Evaluating Elements of Scopes of Practice in the Military Health System

Transcription

1 Evaluating Elements of Scopes of Practice in the Military Health System Joseph D. Wehrman, Ph.D. University of Colorado at Colorado Springs Department of Counseling & Human Services Colorado Springs, CO October 14,1:00 to 2:30pm

2 The Maine Rural Health Research Center performed the only definitive research on scopes of practice for the behavioral health professions and concluded: For all the mental health professions studied, we found little differentiation among the three primary mental health services (assessment, treatment planning and individual and group counseling). Hartley, D., Ziller, E. C., Lambert, D., Loux, S. L., & Bird, D. C. (2002, May). State licensure laws and the mental health professions: Implications for the rural mental health workforce. Portland, ME: Univ. of Southern Maine, Edmund S. Muskie School of Public Service, Maine Rural Health Research Center.

3 The Maine study also found: We found relatively little variation from one state to another in the scope of practice allowed for each profession. While no state specifically restricts any of the licensed profession from performing these services [psychotherapy and diagnosis], many simply do not address them. Three states fail to mention diagnosis, and five fail to mention psychotherapy in the scope of practice for psychologists.

4 Since the 2002 Maine study, many state scopes of practice have been revised to include these core terms. By example, 36 counselor licensure laws currently have diagnosis in the scope of practice.

5 While actual scopes of practice vary somewhat because of revisions that are necessitated by the state legislative process, professional model laws are quite similar. In fact, the model laws for psychology, social work, marriage and family therapy and counseling include all the core terms from the Maine study.

6 Psychology Model Law: Practice of psychology is defined as the observation, description, evaluation, interpretation, and modification of human behavior by the application of psychological principles, methods, and procedures, for the purposes of: (a) preventing, eliminating, evaluating or assessing symptomatic, maladaptive, or undesired behavior; (b) evaluating or assessing and/or enhancing individual, group and/or organizational effectiveness including personal effectiveness, interpersonal relationships, work and life adjustment, health, and individual, group and/or organizational performance, or (c) assisting in legal decision making. The practice of psychology includes, but is not limited to: (a) psychological testing and the evaluation or assessment of personal characteristics, such as intelligence, personality; cognitive, physical, and/or emotional abilities, skills, interests, aptitudes, and neuropsychological functioning; (b) counseling, psychoanalysis, psychotherapy, hypnosis, biofeedback, and behavior analysis and therapy; (c) diagnosis treatment, and management of mental and emotional disorder or disability, alcoholism and substance abuse, disorders of habit or conduct, as well as of the psychological aspects of physical illness, accident, injury, or disability; (d) psychoeducational evaluation, therapy, and remediation; (e) consultation with physicians, other health care professionals and patients regarding all available treatment options, including medication; and (f) consultation to individuals and organizations including advising management on human behavior in organizations; individual psychological assessment for selection and/or development; test and survey development, validation, and interpretation; and organizational assessment, diagnosis and intervention. Psychological services may be rendered to individuals, families, groups, and/or organizations. The practice of psychology shall be construed within the meaning of this definition without regard to whether payment is received for services rendered.

7 Counseling Model Law: Practice of Professional Counseling shall mean the application of mental health, psychological, and human development in order to: (a) facilitate human development and adjustment through the life span; (b) prevent, diagnose, and treat mental, emotional, or behavioral disorders and associated distresses which interfere with mental health; (c) conduct assessments and diagnoses for the purpose of establishing treatment goals and objectives; and (d) plan, implement, and evaluate treatment plans using counseling treatment interventions. Counseling treatment interventions shall mean the application of cognitive, affective, behavioral, and systemic counseling strategies, which include principles of development, wellness, and pathology that reflect a pluralistic society. Such interventions are specifically implemented in the context of a professional counseling relationship. The practice of professional counseling includes, but is not limited to: 1) individual, group, and marriage and family counseling and psychotherapy; 2) assessment; 3)crisis intervention; 4) diagnosis and treatment of persons with mental and emotional disorders; 5)guidance and consulting to facilitate normal growth and development, including educational and career development; 6)utilization of functional assessment and counseling for persons requesting assistance in adjustment to a disability or handicapping condition; 7)consulting; 8) research; and 9)referral.

