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Credentialing Review Application Prescribing Psychologist Permit Submitted by: Nebraska Psychological Association October 30, 2014 Table of Contents Main Proposal Pages 1. Applicant group............................................................................................................................................... 2–3 2. Groups associated with this proposal.............................................................................................................. 3–8 3. Scope of practice for psychologists................................................................................................................. 8–9 4. Proposal to create prescribing psychologist permit ...................................................................................... 9–10 5. Functions performed by licensed psychologist, prescribing psychologist....................................................... 11 6. Other occupations that perform similar functions............................................................................................. 11 7. Functions unique to licensed psychologist, prescribing psychologist......................................................... 11–12 8. Supervisory relationships: licensed psychologist, prescribing psychologist............................................... 11–12 9. Autonomy of profession: licensed psychologist, prescribing psychologist................................................. 12–13 10. Number of licensed psychologists in Nebraska................................................................................................. 13 11. Level of Education: licensed psychologist, prescribing psychologist......................................................... 13–15 12. Work settings..................................................................................................................................................... 16 13. Services to the general public, restrictions.................................................................................................. 16–17 14. Reasons for seeking services ............................................................................................................................ 17 15. Typical referral patterns..................................................................................................................................... 18 16. Need for order to provided services................................................................................................................... 18 17. Continuing competency............................................................................................................................... 18–19 18. Requirements for credential renewal................................................................................................................. 19 19. Jurisdictions where regulated: licensed psychologist, prescribing psychologist............................................... 19 Additional Questions 1. Problem with not creating prescribing psychologist permit.............................................................................. 20 2. Feasibility methods of regulation...................................................................................................................... 21 3. Benefit to the public..................................................................................................................................... 21–22 4. Potential harm to the public......................................................................................................................... 22–23 5. Standards to maintain competency.............................................................................................................. 23–24 6. Third party reimbursement................................................................................................................................ 24 7. Experience of other jurisdictions regulating practitioners................................................................................. 24 8. Anticipated costs of regulation.......................................................................................................................... 25 9. Additional issues.......................................................................................................................................... 25–26 Appendices a. Prescribing psychologist permit.................................................................................................................. 27–29 b. Psychotropic drug prescriptions by medical specialty....................................................................................... 30 c. Number of licensed psychologists per county................................................................................................... 31 d. Provider training in behavioral health............................................................................................................... 32 e. Air Force credentialing of prescribing psychologists.................................................................................. 33–35 f. Comparison of entry-level training models leading to prescriptive authority................................................... 36 g. Survey responses of medical providers............................................................................................................. 37 h. Expanding behavioral health prescribers in Nebraska....................................................................................... 38 i. Bio of Dr. Mikel Merritt, prescribing psychologist, native of North Platte, Nebraska..................................... 39 Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Table of Contents Introduction The Nebraska Psychological Association proposes the creation of a prescribing psychologist permit. This permit would be an extra credential for already licensed psychologists who have met national postdoctoral training standards that would enable them to prescribe medications for mental disorders. This would be a voluntary supplemental credential with its own set of standards and requirements, and would not affect the general scope of practice of psychology. The proposal that psychology pursue prescriptive authority was put forth 30 years ago in Hawaii, by Senator Daniel Patrick Inouye, as a means of meeting shortfalls in the availability of trained behavioral health prescribers. Prescriptive authority has been the official policy of the American Psychological Association for the past 20 years. Psychologists with specialized training have been prescribing mental health medications for two decades in the Department of Defense, and for the past decade in two states (New Mexico and Louisiana). The US Public Health Service and the Indian Health Service permit appropriately trained psychologists to prescribe as well. Illinois passed legislation authorizing prescriptive authority for qualified psychologists in 2014. The prescribing psychologist would not only help to ameliorate the shortage of behavioral health prescribers in Nebraska, he or she would have the advantage of being able to provide combined therapies (psychotherapy and pharmacotherapy) for mental disorders. Available evidence indicates prescribing psychologists, collaborating with a patient’s primary medical provider, have excellent safety records. Contacts Daniel Ullman, Ph.D., MSCP Lincoln [email protected] Mikel Merritt, Ph.D., MACP Prescribing Psychologist, Air Force Active Duty, Missouri [email protected] James Madison, Ph.D. Omaha [email protected] Anne Talbot, Psy.D. Scottsbluff [email protected] Delinda Mercer, Ph.D., MSCP Scottsbluff [email protected] Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –1– Description of the Applicant Group and its Proposal 1. Provide the following information for the applicant group(s): a. Name, address, telephone number, e-mail address, and website of the applicant group in Nebraska, and any national parent organization Applicant Group Nebraska Psychological Association P.O. Box 6785 Lincoln, NE 68506 877-355-7934 (voice) 877-355-9234 (fax) [email protected] www.nebpsych.org Parent Organization American Psychological Association 750 First Street, NE Washington, DC 20002-4242 800-374-2721 or 202-336-5500 www.apa.org b. Composition of the group and approximate number of members in Nebraska; and The Nebraska Psychological Association has a total membership of 215 as of March 27, 2014. Thirty percent of licensed psychologists in Nebraska are members of the Nebraska Psychological Association Numbers by membership categories Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –2– 2. c. Relationship of the group to the occupation dealt with in the application. The Nebraska Psychological Association is the sole organization representing the practice of psychology in the state. The purpose of the Nebraska Psychological Association includes promoting the highest standards of ethical and effective practice and bringing the resources of psychology to bear on social problems in our state. Identify by title, address, telephone number, email address, and website of any other groups, associations, or organizations in Nebraska whose membership consists of any of the following: a. Members of the same occupation or profession as that of the applicant group; The Nebraska Psychological Association is the only professional association in Nebraska that exclusively represents licensed psychologists. The Association of Private Practice Therapists (AAPT) is a multi-disciplinary group of mental health professionals that includes licensed psychologists as members. Association of Private Practice Therapists P.O. Box 45397 Omaha, NE 68145 402-370-6898 www.privatepractice.org b. Members of the occupation dealt with in the application; The occupation dealt with in the application is the same as that represented by the applicant group. c. Employers of the occupation dealt with in the application; Licensed psychologists work in a wide variety of practice locations including private and public facilities, profit and nonprofit organizations, academic settings, and self-employment. d. Practitioners of the occupations similar to or working closely with members of the occupation dealt with in the application; There is a wide variety of practitioners that work closely with licensed psychologists including physicians, advanced practice nurses, nurses, mental health practitioners, attorneys, probation and parole officers, teachers, speech pathologists, occupational therapists, and physical therapists. A variety of professionals work under the supervision of licensed psychologists including psychologist associates, special licensed psychologists, psychological assistants, provisionally licensed psychologists, provisionally licensed mental health practitioners, and those seeking licensure as an alcohol and drug counselor. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –3– Nebraska Medical Association 233 South 13th Street, Suite 1200 Lincoln, NE 68508-2091 402-474-4472 [email protected] www.nebmed.org Nebraska Psychiatric Society c/o Metro Omaha Medical Society 7906 Davenport Street Omaha, NE 68114 402-393-1415 www.omahamedical.com Nebraska Pharmacists Association 6221 South 58th Street, Suite A Lincoln, NE 68516 402-420-1500 [email protected] www.npharm.org Nebraska Nurse Practitioners P.O. Box 22854 Lincoln, NE 68542-2854 [email protected] www.nebraskanp.org Nebraska Nurses Association P.O. Box 3107 Kearney, Nebraska 68848 888-885-7025 www.nebraskanurses.org Nebraska Academy of Family Physicians 11920 Burt Street, Suite 170 Omaha, NE 68154-1598 402-505-9198 www.nebrafp.org Nebraska Association of Behavioral Health Organizations 1141 H Street, Suite B Lincoln, NE 68508 402-475-0727 http://nabho.org Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –4– Health Center Association of Nebraska 3929 South 147th Street Altech Plaza, Suite 100A Omaha, NE 68144-5529 402-505-5426 [email protected] http://hcanebraska.org Behavioral Health Education Center of Nebraska 984242 Nebraska Medical Center Omaha, NE 68198-7697 402-552-7697 [email protected] www.unmc.edu/bhecn Nebraska Office of Rural Health P.O. Box 95026 301 Centennial Mall South Lincoln, NE 68509-5026 402-471-2337 [email protected] http://dhhs.ne.gov/publichealth Nebraska County Attorneys Association Jackie McCullough, Executive Director P.O. Box 80044 Lincoln, NE 68501 402-476-6047 [email protected] http://necaa.org Nebraska Criminal Defense Attorneys Association Coleen J. Nielsen, Interim Executive Director P.O. Box 94973 Lincoln, NE 68508 402-476-1253 [email protected] http://nebraskacriminaldefense.org Nebraska Chapter – National Association of Social Workers 650 J Street, Suite 208 Lincoln, NE 68508 402-477-7344 www.nasw-heartland.org Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –5– Nebraska Division – American Association for Marriage and Family Therapy Sherrie Hubbard, President 205 Galvin Rd. N Bellevue, NE 68005 402-292-7712, extension 18 [email protected] www.amft.org Nebraska Counseling Association P.O. Box 283 Kearney, NE 68848-0283 www.necounseling.org Nebraska Association of Alcoholism and Drug Abuse Counselors 3200 O Street, Ste 5 Lincoln, NE 69510 402-742-9616 www.naadac.org/nebraska Association of Private Practice Therapists P.O. Box 45397 Omaha, NE 68145 402-370-6898 www.privatepractice.org e. Educators or trainers of prospective members of the occupation dealt with in the application; Specific programs, rather than organizations, are as follows: Postdoctoral Masters Program in Clinical Psychopharmacology Fairleigh Dickinson University School of Psychology T-WH1-01 Teaneck, NJ 07666 866-247-2411 [email protected] www.rxpsychology.com Interdisciplinary Masters of Arts in Psychopharmacology Southwestern Institute for the Advancement of Psychotherapy/ New Mexico State University (SIAP/NMSU) Department of Counseling and Educational Psychology MSC 3CEP, P.O. Box 50001 Las Cruces, New Mexico 88003-8001 575-646-2121 [email protected] http://cep.education.nmsu.edu/academic-programs/clinical-psychopharmacology Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –6– Clinical Psychopharmacology Postdoctoral MS Program California School of Professional Psychology Alliant International University One Beach Street San Francisco, CA 94133 415-955-2163 [email protected] www.alliant.edu/cspp/programs-degrees/psychopharmacology Masters in Clinical Psychopharmacology University of Hawaii at Hilo, College of Pharmacy 200 W. Kawili Street Hilo, HI 96720 808-932-7138 [email protected] http://hilo.hawaii.edu/catalog/ms-clinincal-psychopharmacology.html f. Citizens familiar with or utilizing the services of the occupation dealt with in the application (e.g., advocacy groups, patient rights groups, volunteer agencies for particular diseases or conditions, etc.); and Mental Health Association of Nebraska Alan Green, Executive Director 1645 N Street Lincoln, NE 68508 402-441-4371 [email protected] www.mha-ne.org Nebraska Federation of Families for Children’s Mental Health 345 N. Minden Ave., P.O. Box 183 Minden, NE 68959 877-239-8880 [email protected] http://nefamilies4kids.org National Alliance on Mental Illness – Nebraska 415 S 25th St. Omaha, NE 68131-3654 402-345-8101 [email protected] http://naminebraska.org Lutheran Family Services of Nebraska 2900 O Street, #200 Lincoln, NE 68510 402-435-2910 [email protected] www.lfsneb.org Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –7– AARP of Nebraska 301 South 13th Street, #201 Lincoln, NE 68508 866-389-5651 [email protected] www.aarp.org/states/ne.html Nebraska Appleseed 941 O Street, Suite 920 Lincoln, NE 68508 402-438-8853 [email protected] https://neappleseed.org American Civil Liberties Union of Nebraska 941 O Street, Suite 706 Lincoln, NE 68508 885-557-2258 [email protected] www.aclunebraska.org Autism Center of Nebraska 9012 Q Street Omaha, NE 68127 402-315-1000 [email protected] autismcenterofnebraska.org Autism Society of Nebraska P.O. Box 83559 Lincoln, NE 68501-3559 800-580-9279 [email protected] http://autismnebraska.org g. Any other group that would have an interest in the application. Vocational Rehabilitation Services Department of Education P.O. Box 94987 Lincoln, NE 68509 402-471-3644 www.vr.ne.gov 3. If the profession is currently credentialed in Nebraska, provide the current scope of practice of the occupation as set forth in state statutes. If a change in this scope of practice is being requested, identify that change. This description of the desired scope of practice constitutes the proposal. The application comprises the documentation and other materials that are provided in support of the proposal. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –8– No change is being proposed in the scope of practice for psychology. The scope of practice for psychology in Nebraska is provided below. The proposal is for a prescribing psychologist permit that would enable some licensed psychologists with specialized training to prescribe medications for mental disorders. The prescribing psychologist permit would augment the practice of the licensed psychologist. 38-3108. Practice of psychology, defined. (1) Practice of psychology means the observation, description, evaluation, interpretation, or modification of human behavior by the application of psychological principles, methods, or procedures for the purpose of preventing or eliminating symptomatic, maladaptive, or undesired behavior and of enhancing interpersonal relationships, work and life adjustment, personal effectiveness, behavioral health, and mental health. (2) The practice of psychology includes, but is not limited to, psychological testing and the evaluation or assessment of personal characteristics such as intelligence, personality, abilities, interests, aptitudes, and psychophysiological and neuropsychological functioning; counseling, psychoanalysis, psychotherapy, hypnosis, biofeedback, and behavior analysis and therapy; diagnosis and treatment of mental and emotional disorders, alcoholism and substance abuse, disorders of habit or conduct, and the psychological aspects of physical illness, accident, injury, or disability; psychoeducational evaluation, therapy, remediation, and consultation; and supervision of qualified individuals performing services specified in this section. (3) Psychological services may be rendered to individuals, families, groups, organizations, institutions, and the public. The practice of psychology shall be construed within the meaning of this definition without regard to whether payment is received for services rendered. 38-3107. Mental and emotional disorder, defined. Mental and emotional disorder means a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and is associated with present distress or disability or with significantly increased risk of suffering death, pain, disability, or an important loss of freedom. Such disorders may take many forms and have varying causes but must be considered a manifestation of behavioral, psychological, or biological dysfunction in the person. Reasonable descriptions of the kinds and degrees of mental and emotional disorders may be found in the revisions of accepted nosologies such as the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders. 38-3109. Psychologist, defined. Psychologist means a person licensed to engage in the practice of psychology in this or another jurisdiction. The terms certified, registered, chartered, or any other term chosen by a jurisdiction to authorize the autonomous practice of psychology shall be considered equivalent terms. 4. If the profession is not currently credentialed in Nebraska, describe the proposed credential and the proposed scope of practice, and/or the proposed functions and procedures of the group to be reviewed. This description of the desired scope of practice and the proposed credential constitute the core of the proposal. Also, please describe how the proposal would be administered. The application comprises the documentation and other materials that are provided in support of the proposal. Our proposal is for the creation of a prescribing permit for licensed psychologists, with specialized postdoctoral training in clinical psychopharmacology, that would enable them to prescribe medications when treating mental disorders. Licensed psychologists with postdoctoral clinical psychopharmacology training are permitted to prescribe psychotropic medications in two states and in specific agencies within the federal system, but not in Nebraska. In 2014 a third state (Illinois) passed legislation to permit licensed psychologists with specialized training to prescribe medications for mental disorders. The proposal to create a prescribing psychologist permit for qualified licensed psychologists is provided in Appendix A of this application and summarized below. The prescribing permit would enable the licensed psychologist to prescribe psychotropic medications and order laboratory studies as necessary when treating mental disorders. The prescribing psychologist would work in collaboration with the patient’s primary health care practitioner who oversees the patient’s general medical care. This is to promote better integrated patient care in treating medical and mental health issues. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –9– This mandatory collaboration would ensure that necessary medical examinations are conducted, the psychotropic medication is not contra-indicated for the patient’s medical condition, and significant changes in the patient’s medical or psychological condition are addressed. This mandated collaboration would ensure an unusually high level of safety in patient care. The proposal also defines limits of practice for the prescribing psychologists pertaining to the formulary of medications falling under the permit, and treatment of patients with certain co-morbid conditions. The new credential would be administered by the Board of Psychologists. The Board of Psychology regulates multiple credentials beyond the license to practice psychology. The prescribing psychologist permit would add to the list of credentials for the board to regulate. The proposal calls for consultation with the boards of medicine and surgery, nursing, and pharmacy, in developing rules and regulations. The licensed psychologist applying for a provisional prescribing permit would have completed postdoctoral training in clinical psychopharmacology, passed a national examination, and completed a supervised practicum with a minimum of 100 patients, under the supervision of a professional licensed to independently prescribe psychotropic medication. The licensed psychologist with the provisional prescribing psychologist permit would then need to successfully complete a minimum of one year practice under the supervision of a professional licensed to independently prescribe psychotropic medication. The Board of Psychology would establish, by regulation, continuing competency requirements for the prescribing psychologist to renew a prescription permit. At two year intervals the prescribing psychologist would be required to present evidence to the Board demonstrating continuing competency in the provision of psychological treatments combined with psychotropic medications. 5. Describe in detail the functions typically performed by practitioners of this occupation, and identify what if any specific statutory limitations have been placed on these functions. If possible, explain why the legislature created these restrictions. Licensed Psychologist: The profession of psychology is licensed to function independently in all states and jurisdictions. Comprehensive diagnostic examinations are performed by psychologists to evaluate the presenting problems with attention to developmental, emotional, cognitive, educational, family, biological, and social components. Psychologists arrive at a diagnostic formulation which considers all of the above components. An integrated treatment plan may involve individual, group, or family therapy, behavioral modification, referrals to specialists, and consultation with physicians, schools, courts, social agencies, and community organizations. Licensed psychologists must refer a patient to a physician or nurse practitioner or physician assistant if the treatment plan would indicate the need for psychotropic medication, thereby increasing the cost of care and burden of treatment on the patient. Psychologists frequently work with patients presenting with major mental illness. A combination of psychotherapy and psychotropic medication is often required when facilitating recovery for individuals with major mental illness. Currently in Nebraska there is not a mechanism for licensed psychologists to become credentialed to provide a combination of psychosocial interventions and psychotropic medication. The consumer is therefore required to seek out a prescriber from another profession to obtain psychotropic medication(s). As indicated in the application the psychologist’s patient may wait several weeks or months for an appointment with a psychiatrist and this negatively impacts the plan of care and recovery of the patient. Prescribing Psychologist: In other states and federal system the prescribing psychologist can provide the psychotropic medications needed for the patient’s recovery. In these jurisdictions the prescribing psychologist has a formulary consisting of psychotropic medications and the psychologist collaborates with the patient’s primary health care practitioner who oversees the patient’s general medical care. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –10– 6. Identify other occupations that perform some of the same functions or similar functions. Mental health practitioners provide psychotherapy services. Licensed alcohol and drug counselors provide services that are a subset of interventions delivered by licensed psychologists. Psychosocial services are within the scope of practice of physicians and psychiatric nurses. Prescribing Psychologist: Physician and non-physician prescribers provide psychotropic medications for their patients. Although these disciplines occasionally use limited psychotherapy techniques with medications, a full course of psychotherapy is rare. However, the prescribing psychologist may integrate medication, when needed, into the psychotherapy process and utilizes medications only when psychotherapy alone is not sufficient to address symptoms and improve functioning. The formulary for the prescribing psychologist is limited to psychotropic medication, unlike that of physicians, nurse practitioners, and physician assistants. The Army, in policies and procedures, identifies the classes of medications typically prescribed by psychologists with specialized training. The classes of medications include antipsychotics, anxiolytics (benzodiazepines), anticonvulsants used for behavioral health disorders, and Attention Deficit/Hyperactivity/narcolepsy agents. The following link provides a listing of psychotropic medications recognized as within the formulary for prescribing psychologists serving in the Army. This is the foundational formulary; individual psychologists can request additions to the formulary. http://www.nebpsych.org/Resources/Documents/Dept%20of%20Army%20credentialing%20RxP%20Psychologists.pdf Data from retail pharmacies indicate the vast majority of psychotropic medications are provided by general practitioners, obstetrician-gynecologists, and pediatricians. Of the 472 million psychotropic prescriptions processed in retail pharmacies in a twelve month period, only 23% were prescribed by psychiatrists (See Appendix B). Therefore, the vast majority of psychotropic medications are not prescribed by a practitioner with specialized training in behavioral health services. 7. What functions are unique to this occupation? What distinguishes this occupation from those identified in question 6? Licensed Psychologist: Professional psychology is distinguished by its broad approach to human problems, consisting of psychological assessment, diagnosis, consultation, treatment, administration, program development, and research pertaining to numerous populations that include children, adolescents, adults, elderly, families, and groups. Functions unique to professional psychology include assessment of intellectual and cognitive abilities, achievement and aptitude, neuropsychological functioning, forensic, and personality functioning. Prescribing Psychologist: The prescribing psychologist is unique among behavioral health professionals in the provision of combined therapies (psychotherapy and pharmacotherapy) to address mental disorders. This unique function for prescribing psychologists is recognized by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association through the CPT (Current Procedural Terminology) codes which are numbers assigned to every task and service a practitioner may provide a patient. Prescribing psychologists use an add-on CPT code (90863) for medication management when providing psychotherapy (the principal service) plus medication management for a patient. 8. Identify other occupations whose members regularly supervise members of this occupation, as well as other occupations whose members are regularly supervised by this occupation. Describe the nature of the supervision that occurs in each of these practice situations. Licensed Psychologist: As indicated earlier, the licensed psychologist functions autonomously. Provisionally licensed psychologists are supervised by licensed psychologists. Licensed psychologists by Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –11– statute and regulations may supervise provisionally licensed mental health practitioners, special license psychologists, psychologist associates, psychological assistants, and those seeking licensure as an alcohol and drug counselor. Prescribing Psychologist: As indicated earlier, the prescribing psychologist must be supervised during attainment of practicum hours as well as for the first year, or longer, after obtaining a provisional prescribing psychologist permit. In the military where appropriately trained psychologists prescribe, those with an unrestricted prescribing permit supervise other mental health prescribers including psychologists with a provisional prescribing permit, psychiatric nurse practitioners in training, and, in some instances, new or early career psychiatrists. The most frequent supervision would likely involve psychologists seeking a prescribing permit, along with maintaining the normal supervisory roles associated with being a licensed psychologist. Psychologists seeking this type of permit typically receive their supervision in two distinct categories: practicum hours and provisional permit experience. During the practicum hours the candidate would not have the capability to write prescriptions. During this period the candidate would still conduct all of the services for which they are credentialed involving assessment and treatment. However, if psychotropic medication is to be part of the treatment, the preceptor or supervisor (licensed psychologist with an unrestricted prescribing permit or physician) must review the case and discuss treatment formulation as it relates to pharmacological intervention. The preceptor or supervisor would then actually issue the prescription. This may also involve the preceptor or supervisor conducting an “eyes on” evaluation at his/her discretion. The same guidelines would be utilized in the ordering and evaluation of laboratory studies or other diagnostic assessments for which the candidate is not already independently licensed. The licensed psychologist with a provisional permit would also continue to provide all services that she/ he is independently licensed for without additional supervision. When psychotropic medication is to be included as part of the treatment, the case must be discussed with the preceptor or supervisor who also must co-sign the notes, however, at the discretion of the preceptor/supervisor the licensed psychologist with a provisional prescribing permit may write and sign prescriptions without a co-signature. The same guidelines would be utilized in the ordering and evaluation of laboratory studies or other diagnostic assessments for which the candidate is not already independently licensed. A licensed psychologist with a prescribing permit who is serving in a supervisory capacity will ensure that those under his/her supervision are following appropriate treatment protocols and safety guidelines. These guidelines in no way would serve to allow a psychologist to limit or restrict any professional from engaging in practices for which they are independently licensed. 9. What actions, judgments, and procedures of this occupation can typically be carried out without supervision or orders? To what extent is this occupation, or portions of this practice, autonomous? Licensed Psychologist: The autonomy of the profession has been addressed. Prescribing Psychologist: A prescribing psychologist can autonomously perform all of the functions of a licensed psychologist. In addition, a prescribing psychologist can prescribe psychotropic medications and order associated laboratory studies to assist in treatment and differential diagnosis. This includes pharmaceutical selection as well as determining which laboratory studies are indicated for both differential diagnostics and also to monitor drug levels and biological systems that may be impacted by pharmaceuticals. While these functions are carried out autonomously they are performed in collaboration with the primary health care practitioner for each patient. This collaboration includes informing the primary health care practitioner of any medications or medication changes involved in the mental health treatment of the patient, as Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –12– well as discussing any abnormal lab results. Consultation will involve developing a comprehensive treatment plan to address medical and behavioral health concerns. An example of such collaboration includes a finding of thyroid dysfunction that is related to psychiatric symptoms, but the treatment of which would not fall under the purview of a prescribing psychologist. In this instance the prescribing psychologist would discuss the finding with the primary health care practitioner and refer the patient to see her/his medical provider for appropriate treatment. This collaborative arrangement would also be utilized to manage potential medication interactions. As an example, many individuals with migraine headaches may also have a co-occurring mental health concern. Several of the medications used for the treatment of migraine headaches contra-indicate the use of the most common psychotropic medications. In this type of example, the prescribing psychologist, in conjunction with the primary health care practitioner and the patient, would determine the symptoms of highest priority to target for treatment, and appropriate treatment regimens designed to help ensure the safety of the patient. Another example of the collaborative arrangement would involve the use of a medication that may impact biological systems. Certain medications that are metabolized by the liver may lead to elevations in liver enzymes. The prescribing psychologist would have the autonomy to order liver enzyme laboratory studies; however, if the results are outside of the normal values the prescribing psychologist would consult with the primary health care practitioner and the patient to determine the most appropriate course of action. 10. Approximately how many people are performing the functions of this occupation in Nebraska, or are presenting themselves as members of this occupation? To what extent are these people credentialed in Nebraska? Licensed Psychologist: As of July 30, 2014 there are 518 psychologists licensed through the Nebraska Department of Health and Human Services, and 451 indicate a Nebraska residence. Appendix C provides a map depicting the distribution of licensed psychologists through the state. Prescribing Psychologist: There are prescribing psychologists in New Mexico and Louisiana. Approximately 13% of licensed psychologists in Louisiana have a credential to prescribe psychotropic medications. Approximately 7% of licensed psychologists in New Mexico have a credential to prescribe psychotropic medications. The number of prescribing psychologists in these states is increasing, for example, it is estimated that up to 20-25% of psychologists in Louisiana will eventually obtain prescriptive authority. If Nebraska adopts the standards promulgated by the American Psychological Association for training needed to prescribe psychotropic medications it is likely that there would be approximately 58 prescribing psychologists serving citizens across the state in the foreseeable future. Appendix H depicts the increase of behavioral health prescribers in Nebraska (24%) if the current proposal is adopted. 