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CMSA’s view on multistate licensure is clearly stated in the organization’s standards: “The case manager prac- tices in accordance with applicable local, state, and federal laws. The case manager has knowledge of applicable accreditation and regulatory statutes governing sponsoring agencies that specifically pertain to delivery of case management services.” Nurse licensure is regulated on a state-by-state basis with state boards of nursing requiring nurse case man- agers to be licensed within the states where patients reside whenever tele- phonic or on-site interactions occur. When nurses provide case manage- ment services telephonically or onsite without a license to practice in the state of the patient’s residence, he or she is violating the law. The violation is punishable with penalties of up to $1000, permanent loss of licensure, and up to 1 year in jail. Of additional concern to nurse case managers is the fact that no profes- sional liability insurance carrier will cover an improperly licensed or nonli- censed nurse in the event of actions deemed damaging to the patient. Therefore, case managers would be personally responsible for payment of damages if they are assessed. Through the National Council of State Boards of Nursing (NCSBN), 20 states have entered into a compact to recog- nize other states’ licensing of nurses. A listing as of August 2005 is included below. The compact is tied to the state of the nurse’s residence, not the state of practice or the patient’s location. Therefore, if a nurse resides in and is licensed by a state that participates in Multistate Nurse Licensure IN CASE MANAGEMENT T o encourage case managers and CM employers to support compliance with multistate nursing licensure, the Case Management Society of America (CMSA) board of directors has revised an earlier position statement on multistate nursing licensure in case management. According to CMSA President Susan Rogers, RN, BSN, CCM, “CMSA’s fundamental position on this topic remains unchanged. What’s different is a more assertive position in support of appropriate safeguards for our members and case managers nationwide.” March/April 2006 TCM 43 Licensure Liability Special Section: &

Transcript of Multistate Nurse Licensuredev.cmsa.org/portals/0/PDF/MultistateLicensure/... · $1000, permanent...

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CMSA’s view on multistate licensureis clearly stated in the organization’sstandards: “The case manager prac-tices in accordance with applicablelocal, state, and federal laws. The casemanager has knowledge of applicableaccreditation and regulatory statutesgoverning sponsoring agencies thatspecifically pertain to delivery of casemanagement services.”

Nurse licensure is regulated on astate-by-state basis with state boardsof nursing requiring nurse case man-agers to be licensed within the stateswhere patients reside whenever tele-phonic or on-site interactions occur.When nurses provide case manage-ment services telephonically or onsitewithout a license to practice in thestate of the patient’s residence, he orshe is violating the law. The violationis punishable with penalties of up to

$1000, permanent loss of licensure,and up to 1 year in jail.

Of additional concern to nurse casemanagers is the fact that no profes-sional liability insurance carrier willcover an improperly licensed or nonli-censed nurse in the event of actionsdeemed damaging to the patient.Therefore, case managers would bepersonally responsible for payment ofdamages if they are assessed.

Through the National Council of StateBoards of Nursing (NCSBN), 20 stateshave entered into a compact to recog-nize other states’ licensing of nurses.A listing as of August 2005 is includedbelow. The compact is tied to the stateof the nurse’s residence, not the stateof practice or the patient’s location.Therefore, if a nurse resides in and islicensed by a state that participates in

MultistateNurse Licensure

INCASE MANAGEMENT

T o encourage case managers and CM employers to support compliancewith multistate nursing licensure, the Case Management Society

of America (CMSA) board of directors has revised an earlier position statement on multistate nursing licensure in case management. Accordingto CMSA President Susan Rogers, RN, BSN, CCM, “CMSA’s fundamental position on this topic remains unchanged. What’s different is a moreassertive position in support of appropriate safeguards for our membersand case managers nationwide.”

March/April 2006 TCM 43

LicensureLiability

Special Section:

&

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the Nurse Licensure Compact, thenurse’s licensure will be recognized byother states participating in the com-pact.

Jeanne Boling, MSN, CRRN, CDMS,CCM, CMSA executive director,explained, “The purpose of the CMSAposition statement is to alert and topersuade individuals and organiza-tions to aggressively encourage non-compact state boards of nursing to jointhe compact and to encourage federallegislation mandating recognition ofnurse licensure across state lines in thesame manner as driver ’s licenses arerecognized.”

According to Rogers, “In response tothis issue, CMSA is encouraging casemanagers and employers to workaggressively with the state boards ofnursing to encourage compliance andentry into the NCSBN as compact statesso that appropriate multistate nursinglicensure might continue appropriatelyand cost effectively. In addition or as analternate step, CMSA is encouraging theenactment of federal legislation mandat-ing the recognition of nurse licensure inall states. Finally, CMSA has added itsname to the growing list of those orga-nizations supporting and endorsing thenurse compact.”

Here is the revised position statementin its entirety.