8 Social Work Model Law: The practice of Clinical Social Work is a specialty within the practice of Master s Social Work and requires the application of social work theory, knowledge, methods, ethics, and the professional use of self to restore or enhance social, psychosocial, or biopsychosocial functioning of individuals, couples, families, groups, organizations and communities. The practice of Clinical Social Work requires the application of specialized clinical knowledge and advanced clinical skills in the areas of assessment, diagnosis and treatment of mental, emotional, and behavioral disorders, conditions and addictions. Treatment methods include the provision of individual, marital, couple, family and group counseling and psychotherapy. The practice of Clinical Social Work may include private practice and the provision of clinical supervision. Clinical social workers are qualified to use the Diagnostic and Statistical Manual of Mental Disorders (DSM), the International Classification of Diseases (ICD), and other diagnostic classification systems in assessment, diagnosis, and other activities.

9 Marriage and Family Therapy Model Law Marriage and family therapy services" includes the diagnosis and treatment of mental and emotional disorders, whether cognitive, affective, or behavioral, within the context of interpersonal relationships, including marriage and family systems, and involves the professional application of psychotherapy, assessment instruments, counseling, consultation, treatment planning, and supervision in the delivery of services to individuals, couples and families.

10 Some states even share one scope of practice for all the mental health disciplines, such as New Hampshire. 330 A:3 Board. There shall be a board of mental health practice composed of the following members: one licensed psychologist, one licensed pastoral psychotherapist, one licensed clinical social worker, one licensed marriage and family therapist, one licensed clinical mental health counselor, and 3 public members. The members shall be appointed to a term of 3 years by the governor with the approval of the council. The members of the board shall elect a chairperson on an annual basis. No discipline's representative and no public member shall serve as chairperson for consecutive terms.

11 NH Has One Scope of Practice for All Mental Health Disciplines 330 A:2 Definitions. In this chapter: V. ""Mental health discipline'' means the disciplines of those licensed as psychologists, pastoral psychotherapists, clinical social workers, clinical mental health counselors, and marriage and family therapists. VI. ""Mental health practice'' means the observation, description, evaluation, interpretation, diagnosis, and modification of human behavior by the application of psychological and systems principles, methods, and procedures for the purpose of preventing or eliminating symptomatic, maladapted, or undesirable behavior and of enhancing interpersonal relationships, work and life adjustments, personal effectiveness, behavioral health, and mental health, as well as the diagnosis and treatment of the psychological and social aspects of physical illness, accident, injury, or disability. Mental health practice may include, but shall not be limited to, those services based on diagnosis and treatment of mental and emotional disorders and psychoeducational or consultative techniques integral to the treatment of such disorders when diagnosis is specified in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, or an equivalent of such manual as determined by the board. Notwithstanding any other provision to the contrary, no person licensed or registered under this chapter shall assess the need for medications, prescribe medications, or otherwise practice medicine as defined in RSA 329. VII. ""Mental health practitioner'' means persons licensed under this chapter as psychologists, pastoral psychotherapists, clinical social workers, clinical mental health counselors, or marriage and family therapists. For purposes of this chapter, the term clinical social worker shall include independent clinical social worker. VIII. ""Psychotherapist'' means a psychologist, clinical social worker, pastoral psychotherapist, clinical mental health counselor, or marriage and family therapist licensed under this chapter who performs or purports to perform psychotherapy. This definition shall include psychiatrists licensed as physicians under RSA 329 and advanced registered nurse practitioners licensed under RSA 326 B:18 as psychiatric nurse practitioners. IX. ""Psychotherapy'' means the professional treatment, assessment, or counseling of a mental or emotional illness, symptom, or condition.

