Insights into Professional Licensing Compacts AADA 34th Annual Meeting September 21, 2018 Chicago

Topics We Will Cover What is an interstate compact? What is the Nurse Licensure Compact (NLC)? What infrastructure does it require? What does the NLC accomplish? What were the challenges in establishing and maintaining the NLC? How do you make the compact grow? What did it take to develop the compact and get to where we are today?

What is a Compact? A statutory agreement between two or more jurisdictions established for the purpose of remedying a particular problem of multistate concern

What is the Nurse Licensure Compact (NLC)? The NLC is an interstate compact. Authorizes a nurse with primary state of residence (PSOR) in a compact state & holding a multistate license, to practice (physically or via telehealth) in any compact state. Those discussions led to the adoption of the mutual recognition model of licensure and the creation of the Nurse Licensure Compact. One way that we fulfill our mission at NCSBN by promoting the Nurse Licensure Compact.

Primary Concepts Nurse is issued a multistate license in the declared primary state of residence (PSOR) known as the home state Nurse holds only one multistate license issued by the home state Nurse has a multistate licensure privilege to practice in other Compact states (remote states)

Locus of Practice A licensee must have the authority to practice in the state where the receiver of nursing service is located at the time service is provided (unless federally exempted). “As the organizations representing…state…licensing boards…that regulate the practice of medicine, pharmacy and nursing, … (we) affirm that in a consumer protection model, health care practice occurs where the recipient of healthcare services is located.” Source: The Tri-Regulator Collaborative Position Statement on Practice Location for Consumer Protection

A Definition of Nursing Practice Most states will define practice as when a nurse utilizes her or his: Education / knowledge Judgment Decision-making skills

Who Needs Multiple Licenses? Nurse Case Managers Occupational Health Nurses Transport Nurses Ambulatory Care Nurses Distance Educators Travel Nurses Triage Nurses Home Health Nurses Emergency Room Nurses Hospice Nurses Acute Care Nurses CNOs Nurses who live near borders and work in the adjacent state Telephonic Nurses Wellness Coach Nurses Military Spouses Military, V.A. or Federal Nurses Practicing in Civilian Facilities Dialysis Nurses Camp Nurses Parish Nurses Vascular Access Nurses Utilization Review Nurses Workers Compensation Nurses Nurses in Insurance /Managed Care Industries

Two Distinct Compacts Original NLC is the compact that began in 2000 25 member states dissolves 7/18/18 Enhanced NLC (eNLC) Updated version adopted 2015 Implemented Jan 19, 2018

Requires Legislative Enactment in Each State

History of Original NLC 1994 - Task Force to Study Regulation 1995 – Regulation Task Force charged to consider models; Telecommunications Task Force authorized 1996 – Study Issue (magnitude of need, impact on state regulatory processes) 1997 – Endorsed mutual recognition model 1997 (special) – approved Interstate Compact

Drivers for Change in 1990s Healthcare Delivery System Restructuring Managed care/capitation Movement away from acute care Mergers and acquisitions resulting in large, multijurisdictional integrated health care delivery systems Emergence of Call Centers and Telephone Triage

Drivers (continued) Technological Advances Internet Cellular telephone and computers Interactive video Videoconferencing, teleconferencing Advanced electronic diagnostic technologies Robotics Internet of things

Drivers (continued) Consumerism Growing expectation for health care information Expectations for information about treatment options and inclusions in decisions about their own treatment plan Health Tourism

Dilemma – Which model of nurse licensure is best for the 21st century? Licensure remains state based Practice is not bound by state lines

Licensure Model Chosen Mutual Recognition A state-based license, nationally recognized and locally enforced.

Portability and Mobility Enhanced by Multistate Licensure Telehealth practice (call center, triage, case managers, etc) Disaster recovery assistance Military spouse relocation; military moonlighting or training in civilian facilities Nursing faculty engaged in distance education Access for rural populations and healthcare shortage areas Facility staffing: travel nursing Home health and hospice Transport nursing Nurses residing near borders and practicing in an adjacent state.

Benefits Related to Recruitment of Nurses Today’s millennials want mobility and maximized benefits. Nursing students overwhelmingly self-report planning to live and work in a NLC state rather than a non-NLC state. When a nurse holds a multistate license and is being recruited by an employer in another NLC state, the nurse can be available to the prospective employer immediately since the nurse already has the authority to practice in that state.

Benefits for Boards of Nursing Ability to share complaint and investigative information throughout the investigative case Shared responsibility for patient safety not governed by geographical boundaries Shared commitment to improving our collective ability to protect patients, i.e., multiple states working together to assure patient safety Ability to locate, isolate or limit ability to practice on Privilege to Practice Reduces duplicative board actions Uniform statutes, rules and policies applicable and enforceable to all compact states

Policy Goal Simplify governmental processes and remove regulatory barriers to increase access to safe nursing care.