11. Describe the general level of education and training possessed by practitioners of this occupation, including any supervised internship or fieldwork required for credentialing. Typically, how is this education and training acquired? Licensed Psychologist: The extensive training of licensed psychologists in mental and behavioral health is depicted in Appendix D. The licensed psychologist has completed 4 years of undergraduate education, 6-7 years of graduate school, a one year internship, and one year of postdoctoral supervised practice, and has passed a national competency examination. Prescribing Psychologist: A licensed psychologist may apply for specialized training to prescribe psycho- Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –13– tropic medications. If accepted, the licensed psychologist completes postdoctoral training that is consistent with or exceeds the American Psychological Association standards for prescriptive authority. In the states and federal systems in which appropriately trained psychologists now prescribe, licensed psychologists have earned a postdoctoral masters degree in clinical psychopharmacology. The APA standards can be accessed using the following link: https://www.apa.org/about/policy/rxp-model-curriculum.pdf There are currently three postdoctoral degree training programs that have achieved designation status from the American Psychological Association and trained psychologists across the county. There is a fourth program in a school of pharmacy that is being reviewed for APA designation status. The APA standards for the didactic content areas and supervised clinical experience are outlined below. Didactic Content Areas I. Basic Science a. Anatomy & Physiology b.Biochemistry II.Neurosciences a.Neuroanatomy b.Neurophysiology c.Neurochemistry III. Physical Assessment and Laboratory Exams a. Physical Assessment b. Laboratory and Radiological Assessment c. Medical Terminology and Documentation IV. Clinical Medicine and Pathophysiology a. Pathophysiology with particular emphasis on cardiac, renal, hepatic neurologic, gastrointestinal, hematologic, dermatologic, and endocrine systems b. Clinical Medicine, with particular emphasis on signs, symptoms and treatment of disease states with behavioral, cognitive and emotional manifestations or comorbidities c. Differential Diagnosis d. Clinical correlations – the illustration of the content of this domain through case study e. Substance-Related and Co-Occuring Disorders f. Chronic Pain Management V. Clinical and Research Pharmacology and Psychopharmacology a.Pharmacology b. Clinical Pharmacology c.Pharmacogenetics d.Psychopharmacology e. Developmental Psychopharmacology f. Issues of diversity in pharmacological practice VI. Clinical Pharmacotherapeutics a. Combined therapies – Psychotherapy/pharmacotherapy interactions b. Computer-based aids to practice c.Pharamacoepidemiology VII.Research a. Methodology and Design of psychopharmacological research b. Interpretation and Evaluation of research c. FDA drug development and other regulatory processs VIII. Professional, Ethical, and Legal Issues a. Application of existing law, standards and guidelines to pharmacological practice b. Relationships with pharmaceutical industry Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –14– i. Conflict of interest ii. Evaluation of pharmaceutical marketing practices iii. Critical consumer Supervised Clinical Experience I. Physical Exam and Mental Status II. Review of Systems III. Medical History Interview and Documentation IV. Assessment: Indications and Interpretation V. Differential Diagnosis VI. Integrated Treatment Planning VII. Consultation and Collaboration VIII. Treatment Management Standards for prescriptive authority involving psychologists in the military (Air Force, Army, Navy) are consistent with American Psychological Association standards. In these jurisdictions the licensed psychologist must complete a postdoctoral master’s degree in clinical psychopharmacology, pass the Psychopharmacology Examination for Psychologists, and receive a minimum of one year of documented supervision. Supervision is provided by a psychiatrist or a psychologist with prescriptive authority. Appendix E provides the specific credentialing standards in the Air Force for prescribing psychologists (see section 7.8.3.17). The following link accesses standards for all three branches of the military: http://rxpsychology.fdu.edu/Resources/Military_Support_Manual.pdf In New Mexico the licensed psychologist must complete a 450-hour didactic training program (New Mexico has its own postdoctoral training program), pass an examination on clinical psychopharmacology, complete an 80-hour practicum in clinical assessment and pathophysiology, and complete a 400-hour/100 patient practicum under the supervision of a physician. The licensed psychologist is then eligible for a conditional prescribing permit. Following two more years of supervised experience the psychologist can apply to prescribe independently. In Louisiana the licensed psychologist completes a postdoctoral master’s degree in clinical psychopharmacology, passes an examination in clinical psychopharmacology, and then is immediately eligible for licensure as a medical psychologist (alternative to the term prescribing psychologist). The Louisiana law allows the medical psychologist to prescribe psychotropic medications with the concurrence of the patient’s physician. To obtain independent prescriptive authority, the medical psychologist is required to complete three years of experience practicing as a medical psychologist, have treated a minimum of one hundred patients involving major psychotropic medication, have recommendations from two collaborating physicians, and complete a minimum of one hundred hours of continuing medical education related to the use of medications in the management of patients with psychiatric illness. A requirement for prescribing psychologists includes maintaining and filing with their regulatory boards all individual federal drug enforcement registrations and numbers. Illinois has just passed legislation and has no actual experience with prescribing psychologists. Regulations are to be developed for credentialing certain psychologists to prescribe psychotropic medications. Appendix F provides a table comparing the entry-level training models for psychiatric nurse practitioners, physicians, and prescribing psychologists. This table contrasts training for the three professionals in content areas that include biochemistry-neuroscience, pharmacology, clinical practicum, behavioral assessment/diagnosis & psychometrics, and psychosocial interventions. Data on graduate contact hours were obtained from institutions that include the Mayo College of Medicine, Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –15– Yale University, Stanford University, and Vanderbilt University. The full article comparing the graduate training of the three professions can be found using the following link: http://rxpsychology.fdu.edu/Resources/MuseMcGrath2010.pdf 12. Identify the work settings typical of this occupation (e.g., hospitals, private physicians’ offices, clinics, etc…) and identify the predominant practice situations of practitioners, including typical employers for practitioners not self-employed (e.g., private physician, dentist, optometrist, etc.). Licensed Psychologist: National and local surveys of licensed psychologists indicate psychologists work in a wide range of settings. A Nebraska Psychological Association survey of licensed psychologists in 2008 and 2009 obtained 200 responses. The majority of respondents (57%) worked in outpatient practice (private or group), followed by psychologists employed in hospital settings (35%, public or private). Other employment settings included, but were not limited to, academia, college/university counseling centers, community mental health centers, residential/group homes, school systems (K-12), and assisted living/nursing homes. Prescribing Psychologist: The licensed psychologists who earned the credential to prescribe added this clinical intervention to their existing practices. However, there are emerging models of practice, utilizing prescribing psychologists, which reflect the evolution of the healthcare system to provide integrated care. An example of an emerging model of care was described in the Journal of Clinical Psychology in Medical Settings (volume 19, issue 4, pp 420-429). Link to the article: http://www.nebpsych.org/Resources/Documents/Shearer%20et%20al.%202012.RxP.pdf This model involves a licensed psychologist with an independent prescribing permit who is fully integrated in a family practice clinic. The primary care providers and prescribing psychologist work side-by-side in the same shared space and use the same medical record for treatment documentation. The prescribing psychologist utilizes a flexible approach involving psychotherapy, psychotropic management, or both. All referrals to the prescribing psychologist originate from the primary care provider within the family medicine clinic. Patients with a mental health crisis are seen on the same day by the prescribing psychologist. The primary care providers receive feedback that includes “the therapeutic plan, anticipated length of treatment, next scheduled appointment, and are notified if any psychotropic medications are modified or started. The record also includes information about the indications for a particular medication (if prescribed), the risks, benefits, side effects, typical length of time to onset of therapeutic response, and potential alternative course of treatment.” Following two years of experience with this model the primary care providers rated their views on the safety, impact, and utility of prescribing psychology services in the clinic. Appendix G summarizes the responses of the forty-seven medical providers who completed the anonymous, voluntary survey. Results of the survey indicated 95.6% of the medical providers found consultation with the prescribing psychologist to be helpful. The respondents also asserted the prescribing psychologist made appropriate referral decisions (93.6%), prescribed appropriate medications and dosages (95.7%), and had adequate knowledge of medical terminology (97.9%). 13. Do practitioners routinely serve members of the general population? Are services frequently restricted to certain segments of the population (e.g., senior citizens, pregnant women, etc.)? Licensed Psychologist: There are no restrictions on licensed psychologists regarding what members of the public are treated. Prescribing Psychologist: Licensed psychologists with prescriptive authority in Louisiana do not have restrictions on the populations they serve. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –16– Prescribing psychologists practicing in the military are permitted to utilize medications with patients between the ages of 18 and 65. Prescribing psychologists in New Mexico are not permitted to prescribe psychotropic medications for patients with the following conditions unless agreed to by the patient’s health care practitioner: serious co-morbid disease of the central nervous system; cardiac arrhythmia; those pharmacologically treated for coronary vascular disease; blood dyscrasia; acute medical condition requiring hospitalization; or, pregnancy or breast feeding. There are no rules and regulations yet developed to implement the bill passed by the Illinois legislature and signed by the governor in 2014. However, the statute indicates the prescribing psychologists will not be allowed to prescribe to patients less than 17 years of age or over 65 years of age; patients during pregnancy; patients with serious medical conditions such as heart disease, cancer, stroke, seizures; or, patients with developmental and/or intellectual disabilities. 14. Identify the typical reasons a person would have for using the services of a practitioner? Are there specific illnesses, conditions or situations that would be likely to require the services of a practitioner? If so, please specify. Licensed Psychologist: There are many reasons the public seeks the services of a psychologist besides the treatment of major mental illness. The scope of practice of licensed psychologist is defined as disorders listed in the Diagnostic and Statistical Manual and International Classification of Diseases of the World Health Organization. Licensed psychologists commonly treat conditions that include, but are not limited to: depression, anxiety disorders, obsessive –compulsive and related disorders, schizophrenia spectrum disorders, trauma and stress related disorders, dissociative disorders, sleep disorders, disruptive and impulse-control disorders, substance use disorders, eating disorders, somatic disorders, personality disorders, paraphilic disorders and sexual dysfunctions, and neurodevelopmental disorders. The wide range of psychological services provided by licensed psychologists is discussed in the response to item #3 of the application. Psychological services can be provided to individuals, family systems, groups, organizations, and institutions. Licensed psychologists treat the psychological aspects of physical illness. For example, psychologists provide services for pain management, smoking cessation, sleep disorders, stress management, weight management, and other health conditions. Prescribing Psychologist: A prescribing psychologist is first a licensed psychologist, and the reasons for seeking the services of this type of professional are listed above. Reasons for using services outside of those listed above would include a desire for pharmacological intervention in conjunction with other therapies traditionally provided by a licensed psychologist. Often patients prefer to have their medication closely integrated with their therapy, and there is evidence that this leads to improved outcomes. By seeing only one provider for both needs, the patient is ensured that medication management is conducted in a manner that takes into account the progression of therapy. Many patients also discuss becoming frustrated by having to recount all of their symptoms to multiple providers. In conjunction with this concern, it can be difficult for patients with mental health concerns to accurately recall what information they have already disclosed to each provider. This creates a potential safety risk if a patient believes he/she has told a provider about a symptom or medication side effect, when in fact it was another member of the care team. For prescribing psychologists the requirement to collaborate with primary health care providers reduces this risk. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –17– 15. Identify typical referral patterns to and from members of this occupational group. What are the most common reasons for referral? Licensed Psychologist: There is a wide range of referral sources for licensed psychologists that include, but is not limited to: hospitals, medical providers, behavioral health professionals, courts, schools, other educational settings, social service agencies, churches and clergy, and state and federal agencies. These would all refer patients to a psychologist and psychologists, in return, would refer patients to them. The licensed psychologist refers a patient needing psychotropic medication to a psychiatrist or other qualified prescriber. The licensed psychologist refers to other medical specialties if, for example, there are signs and symptoms of previously undetected general medical conditions. Prescribing Psychologist: There are two primary sources of referral for prescribing psychologists. First are self-referrals from patients who desire services and may have a predilection for both talk therapy and pharmaceutical intervention. Self-referrals are the primary source of referral, followed closely by referrals from primary health care practitioners. These referrals are generally made when a primary health care practitioner identifies a patient with psychiatric concerns who may benefit from both talk therapy and pharmacological treatment. Often primary health care practitioners will make referrals to a prescribing psychologist if they are uncomfortable with managing psychotropic medication, or do not feel that they can closely monitor a patient’s medications. Prescribing psychologists would make referrals to other professions if an underlying medical condition were suspected or detected (i.e. thyroid dysfunction, potential brain mass etc.), or if treatment with pharmaceuticals impacted other biological systems that then required treatment by a primary medical provider. In addition, as with any psychologist, treatment of conditions outside of their scope of competency would be referred to specialty care. Finally, in situations of acute risk for self-harm or harm to others, referrals for inpatient treatment would be made when outpatient treatment would no longer the least restrictive option. 16. Is a prescription or order from a practitioner of another health occupation necessary in order for services to be provided? Licensed Psychologist: A prescription or order is not generally required to access the services of a licensed psychologist. Hospitals may require the attending physician to order the patient be evaluated or treated by a licensed psychologist. Prescribing Psychologist: A prescription or order is not generally required for the services of a prescribing psychologist. As above there may exist institutional requirements for a patient to be evaluated in order to determine the need for services. 17. How is continuing competency of credentialed practitioners evaluated? Licensed Psychologist: In Nebraska the requirement is 24 hours of professional activities directed at maintaining competency during a 24-month period, for license renewal. There is a wide range of professional activities that is recognized per rules and regulations. Continuing competency activities may involve attending workshops, seminars, symposia, and/or colloquia approved by organizations such as the American Psychological Association, American Medical Association or Nebraska Medical Association, American Nurses credentialing Center’s Commission on Accreditation, National Association of Alcohol and Drug Abuse Counselors, and national associations for other behavioral health providers. Other professional activities listed in rules and regulations include completing a graduate level course, teaching an academic course the Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –18– first time, and authoring or editing a peer-reviewed psychological practice oriented publication. Prescribing Psychologist: In New Mexico the prescribing psychologist is required to complete 40 hours of continuing professional education in the area of psychopharmacology and psychopharmacotherapy, within a 24 month period. Licensed psychologists that prescribe in Louisiana have a similar set of requirements for maintaining the credential to prescribe psychotropic medications. 18. What requirements must the practitioner meet before his or her credentials may be renewed? Licensed Psychologist: As indicated above, the licensed psychologist must complete, at minimum, 24 hours of professional activities directed at maintaining continuing competency. Prescribing Psychologist: In addition to the continuing competency requirements specific to prescribing psychotropic medications, the prescribing psychologists in New Mexico and Louisiana must maintain malpractice insurance for their prescribing activities (in addition to their existing psychological practice). The proposal for Nebraska would require a minimum of 40 hours of continuing competency hours in the provision of psychological treatments combined with psychotropic medications, and medical education relevant to safe prescribing practices. 19. Identify other jurisdictions (states, territories, possessions, or the District of Columbia) wherein this occupation is currently regulated by the government, and the scopes of practice typical for this occupation in these jurisdictions. Licensed Psychologist: All 50 states provide for licensing the practice of psychology. The practice of psychology is also regulated in the federal system. Prescribing Psychologist: States, territories and agencies include the Department of Defense (1991), New Mexico (2002), Louisiana (2004), Illinois (passed in 2014), Guam (1999) and US Public Health Service. In 1993 Indiana began permitting trained psychologists to prescribe in relevant federal programs. The Indian Health Service was the first to authorize a psychologist to prescribe medications in 1988 to address a shortage in the availability of appropriate mental health care in the Santa Fe, New Mexico, region. Prescriptive authority has expanded in the Indian Health Service to include Montana and South Dakota. For example, there are multiple prescribing psychologists meeting the mental health needs of Native American’s in Montana. Please note the following link to a brief description of how prescribing psychologists are improving access to care at an Indian Health Service facility. http://www.apa.org/monitor/2014/09/reservation.aspx Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –19– Additional Questions an Applicant Group Must Answer about their Proposal 1. What is the problem created by not regulating the health professional group under review, or by not changing the scope of practice of the professional group under review? The problem this proposal addresses is the critical shortage in the supply of prescribers of mental health medications (Behavioral Health Education Center of Nebraska FY 2012-2013 Legislative Report, link to report is below). Per this legislative report over three-fifths (63%) of prescribers of mental health medications in the state are over the age of 50. In 2013 there were 156 psychiatrists working full or part-time in Nebraska. As indicated earlier, there are 518 licensed psychologists licensed in Nebraska, 451 of whom reside in Nebraska. With a reasonable set of rules and regulations, it is estimated that at least 58 of those licensed psychologists could provide mental health medications in the foreseeable future (see Appendix H). http://www.unmc.edu/bhecn/workforce/BHECN_Legislative_Report_2013.pdf Moreover, there are 33 provisionally licensed psychologists completing requirements to practice independently in Nebraska. This represents a continuous supply of early career psychologists who may be added to the number of prescribing psychologists. The proposal also allows for DHHS to credential prescribing psychologists relocating to Nebraska who would meet standards for the credential. This would apply to one member of the applicant group, Dr. Mikel Merritt, who is credentialed in the Air Force to prescribe psychotropic medications (see Appendix I). Of the 93 counties in Nebraska, 85 are state designated shortage areas for psychiatry and mental health (Nebraska Rural Health Commission, 2014). Parts of the other eight counties also are designated as shortage areas. Appendix C represents the distribution of licensed psychologists in Nebraska. It has been argued that psychologists with prescriptive authority would be no more likely to locate in underserved and rural areas than psychiatrists. However, the imbalance in the number of licensed psychologists relative to psychiatrists is sufficient to significantly increase the number of prescribers for mental disorders. For example, two licensed psychologists on the NPA committee which produced this application live and work in Scottsbluff. There are reportedly two full time psychiatrists currently working in Scottsbluff. When both of these licensed psychologists meet credentialing standards for a prescribing psychologist permit, it would double the number of doctoral-level prescribers for mental disorders in that area. A 2013 survey in New Mexico examined the impact of prescribing psychologist on mental health disparities. The conclusions from the survey were as follows: “New Mexico psychologists with prescriptive authority, though still small in number of practitioners, are collectively making a significant impact on reducing mental health disparities among rural and low-income patients. More than 90% of prescribing psychologists surveyed accept Medicaid payments and 62.9 percent of patients served are living in rural areas with limited access to other behavioral health prescribers. This survey demonstrates that the grass roots efforts for psychologists’ prescriptive authority highlighting the mental health disparity in rural and low income communities has been successful in getting trained prescribers to help serve those most in need.” Christina E. Vento, PsyD, ABMP, author of the survey http://www.amphome.org/pdf/ArchivesSpring2014.pdf This proposal addresses the economic and social costs of seeing multiple providers. The consumer accessing a prescribing psychologist would experience savings by obtaining psychotherapy and mental health medication from a single provider. Savings would include reduced co-pays, reduced travel time, and less time away from work. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –20– 2. If the proposal is for the regulation of a health professional group not previously regulated, all feasible methods of regulation, including those methods listed below, and the impact of such methods on the public, must be considered. For each of the following evaluate the feasibility of applying it to the profession and the extent to which the regulatory method would protect the public. a. Inspection requirements: Inspection provides a strong measure of public protection; for example, inspection for proper sanitation, materials storage, and record-keeping procedures. These types of inspections clearly apply to professions such as cosmetology, body art, and funeral directing. However, the practice of prescribing psychologists would not appear to pose a significant danger in these areas. In Nebraska inspections are not used as a regulatory option for independent, doctoral-level practitioners such as physicians, optometrists, or psychologists. The added dimension of prescribing would not, in itself, justify adding an inspection requirement, nor would such a requirement enhance public protection. b. Injunctive relief: This remedy is generally sought in situations in which there is a high likelihood that an individual has broken or will break the law and is intended to prevent future harm. Under the Uniform Credentialing Act, which would govern prescribing psychologists, a stronger remedy is available in these types of situations: summary suspension. Therefore no added protection to the public would arise from this alternative method of regulation. c. Regulating the business enterprise rather than individual providers: Psychologists are, and prescribing psychologists would be, overwhelmingly located in two types of settings: private practice (usually group practice) and inpatient or outpatient centers. Such centers are already regulated. Psychologists and prescribing psychologists do not practice in other business settings. d. Regulating or modifying the regulation of those who supervise the providers under review: After receiving a full practice permit, the practice of prescribing psychologists would be fully independent, as is the practice of psychologists today. For prescribing psychologists still working toward a full practice permit, supervision would be provided by licensed physicians, prescribing psychologists with an independent permit, or other licensed practitioners who independently prescribe medications for mental disorders. e. Registering the providers under review: Registration is seldom used in Nebraska, and when it does occur it is confined to groups with lower standards of education and training, such as nurses’ aides. Registration would not be appropriate for a group whose educational standards require post-doctoral studies. f. Certifying the providers under review by the State of Nebraska: State certification is a voluntary form of title protection only, and does not restrict the practice of individuals. This level of regulation would be inappropriate for a profession authorized to prescribe medications. g. Licensing the providers under review: The permit requested in this application is essentially a license. It has a delimited scope of practice, has strong entry standards, and a provision for assessing continuing competency. Persons not holding the permit may not represent themselves either by the protected title or as performing the scope of practice of a permit holder. Thus the permit may be seen as being tantamount to a license. 3. What is the benefit to the public of regulating the health professional group under review or changing the scope of practice of the regulated health profession under review? The public has benefitted from credentialing non-physicians to prescribe medications. Similar benefits have been identified when credentialing psychologists to fully practice within their area of expertise. The specific benefits for the public from the provision of prescribing psychologist services include the following. Increased access to care. The literature is replete with data on the shortage of health care providers and inability to meet the demand for services. Implementation of the Patient Protection and Affordable Care Act (Public Law 111-148) further increases the gulf between supply and demand of health care services. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –21– Currently consumers of mental health services may have to wait three months to see a psychiatrist. As indicated earlier there is a shortage area in every Nebraska county for psychiatric and mental health services As indicated earlier, Nebraska has a shortage of psychiatrists to meet the increasing needs of consumers of mental health services. This shortage of psychiatrists was addressed by influential psychiatrist, Dr. Carlat. Dr. Carlat is an associate professor of psychiatry at Tufts University School of Medicine in Boston and editor in chief of the Carlat Psychiatry Report, a monthly newsletter on psychopharmacology. His article titled “45,000 More Psychiatrists, Anyone?” was published in Psychiatric Times (2010). In this article Dr. Carlat estimates the need for psychiatrists at approximately 26 per 100,000 population; and there is only 10 psychiatrists per 100,000 in the US. To make matters worse, Dr. Carlat anticipates many of the psychiatrists in practice will be retiring soon. Dr. Carlat reviewed possible solutions to the shortage and proposed granting medically- trained psychologists prescriptive authority. Dr. Carlat considered other possible solutions (increasing load on primary care physicians, increasing number of psychiatrists, training more APRNs and PAs) but voiced concerns about these options. Reduced Barriers to care: As mentioned in item 14 of the first section, many patients experience frustration in having to recount their psychiatric symptoms to multiple professionals in order to receive comprehensive care. The prescribing psychologist can reduce this barrier to comprehensive care by providing both talk-therapy and medication management. Additionally the cost of engaging multiple providers can be prohibitive for some patients. The prescribing psychologist can provide both talk-therapy and medication management in the same session for a lower cost than would be incurred by seeing both a talk-therapist and a separate prescriber. Aside from the purely financial cost there is also a reduced cost in terms of lost work hours. By seeing a provider who manages both talk-therapy and medication patients do not have to schedule additional appointments that could result in non-paid absence from work or simply the interruption of daily activities. Improved Safety: Also as mentioned in item 14, when a patient is seeing multiple providers, there is a risk the patient could believe he/she had disclosed important information to that provider when it was actually a different mental health provider with whom the concern was discussed. Currently if a patient discusses a medication side effect with his/her talk-therapist, he/she may be advised to discuss this with his/her prescribing provider. However, if the patient forgets or mis-remembers with whom he/she had the discussion, then the prescriber may be missing important information. This concern is alleviated by having only one provider who is managing both. In addition, the collaboration requirement between prescribing psychologists and primary health care practitioners adds a layer of safety that currently is not required of other prescribers. This serves to create a more comprehensive care approach which would have the effect of enhancing the safety of the public. 4. What is the extent to which the proposed regulation or the proposed change in scope of practice might harm the public? The public is at a certain risk of error or incompetence on the part of any regulated professional who prescribe medications. Extending prescribing privileges to psychologists who meet the terms of our proposal will engender no more, or any less, such risk as is provided by the competently trained practitioners who have prescribing privileges in Nebraska today. We are fortunate, however, in having multiple sources of data addressing the safety record of prescribing psychologists. In particular there is evidence from the Department of Defense and the two states that have credentialed prescribing psychologists for at least a decade. In 1989 the US Congress funded a program to train psychologists in the Department of Defense to prescribe medications. The program proved to be controversial and encountered many roadblocks in implementation. Nevertheless, ten psychologists completed the academic coursework and practicum and were credentialed Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –22– to prescribe medications to treat mental disorders. The final evaluation report on the program by the General Accounting Office (GAO), which was completed in 1999 and focused on the performance of the graduates, arrived at many positive conclusions. A reading of the GAO report indicates physicians who supervised the prescribing psychologists – including psychiatrists – were uniformly positive in their evaluations of the participant’s performance. The following are excerpts from the attached GAO report. “The 10 PDP graduate seem to be well integrated at their assigned military treatment facilities. For example, the graduates generally serve in positions of authority, such as clinic or department chiefs. They also treat a variety of mental health patients; prescribe from comprehensive lists of drugs, or formularies; and carry patient caseloads comparable to those of psychiatrists and psychologists at the same hospitals and clinics. Also, although several graduate experienced early difficulties being accepted by physicians and others at their assigned locations, the clinical supervisors, providers, and officials we spoke with at the graduates’ current and prior locations – as well as a panel of mental health clinicians who evaluated each of the graduates – were complimentary about the quality of patient care provided by the graduates.” “Overwhelming, the officials with whom we spoke, including each of the graduates’ clinical supervisors, and an outside panel of psychiatrists and psychologists who evaluated each of the graduates rated the graduates’ quality of care as good to excellent. Further, we found no evidence of quality problems in the graduates’ credential files.” “The graduates’ clinical supervisors have the most extensive knowledge about the graduates’ clinical performance because they have been responsible for reviewing the graduates’ charts, discussing cases with the graduates, and observing the graduates’ interactions with patients. Without exception, these supervisors – all psychiatrists – stated that the graduates’ quality of care was good. One supervisor, for example, noted that each of the graduate’s patients had improved as a result of the graduate’s treatment; another supervisor referred to the quality of care provided by the graduate as “phenomenal.” The supervisors noted that the graduates are aware of their limitations and know when to ask for advice or consultation or when to refer a patient to a psychiatrist. Further, the supervisors noted that no adverse patient outcomes have been associated with the treatment provided by the graduates.” (underline added) Link to the 1999 GAO report, www.gao.gov/archive/1999/he99098.pdf The American College of Neuropsychopharmacology (ACNP), composed of psychiatrists and psychologists, was contracted to perform an analysis of the Department of Defense project to train psychologists to prescribe medications for mental disorders. Their evaluation judged the psychologists with specialized training to be safe prescribers and assumed positions as chiefs of mental health clinics. The report noted the absence of a single significant adverse event among patients treated by the prescribing psychologists. The ACNP report raised concerns about how far the results could be generalized as there were 10 psychologist prescribers and their practice was restricted to relatively low levels of pathology in individuals between the ages of 18 and 65. However, in New Mexico and Louisiana qualified psychologists have been licensed to prescribe for the past decade without these restrictions. There are approximately 40 prescribing psychologists licensed in New Mexico and 82 prescribing medical psychologists in Louisiana. Combined, the qualified psychologists with prescriptive authority have written hundreds of thousands of prescriptions without a single complaint indicating harm to the public. Physicians working with prescribing psychologists find them to be conservative in their use of medications, and the expertise of psychologists in psychosocial alternatives results in less medication use. 5. What standards exist or are proposed to ensure that a practitioner of the health professional group under review would maintain competency? Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –23– The prescribing psychologist would have dual responsibilities for maintaining competence. There is the existing standard that the renewal of the license to practice psychology requires 24 hours of continuing competency earned within 24 months. The proposal for renewal of the prescribing psychologist permit would require 40 hours of continuing competency training earned within 24 months. The continuing competency training would pertain to the provision of psychological treatments and psychotropic medications. The board would adopt regulations related to continuing competency in consultation with relevant professional organizations. Therefore, the prescribing psychologist would have to complete 24 hours for the psychology license and an additional 40 hours to maintain the prescribing permit, for a total of 64 hours of continuing competency training within 24 months. 