Position Statement: Multistate Nursing Licensure in Case ManagementRevised 11-04-05PurposeCMSA is frequently asked by its mem-bers how they should approach licen-sure in compliance with state nurselicensure laws when conducting casemanagement outside their state of res-idence and licensure. The purpose ofthis paper is to clarify CMSA’s positionas it applies to the issue of multistatenurse licensure.

SummaryNurse licensure is regulated on a state-by-state basis with State Boards ofNursing requiring nurse case man-agers to be licensed within the stateswhere patients reside when case man-

ager-patient telephonic or on-siteinteractions occur. In general, nursesare required to be licensed in the statein which they are practicing and inwhich their patients reside. The 1997Policy Statement by the NationalCouncil of State Boards of Nursing(NCSBN) defines “telenursing” as thepractice of nursing and asserts that itis regulated by state boards of nursing.This paper is limited specifically tonursing licensure as there are uniquequalifications associated specifically tonursing. Other professional specialtiesperform case management servicesand will be guided by their specificregulatory requirements.

This paper will address three relatedquestions:1. Which activities performed by

licensed nurse case managers aredefined as the practice of nursingand thus fall under regulatory con-trol?

2. Do CMSA Standards of Practice forCase Management, Revised, 2002address the issue of multistate nursecase manager licensure?

3. What action can case managers taketo support reasonable licensurerequirements to practice in today’stelephonic care world?

FactsA license is a legal document that per-mits the holder to offer special skillsand knowledge to the public in a par-ticular jurisdiction, where such prac-tice would otherwise be unlawful. Tooffer nurse case management services,the case manager must have properstate licensure, recognized endorse-ment, or statutory waiver (typicallylimited to those working with the Vet-erans Administration or military ser-vice). Without such legal permission, aprofessional may not be adhering totheir state of residence licensurerequirements or the licensure require-ments of the state in which the patientto whom they are providing servicesresides.

All registered nursing graduates musttake the US qualifying exam, NationalCouncil Licensure Exam-RN (NCLEX),in order to obtain licensure. Manystates “endorse” licenses from otherstates. For example, a nurse licensed inone state can submit paperwork andreceive a license in another state with-out re-taking the NCLEX.

The NCLEX is currently also availableto nurses outside the US. Therefore,nurses educated in foreign countries

TCM 44 March/April 2006

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can demonstrate equivalency by pass-ing of the NCLEX exam.

The IssueWhen nurses provide case manage-ment services telephonically or on sitewithout a license to practice in thestate of the patient’s residence, he/sheis violating the law. The violation ispunishable variably in states withpenalties of up to $1000, permanentloss of licensure, and up to 1 year injail. Of additional concern to nursecase managers is the fact that not oneprofessional liability insurance carrierwill cover an improperly licensed ornonlicensed nurse in the event ofactions which are deemed damagingto the patient. Therefore, case man-agers would be personally responsiblefor payment of damages if they areassessed.

As one might imagine, licensure in 31states (30 which are not within theCompact states and 1 within the Com-pact states) is financially and adminis-tratively burdensome to the organiza-tion. With pressure to demonstratecost containment, current practice forsome large organizations is to selfinsure the risk of incurring a damageassessment for the organization and todirect nurses to proceed whetherlicensed properly or not. This practiceleaves the nurse vulnerable to beingnamed in a lawsuit for damages with-out recourse to professional liabilityinsurance.

GoalThe goal of the CMSA position state-ment is not to create an administrativenightmare or to create additional coststo organizations or to the US healthcaresystem. The purpose of the CMSA posi-tion statement is to alert and to encour-age individuals and organizations toaggressively encourage the non-Com-pact State Boards of Nursing to join theCompact or to encourage federal legisla-tion mandating recognition of nurselicensure across state lines just as driv-er’s licenses are recognized.

Nurse Licensure Compact States as of August 2005 Through the NCSBN, 20 states haveentered into a compact to recognize

other states’ licensing of nurses; a list-ing as of August 2005 is included inthe sidebar.

The compact is tied to the state of thenurse’s residence, not the state ofpractice or the patient’s location.Therefore, if a nurse resides in and islicensed in a state that participates inthe Nurse Licensure Compact, thenurse’s licensure will be recognizedby other states participating in thecompact. The nurse should checkwith her State Board of Nursing forappropriate procedures for recogni-tion.

Nurse Licensure Compact Implementation (Excerpted fromwww.ncsbn.org)The table and map indicate whichstates have enacted the RN andLPN/VN Nurse Licensure Compact.Please note that, although New Jerseyand New Hampshire have enacted theNurse Licensure Compact, these stateshave not yet implemented the com-pact. On April 25, 2005, Iowa andUtah agreed to mutually recognizeAPRN licenses. No date has been setfor the implementation of the APRNCompact.