Challenges to Implementation Need for full participation in the coordinated licensure information system, Nursys Perceived state sovereignty issues Lack of understanding of licensure compacts by legislators Concerns with board of nursing revenue loss Lack of support from nurse unions

Other Interstate Licensure Compacts for Healthcare Professions Compacts in Progress Compacts Under Development or Being Considered Nursing (RN/LPN) Nursing (APRN) Physicians Physical Therapists Emergency Medical Technicians Psychologists Occupational Therapists Speech Pathologists / Audiologists Nutritionists / Dieticians Athletic Trainers Physician Assistants Social Workers

Why Did We Pursue Enhancing the NLC? Several states expressed concerns that they couldn’t join current NLC for various reasons, including lack of criminal background check requirements in original NLC Current NLC states wanted to ensure long-term growth and viability of the NLC Need for facilitating interstate nursing practice continues to grow

What Does it Take to Join? A state must enact the enhanced NLC model language into law A state must have the ability to conduct a federal criminal background check of a nurse upon initial licensure or licensure by endorsement Participate in Nursys national database With a nationwide initiative, this takes time. The impact of the union varies. Their level of influence on the legislature varies by state. Also, not all unions oppose the compact.

Currently 29 States in Which a Nurse Holding a Multistate License can Practice

Growing the Compact Remove the barriers to embracing compact Know your supporters Have state and national coalitions Identify opposition and unlikely allies Capitalize on the tailwind Grab the low hanging fruit Build consensus among membership Contract lobbyists when necessary

11 Uniform Licensure Requirements To receive a multistate license, a nurse must: Meet the home state’s qualifications Graduate from qualifying education program (or graduated from a foreign program verified by independent credentials review agency) Pass the NCLEX-RN® or NCLEX-PN® exam (or predecessor SBTPE)

Uniform Licensure Requirements (Continued) Have no active discipline on a license Submit to a federal and state fingerprint-based criminal background check Not be currently enrolled in an alternative program 7) Have a valid U.S. Social Security number

Uniform Licensure Requirements (Continued) Self-disclose participation in an alternative program Have no misdemeanors related to practice of nursing, determined on a case by case basis by the BON 10) Passed English proficiency exam if foreign grad 11) Have no prior state or federal felony convictions NOTE: A nurse who does not meet a requirement may be eligible to receive a single state license.

Interstate Commission Governing body that is also a public agency (The term “Commission” is commonly used by other modern interstate compact governing bodies) Elected leadership: Executive Committee Commissioners: “the head of the board of nursing” or designee

Rulemaking Rules adopted directly by the Commission Legally binding in all party states Allows for simultaneous adoption and uniformity of rules in all NLC states See… https://www.ncsbn.org/enlcrules.htm

Investigations and Discipline A complaint may be received by the home state or the remote state board of nursing. Not all complaints result in an investigation. If an investigation is justified, the party states will decide who will take the lead. The investigation is generally carried out in the state where the violation occurred. (Both home & remote states have the authority to conduct the investigation). For purposes of investigation and discipline, a BON treats a remote state licensee as if the licensee were a resident of that state, applying its state laws to the case.

Investigations and Discipline (Cont’d) IV. The remote state takes action on the licensee’s privilege to practice (PTP); not on the license. This action protects the public in this remote state only. V. The remote state shares the investigative information/file with the home state. VI. The home state takes action on the multistate license, removing multistate privileges and thereby protecting all other NLC states.

Public Protection Features of eNLC Requirements of member states: conduct state and federal criminal background checks at initial and license by endorsement. fully participate in Nursys share licensee investigation & disciplinary information with other member states indicate in Nursys: participation in alternative programs & significant investigations. Nurses under discipline or in an alternative program (ATD) have multistate privileges removed. Nurses not meeting Uniform Licensure Requirements are not eligible for multistate license but may qualify for a single state license. Nurses with a felony conviction are not eligible for a multistate license. Party state may take adverse action against the multistate privilege to practice in that party state.

Operational Impact on BON When Joining NLC Areas: Education of all stakeholders: nurses, employers, public Joint investigations & discipline Decrease in License renewals Verification completed through Nursys.com

Nursys.com The national nurse licensure database

Where Does a Nurse Have the Authority to Practice?

Authority to Practice Map on www.Nursys.com

Lessons Learned and Words of Advice Decide on your core principles and educate members on them Correct inaccuracies; be able to respond Know that educating stakeholders is continuous Approach rulemaking in small bites Learn from others Decide what constitutes a material deviation Promote the public protection value of the compact

Thank you! Jim Puente, MS, MJ, CAE Director, Nurse Licensure Compact nursecompact@ncsbn.org nursecompact.com