6. What is the current and proposed role and availability of third-party reimbursement for the services provided by the health professional group under review? Prescribing psychologists can use an “add-on” CPT code when providing medication management and psychotherapy. Add-on codes identify an additional part of the treatment above and beyond the principle service. Current Procedural Terminology (CPT) codes are developed by the American Medical Association, which contracts with the Center for Medicare and Medicaid Services (CMS) to officiate the coding system. The add-on code 90863 is used for pharmacologic management, including prescription and review of medication, when performed with psychotherapy services. A psychologist providing a psychotherapy service with medication management would report the 90863 add-on code along with the applicable psychotherapy code. In addition, per the Medical Assistance Division, New Mexico Human Service Department, prescribing psychologists are authorized to utilize the following codes: evaluation and management service, comprehensive medication service, and brief office visit for the sole purpose of monitoring or changing drugs. 7. What is the experience of other jurisdictions in regulating the practitioners affected by the proposal? Identify appropriate statistics on complaints, describing actions taken, etc., by jurisdictions where the profession is regulated. Psychologists with specialized training have been prescribing medications for mental disorders for 20 years in federal agencies and for 10 years in two states (New Mexico and Louisiana). The General Accounting Office evaluated the safety record of psychologists who participated in the Department of Defense Psychopharmacology Demonstration Project. An excerpt from the GAO report, focused on the safety record of prescribing psychologists, was provided in the response to item #4. In addition, information was obtained from individuals involved with regulating prescriptive authority for psychologists in Louisiana and New Mexico. Cecilia Mouton, MD, Executive Director of the Louisiana State Board of Medical Examiners, indicated there has not been a practice related discipline for a medical psychologist (personal communication, October 27, 2014). A recent chair for the New Mexico Board of Psychology Examiners noted there has not been a complaint from a patient to their board regarding a prescribing psychologist. The immediate past chair for the American Psychological Association Insurance Trust, the largest professional liability insurance policy for psychologists in the United States, addressed the safety record of prescribing psychologists in written correspondence. This information is available using the following link: http://www.nebpsych.org/Resources/Documents/PrescriptAuthCorresp.pdf. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –24– 8. What are the expected costs of regulating the health professional group under review, including the impact of registration, certification, or licensure on the costs of services to the public? What are the expected costs to the state and the general public of implementing the proposed legislation? The proposal is not for a new license, or to change the current license for psychologists. The proposal is for a specialty certification that would permit some psychologists with specialized training to prescribe medications for mental disorders. This permit would augment the psychology license. The Board of Psychology and the Department currently manages a range of credentials and registrations beyond the license to practice psychology. The list of credentials and registrations include the following: psychological assistant, psychologist associate, supervisory registration form, temporary psychologist, 30 days temporary practice, special license supervisory registration, special psychologist. Fees for all these credentials are set using a statutory formula, which would be employed to set fees for prescribing psychologists as well. The safety record of prescribing psychologists presented in the application predicts there would be minimal increased costs to the DHHS Licensure and Regulation Division. Lastly, the expense of adding another professional member to the board of psychology is not necessary since the Board of Health, if it determines it necessary, can fill a board vacancy with a professional with expertise in prescriptive authority. The consumer needing both psychological services and medications for mental disorders would experience a cost savings. There would not be the added cost of seeing both a psychologist and a psychiatrist. The cost savings would involve fewer co-payments for office visits, decreased travel expenses, and less time away from gainful employment. 9. Is there additional information that would be useful to the technical committee members in their review of the proposal? Practice Guidelines. The American Psychological Association (APA) has developed standards for training programs and a national competency examination for prescriptive authority. In addition, the APA has published practice guidelines regarding psychologists’ involvement in pharmacological issues. The practice guidelines recommend general principles for optimal professional practice. A sample of the seventeen guidelines is provided below. Guideline 3. Psychologists involved in prescribing or collaborating are sensitive to the developmental, age and aging, educational, sex and gender, language, health status, and cultural/ethnicity factors that can moderate the interpersonal and biological aspects of pharmacotherapy relevant to the populations they serve. Guideline 14. Psychologists involved in prescribing or collaborating strive to be sensitive to the subtle influences of effective marketing on professional behavior and the potential for bias in information in their clinical decisions about the use of medications. The APA practice guidelines regarding psychologists’ involvement in pharmacological issues are located at the following website: http://www.apa.org/practice/guidelines/pharmacological-issues.pdf Nebraska licensed psychologists already are required to adhere to the American Psychological Association ethical principles and code of conduct. National Psychopharmacology Examination for Psychologists. The national competency examination for psychologists seeking prescriptive authority was developed for use by state and provincial psychology licensing boards. The examination was created under the guidance of Professional Examination Service (PES), which is a nationally recognized testing firm. The Psychopharmacology Examination for Psychologists (PEP) is updated frequently to reflect the changing knowledge required for safe and effective practice. Examination test items are Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –25– developed by an expert work group that includes prescribing psychologists, physicians, pharmacists, nurses, and academic researchers in pharmacology and psychopharmacology. Content areas for the PEP are listed below. • • • • • • • • • • Integrating clinical psychopharmacology with the practice of psychology Biopsychosocial and pharmacologic assessment and monitoring Professional, legal, ethical, and interprofessional issues Physiology and pathophysiology Clinical psychopharmacology Nervous system pathology Differential diagnosis Pharmacology Neuroscience Research A detailed breakdown of the content areas for the PEP is located at the following website: http://www.apapracticecentral.org/ce/courses/pep-info.aspx Designation Criteria for Training Programs. The American Psychological Association has established a process for designating postdoctoral education and training programs in psychopharmacology. The purpose of the process is to provide for public recognition of education and training programs that meet published standards for prescriptive authority for psychologists. The designation criteria require programs to meet many standards such as whether the program has sufficient resources to support the training mission, qualified administrators, sufficient and qualified faculty and clinical supervisors, quality assurance procedures, essential didactic curriculum, clinical competencies for supervised clinical experience, and capstone competency evaluation. A complete description of the designation process is located on the following website: http://www.apa.org/education/grad/psychopharmacology.aspx Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –26– Appendix A Proposal: Prescribing Psychologist Permit Board, defined. Board means the Board of Psychology. Provisional prescribing psychologist permit, defined. Provisional prescribing psychologist permit means a document issued by the board to a licensed psychologist who has completed specialized training in clinical psychopharmacology, passed a national proficiency examination in psychopharmacology approved by the board, and completed a supervised practicum. This would permit the holder to prescribe psychotropic medication under the supervision of a professional licensed to independently prescribe psychotropic medication, pursuant to the Psychology Practice Act. Prescribing psychologist permit, defined. Prescribing psychologist permit means a document issued by the board to a licensed psychologist who has successfully completed supervised experience under a provisional prescribing psychologists permit. The prescribing psychologist permit allows the holder to independently prescribe psychotropic medication. Psychotropic medication, defined. Psychotropic medication means a drug, except a narcotic, that may not be dispensed or administered without a prescription and which is recognized in or customarily used in the diagnosis, treatment, and management of a person with a mental, cognitive, nervous, emotional, substance abuse, or behavioral disorder, in accordance with rules and regulations adopted by the board, in consultation with the Board of Pharmacy. The holder of a prescribing psychologist permit may independently prescribe, administer, discontinue, and provide samples of, psychotropic medications. “Mental, cognitive, nervous, emotional, substance abuse, or behavioral disorders” means those disorders, illnesses, or diseases listed in either the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association or the mental, cognitive, nervous, emotional, substance abuse, or behavioral disorders listed in the International Classification of Diseases published by the World Health Organization. Prescribing psychologist, defined. Prescribing psychologist means a licensed psychologist who holds a valid prescribing psychologist permit or provisional prescribing psychologist permit. The licensed psychologist with a provisional prescribing psychologist permit will inform the public of the supervisory relationship required for this permit. Prescribing psychologist, laboratory studies. The prescribing psychologist may order and interpret laboratory studies and other medical diagnostic procedures, as necessary for the following: pretreatment health screening; diagnosis of mental, nervous, emotional, behavioral, substance abuse, and cognitive disorders; and treatment maintenance. This includes laboratory studies necessary for the monitoring of potential side-effects associated with psychotropic medications prescribed by the prescribing psychologist. The board shall establish regulations relating to the prescribing psychologist ordering and interpreting laboratory studies. The psychologist with a provisional permit shall interpret test results under supervision. Primary health care practitioner, defined. Primary health care practitioner means a physician, nurse practitioner, or physician assistant, licensed in Nebraska, who oversees a patient’s general medical care. Collaboration; prescribing psychologist. When prescribing psychotropic medication for a patient, the prescribing psychologist shall maintain an ongoing collaborative relationship with the primary health care practitioner who oversees the patient’s general medical care. The collaborative relationship will ensure that necessary medical Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –27– examinations are conducted, the psychotropic medication is not contraindicated for the patient’s medical condition, and significant changes in the patient’s medical or psychological condition are addressed. The prescribing psychologist shall provide the primary health care practitioner a summary of the treatment plan at the initiation of the mental health treatment and follow up reports as dictated by the patient’s condition. The prescribing psychologist cannot prescribe medication for a patient unless there is an identified primary health care practitioner of record. The board shall establish regulations relating to collaboration between a prescribing psychologist and primary health care practitioner, in consultation with the board of medicine and surgery and board of nursing. Limits of practice, co-morbid medical conditions. Unless specifically agreed to by the primary health care practitioner, a prescribing psychologist shall not prescribe psychotropic medications for patients with serious co-morbid disease of the central nervous system, cardiac arrhythmia, blood dyscrasia, women who are pregnant or breast feeding, and other conditions as defined in regulations. Applicant for provisional prescribing psychologist permit; qualifications. A licensed psychologist may apply to the board for a provisional prescribing psychologist permit. The application shall be made on a form approved by the board, and accompanied by evidence satisfactory to the board that the applicant: 1. 