12 Arizona provides another example Counseling Scope Definitions 8. "Practice of professional counseling" means the professional application of mental health, psychological and human development theories, principles and techniques to: (a) Facilitate human development and adjustment throughout the human life span. (b) Assess and facilitate career development. (c) Treat interpersonal relationship issues and nervous, mental and emotional disorders that are cognitive, affective or behavioral. (d) Manage symptoms of mental illness. (e) Assess, appraise, evaluate, diagnose and treat individuals, couples, families and groups through the use of psychotherapy. Social Work Scope Definitions 9. "Practice of social work" means the professional application of social work theory, principles, methods and techniques to: (a) Treat mental and emotional disorders. (b) Assist individuals, families, groups and communities to enhance or restore the ability to function physically, socially, emotionally, mentally and economically. (c) Assess, appraise, diagnose, evaluate and treat individuals, couples, families and groups through the use of psychotherapy. Marriage and Family Therapy Scope Definitions 7. "Practice of marriage and family therapy" means the professional application of family systems theories, principles and techniques to treat interpersonal relationship issues and nervous, mental and emotional disorders that are cognitive, affective or behavioral. The practice of marriage and family therapy includes: (a) Assessment, appraisal and diagnosis. (b) The use of psychotherapy for the purpose of evaluation, diagnosis and treatment of individuals, couples, families and groups. Psychology Scope Definitions; court ordered evaluation 8. "Practice of psychology" means the psychological assessment, diagnosis, treatment or correction of mental, emotional, behavioral or psychological abilities, illnesses or disorders or purporting or attempting to do this consistent with section

13 Current practice is to regulate competency through licensure laws. State laws include competency provisions that prohibit behavioral health professionals from practicing outside their competency. Below are such provisions from the model state laws: Social work Competence: Continued competence. A social worker shall take all necessary and reasonable steps to maintain continued competence in the practice of social work. Limits on practice. A social worker shall limit practice to the permissible scope of practice for the social worker s license. Psychology Psychologists are required to limit their practice to their demonstrated areas of professional competence. Counseling The use of specific methods, techniques, or modalities within the practice of professional counseling is restricted to professional counselors appropriately trained in the use of such methods, techniques, or modalities.

14 The Maine study findings are validated by a recent study of Cigna Behavioral claims data. An evaluation of over 5 million claims from every state demonstrated that all of the mental health disciplines diagnosed (using the DSM IV) and treated (using the CPT codes) every form of disorder. The research demonstrates that despite variations in the state scopes of practice, all the professions are doing the same things. Services and Diagnoses. Data for all psychotherapy charges billed for individual or family therapy were available. The claims lines were classified by providers under the Current Procedural Terminology (CPT) codes of individual psychotherapy therapy (90806) or family psychotherapy therapy (90847) (American Medical Association, 2006). Also, provider assigned Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses for each claim were included. DSM diagnostic categories were summarized into eleven groups: Anxiety & PTSD, Mood Disorders, Disruptive Behavior, Substance use & abuse, Dissociative Disorders, Sexual Disorders, Schizophrenic/Psychotic, Eating Disorders, Adjustment Disorders, Relational Problems, and All Other (Doherty & Simmons, 1996).

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16 The trend is to expand scopes of practice to allow health care professionals to practice consistent with their education and training. This is demonstrated in the IOM report released this month, The Future of Nursing: Leading Change, Advancing Health.

17 Restrictions on scope of practice, policy and reimbursement related limitations, and professional tensions have undermined the nursing profession s ability to provide and improve both general and advanced care. Producing a health care system that delivers the right care quality care that is patient centered, accessible, evidence based, and sustainable at the right time will require transforming the work environment, scope of practice, education, and numbers of America s nurses.. Institute of Medicine The Future of Nursing: Leading Change, Advancing Health

18 Institute of Medicine The Future of Nursing: Leading Change, Advancing Health Because virtually all states still base their licensure frameworks on the persistent underlying principle that the practice of medicine encompasses both the ability and the legal authority to treat all possible human conditions, the scopes of practice for APRNs (and other health professionals) are exercises in legislative exception making, a carving out of small, politically achievable spheres of practice authority from the universal domain of medicine. As a result, APRNs scopes of practice are so circumscribed that their competence extends far beyond their authority. At any point in their career, APRNs can do much more than they may legally do. As APRNs acquire new skills, they must seek administrative or statutory revision of their defined scopes of practice (a costly and often difficult enterprise).

19 Evaluating Elements of Scopes of Practice in the Military Health System Joseph Wehrman, Ph.D. University of Colorado at Colorado Springs Department of Counseling & Human Services Colorado Springs, CO