Arizona 7/1/2002Arkansas 7/1/2000 Delaware 7/1/2000 Idaho 7/1/2001 Iowa 7/1/2000 Maine 7/1/2001 Maryland 7/1/1999 Mississippi 7/1/2001 Nebraska 1/1/2001 New Mexico 1/1/2004North Carolina 7/1/2000 North Dakota 1/1/2004South Dakota 1/1/2001 Tennessee 7/1/2003 Texas 1/1/2000 Utah 1/1/2000 Virginia 1/1/2005Wisconsin 1/1/2000

Nurse Licensure Compact Map

Nurse Licensure Compact Statesas of August 2005

CompactStates

ImplementationDate

If you are seeking Compact licensure,please contact your state board ofnursing for primary state of residencerequirements. For state board ofnursing contact information, go towww.ncsbn.org.

March/April 2006 TCM 45

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Which activities performed bylicensed nurse case managersare defined as the practice ofnursing and thus fall under regulatory control?The practice of nursing is defined instate law and therefore varies by state.The 1997 position paper of NCSBNnoted that some common functions ofnursing practice include interactingwith an individual client, receivingindividual health-status data, initiatingand transmitting therapeutic interven-tions and regimens, and monitoringand reporting client response andnursing care outcomes.

In 2004 and 2005, CMSA conducted a sur-vey of all 50 State Boards of Nursing todetermine if case management as definedby CMSA’s Standards of Practice is seenas the practice of nursing. The surveyresults indicated that in all 50 states casemanagement is considered the practice ofnursing when practiced by an RN.

The policy statement by NCSBN recog-nizes that states consider telenursingconducted by health call centers, tele-phonic disease management and casemanagement to be the practice of nurs-ing. Utilization management has madean active argument that it falls under thecategory of administrative oversight, andis not nursing practice. However, previ-ously silo UM, CM, and DM services arenow being integrated, which reopens theissue of licensure.

Nurse case managers then are governedby the state law governing the residenceof the patient with whom the case man-ager is interacting. In the instances ofnurse case managers working withpatients in several states, licensure is nec-essary in each state. Should patientsreside in a Compact state and the nursecase manager is licensed in one of theCompact states, the nursing licensurewould be recognized. Should the patientreside in a state not a part of the Compactor should the nurse case manager not belicensed in a Compact state, the nursecase manager would need to comply withthe state law by obtaining licensure in thestate where the patient resides.

In August 2005, the Case ManagementLeadership Coalition recognized the

Nurse Compact and recommended toeach of the participating organizationsthat they aggressively support theCompact.

The Compact is currently recognized by:1. Case Management Society of

America2. Case Management Leadership

Coalition3. Several state nursing associations

whose states have adopted theCompact

4. American Organization of NurseExecutives (AONE)

5. Several State Hospital Associationswhose states have adopted theCompact

6. American Association of Occupa-tional Health Nurses

7. US Department of Commerce8. Telehealth Leadership Council

CMSA PositionCMSA’s position is clearly stated byCMSA’s Standards of Practice for CaseManagement, Revised 2002©, whichstate that: “The case manager practices inaccordance with applicable local, state, andfederal laws. The case manager has knowl-edge of applicable accreditation and regula-tory statues governing sponsoring agen-cies that specifically pertain to delivery ofcase management services.”1. CMSA encourages case managers and

case manager employers to workaggressively with the State Boards ofNursing to urge compliance and entryinto the NCSBN as Compact States sothat appropriate multi-state nursinglicensure might continue appropriate-ly and cost effectively.

2. Alternatively, CMSA encourages theenactment of federal legislation man-dating the recognition of nurse licen-sure in all states.

3. CMSA has added its name to thegrowing list of those organizationssupporting and endorsing the NurseCompact. ❑

ResourcesCase Management Society of Americaboard meeting, November 4, 2005

Case Management Leadership Coalition meeting, August 12, 2005

CMSA 2004-2005 Survey of StateBoards of Nursing, available atwww.cmsa.org

2001 Report to Congress onTelemedicine, last updated May 16, 2002,Office for the advancement of Telehealth,5600 Fishers Lane, Room 11A-55,Rockville, MD 20857; (301) 443-0447.

AAOHN Multistate Practice Advisoryavailable for a fee from AmericanAssociation of Occupational HealthNursing, 2920 Brandywine Road, Suite100, Atlanta, GA 30341.

Center for Telemedicine Law issuedits findings and recommendations oninterstate licensure on Feb 12, 1997.Their detailed report can be obtained bycontacting the Center at (202) 775-5722.

CMSA’s Standards of Practice forCase Management, Revised 2002©,available at www.cmsa.org or fromCMSA, 8201 Cantrell Road, Suite 230,Little Rock, AR 72227

Interstate Practice in the Age of Infor-matics and E-Technology, DeborahDiBenedetto, AAOHN Journal, Sept 2003,Vol. 51, No. 9, pp. 367-369

National Council of State Boards ofNursing, www.ncsbn.org

doi:10.1016/j.casemgr.2006.01.005

“The case manager practices in accordance with applicablelocal, state, and federal laws. The case manager has

knowledge of applicable accreditation and regulatory statuesgoverning sponsoring agencies that specifically pertain

to delivery of case management services.”

TCM 46 March/April 2006