every Single Day' and requirements if the nurse practitioner holds an active so as Not to Be Forgotten: Factors Supporting Resiliency certification issued by the board. The bill would require in Adult Day Service Centers Amidst COVID-19-Related the board to issue that certification to a nurse practitioner Closures," Journal of Gerontological Social Work 64, no. 3 who meets additional specified education and experience (January 2021), 291–302. requirements, and would authorize the board to charge a fee 13.Several California statutes granted NPs authority to for the cost of issuing the certificate." perform functions pursuant to "standardized procedures" 3.The postgraduate transition-to-practice requirement in as defined in BPC § 2725(c) and the California Code of California is a minimum of three full-time equivalent years or Regulations (CCR) title 16, §§ 1470–1474. 4,600 hours. BPC § 2837.103(a)(1)(D). 14."Issues at a Glance: Signature Authority," American 4.P. I. Buerhaus et al., "Practice Characteristics of Primary Care Association of Nurse Practitioners, accessed June 28, 2021. Nurse Practitioners and Physicians," Nursing Outlook 63, no. 2 (March/April 2015): 144–53; M. A. Davis et al., "Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status," Journal of General Internal Medicine 33, no. 4 (2018): 412–14; Impact of State Scope of Practice Laws and Other Factors on the Practice and Supply of Primary Care Nurse Practitioners, US Department of Health and Human Services, November 2015; M. A. Fraser and C. Melillo, "Expanding the Scope of Practice of APRNs: A Systematic Review of the Cost Analyses Used," Nursing Economics 36, no. 1 (2018): 23–28; M. Weinberg and P. Kallerman, Full Practice Authority for Nurse Practitioners Increases Access and Controls Cost (PDF), Bay Area Council Economic Institute, 2014. 5.F. Donald et al., "A Systematic Review of the Effectiveness of Advanced Practice Nurses in Long-Term Care," Journal of Advanced Nursing 69, no. 10 (2013), 2148 – 61; S. Kaasalainen et al., "The Effectiveness of a Nurse Practitioner- Led Pain Management Team in Long-Term Care: A Mixed Methods Study," International Journal of Nursing Studies 62 (October 2016): 156 – 67. 6.J. Spetz et al., "Nurse Practitioner and Physician Assistant Waivers to Prescribe Buprenorphine and State Scope of Practice Restrictions," JAMA 321, no. 14, (2019): 1407–8. Executive Summary: Final Report of the California Future 7. Health Workforce Commission (PDF), California Future Health Workforce Commission, February 2019. California Health Care Foundation www.chcf.org 16