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

2. 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?

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

4. 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.

5. 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)

6. 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

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

8. 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

9. 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

10. Requires Legislative Enactment in Each State

11. History of Original NLC
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

12. 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

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

14. 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

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

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

17. 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.

18. 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.

19. 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

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

21. 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

22. 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

24. 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

25. 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.

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

27. 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

28. 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)

29. 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

30. 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.

31. 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

32. 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…

33. 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.

34. 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.

35. 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.

36. 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

37. Nursys.com The national nurse licensure database

38. Where Does a Nurse Have the Authority to Practice?

39. Authority to Practice Map on www.Nursys.com

41. 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

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