2. 3. 4. 5. 6. Possesses a doctoral degree in professional psychology and holds an unrestricted license to practice psychology in Nebraska. Has successfully completed a postdoctoral degree in clinical psychopharmacology from a regionally accredited institution or has completed equivalent training approved by the board. Equivalent training shall meet or exceed American Psychological Association standards for postdoctoral education and training in psychopharmacology for prescriptive authority. The curriculum shall include instruction in anatomy and physiology, biochemistry, neurosciences, physical assessment and laboratory exams, clinical medicine and pathophysiology, clinical and research pharmacology and psychopharmacology, clinical pharmacotherapeutics, and professional ethical and legal issues. Has passed a national examination, approved by the board, which tests the applicant’s knowledge associated with the safe and effective practice of prescribing psychotropic medications. The examination developed by a nationally recognized body, such as the American Psychological Association Practice Organization’s College of Professional Psychology, shall be passed within two years immediately preceding the date of application for the provisional prescribing psychologist permit. Has completed a supervised practicum of at least four hundred hours treating no fewer than one hundred patients with mental disorders. This practicum shall be supervised by a professional licensed to independently prescribe psychotropic medication. The practicum experience may be integrated with the didactic training in clinical psychopharmacology. The board shall establish, by regulation, requirements for the clinical practicum to include the number of hours involving face-to-face supervision. Has malpractice insurance in place, sufficient to meet regulations adopted by the board. Has submitted registration of a supervisory relationship with a professional licensed to independently prescribe psychotropic medication, approved by the board, in order to practice with a provisional prescribing psychologist permit. The supervisory registration form shall address limitations, if any, on patient populations treated with psychotropic medications, based on the training and experience of the psychologist and supervisor. Applicant for a prescribing psychologist permit; qualifications: A licensed psychologist may apply to the board for a prescribing psychologist permit. The application shall be made on a form approved by the board and be accompanied by evidence satisfactory to the board that the applicant: 1. 2. 3. Holds a current unrestricted license to practice psychology in Nebraska. Has malpractice insurance in place, sufficient to meet regulations adopted by the board. Has been issued a provisional prescribing psychologist permit and has successfully completed at min- Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –28– imum one year of prescribing psychotropic medications to a diverse patient population, as certified by a supervisor licensed to independently prescribe psychotropic medication. The board shall establish, by regulation, requirements for the minimum one year of supervised experience that will include number of patients treated with psychotropic medications, and the number of hours involving face-toface supervision. This supervised experience shall include competency in review of systems, medical history, physical examination, interpretation of appropriate medical tests, differential diagnosis, integrated treatment planning, collaboration with health care practitioners, and treatment management. Provisional prescribing psychologist permit, expiration. The provisional prescribing psychology permit expires upon receipt of the prescribing psychologist permit or two years after the date of issuance, whichever occurs first. The supervisory period and the provisional prescribing psychologist permit may be extended with approval of the board. A supervisory plan shall be submitted to the board for the extended period of practice under supervision. Renewal, prescribing psychologist permit. The board shall establish, by regulation, a method for the renewal every two years of a prescribing psychologist permit at the time of, or in conjunction with, the renewal of the psychology license. Renewal; prescribing psychologist permit; requirements. Each applicant for renewal of the prescribing psychologist permit shall present satisfactory evidence to the board demonstrating continuing competency in the provision of psychological treatments combined with psychotropic medications, and continuing medical education relevant to safe prescribing practices. The board shall adopt regulations related to the methods of continuing competency in consultation with relevant professional associations. The applicant for renewal of the prescribing psychologist permit shall present evidence of no fewer than 40 hours of continuing competency hours within 24 months. Reciprocity. The department, with recommendations of the Board, may issue a provisional prescribing psychologist permit or prescribing psychologist permit based on licensure or credentialing in another jurisdiction to a person who meets the criteria for prescribing psychotropic medications per the Psychology Practice Act. Other jurisdictions include, but are not limited to, the Department of Defense, US Public Health Service, Indian Health Service, and states that permit psychologists prescriptive authority. Prescriptive authority; practice of psychology. A psychologist licensed in this state shall not administer or prescribe psychotropic medications in the practice of psychology unless he or she has been issued a prescribing psychologist permit or provisional prescribing psychologist permit, pursuant to the Psychology Practice Act. Prescriptive authority; violation; board duties. A violation of provisions of the Psychology Practice Act relating to the administration of psychotropic medication may result in action against the psychologist’s permit, license, or both. The board shall ensure through rules and regulations and enforcement that prescribing psychologists limit their practice to demonstrated areas of competence as documented by relevant professional education, training, and experience. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –29– Appendix B Datapoints Psychotropic Drug Prescriptions by Medical Specialty Tami L. Mark, Ph.D., M.B.A. Katharine R. Levit Jeffrey A. Buck, Ph.D. T he important role of general practitioners in prescribing antidepressant medications and treating depression has been documented. However, the extent to which general practitioners are prescribing other types of psychotropic medications has received less emphasis. This study used data from August 2006 to July 2007 from the National Prescription Audit (NPA) Plus database of IMS to examine this question. IMS collects transaction information each month from approximately 36,000 retail pharmacies, representing about 70% of all retail pharmacies, which when weighted represent all prescriptions filled in retail outlets in the United States. Using a separate sample of retail pharmacy transactions that includes the physician’s Drug Enforcement Administration number, IMS assigns physician specialty information to obtain an estimate of the total number of prescriptions filled in retail pharmacies by medical specialty. As shown Figure 1, of the 472 million prescriptions for psychotropic medications, 59% were written by general practitioners, 23% by psychiatrists, and 19% by other physicians and nonphysician providers. General practitioners wrote prescriptions for 65% of the anxiolytics in the sample, 62% of the antidepressants, 52% of the stimu- lants, 37% of the antipsychotics, and 22% of the antimania medications. Conversely, psychiatrists and addiction specialists wrote prescriptions for 66% of the antimania medications, 49% of the antipsychotics, 34% of the stimulants, 21% of the antidepressants, and 13% of the anxiolytics. Pediatricians were included as general practitioners and wrote 25% of all stimulant prescriptions but only 3% of all other types of psychotropic medications (data not shown). Prescribing of psychotropic medications by nonpsychiatrists improves access to treatment. However, concerns remain about whether patients treated in the general medical setting are receiving treatment concordant with evidence-based guidelines, psychotherapy, adequate medication monitoring, and appropriate intensity of treatment. PSYCHIATRIC SERVICES Acknowledgments and disclosures This study was funded through a contract from the Substance Abuse and Mental Health Services Administration. The authors report no competing interests. Reference 1. Cunningham PJ: Beyond parity: primary care physicians’ perspectives on access to mental health care. Health Affairs 28:w490–w501, 2009 Figure 1 Percentage of U.S. retail psychotropic prescriptions written from August 2006 to July 2007, by type of providera Psychiatrists and addiction specialists General practitioners, obstetriciangynecologists, and pediatricians 100 80 13% 6% Physician assistants and nurse practitioner All other specialties and psychologists 6% 6% 8% 9% 11% 6% 22% 5% 37% 52% 6% 59% 62% 17% 5% 65% 66% 60 Dr. Mark and Ms. Levit are affiliated with Thomson Reuters, 4301 Connecticut Ave., N.W., Suite 330, Washington, DC 20008 (e-mail: [email protected]). Dr. Buck is with the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Amy M. Kilbourne, Ph.D., M.P.H., and Dr. Mark are editors of this column. In 2004–2005, about two-thirds of primary care physicians reported that they were unable to obtain outpatient mental health services for patients (1). Given the large role of primary care providers in psychotropic drug prescribing, additional efforts may be needed to enhance the quality of psychiatric treatment in general practice settings across a range of psychiatric conditions. 49% 40 34% 20 23% 21% 13% 0 a Total (N=472,173) Antimania (N=4,163) Antipsychotics Stimulants Antidepressants Anxiolytics (N=53,328) (N=35,634) (N=232,660) (N=146,388) Ns represent prescriptions in thousands ' ps.psychiatryonline.org ' September 2009 Vol. 60 No. 9 Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit 1167 Page –30– Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Cheyenne Morrill 1 Box Butte Deuel Garden 1 Sheridan Dundy Chase Perkins Keith Arthur Grant Counts Provided by: STATE OF NEBRASKA Licensure Unit P.O. Box 94986 Lincoln, NE 68509 402-471-2117 [email protected] Kimball Banner 11 Scotts Bluff Sioux Dawes Hitchcock Hayes 5 Frontier Gosper Dawson Harlan Phelps 1 Boyd Greeley 11 Franklin Nance Note: Polk 2 Thayer 1 Fillmore Otoe Cass 2 2 Pawnee Richardson Based on licensee mailing addresses. 9 1 22 174 Nemaha Sarpy Gage Johnson 160 2 SaundersDouglas 1 Washington 1 Burt Lancaster Jefferson Saline 1 Seward Butler Colfax Dodge Updated 8/12/2014 Nuckolls Clay Dakota Thurston 2 Cuming Dixon Wayne 1 Cedar Platte York Hamilton 3 Merrick Webster Kearney Adams 5 1 11 Hall 1 Sherman Howard Valley Boone 17 Pierce Knox 1 Garfield Wheeler Madison Antelope Stanton Holt Buffalo Loup Rock Custer Blaine Brown Keya Paha Red Willow Furnas Lincoln Logan Thomas McPherson Hooker Cherry Number of Licensed Psychologist per County Total Licensed in Nebraska 451 Appendix C Page –31– Appendix D PROVIDER TRAINING IN BEHAVIORAL HEALTH Undergraduate - Number of Years Discipline Psychologist Psychiatrist General Practitioner 4 year Undergraduate Bachelor's (BA/BS) 4 year Undergraduate Bachelor's (BA/BS) 4 year Undergraduate Bachelor's (BA/BS) Psychiatric Nurse Practitioner Physician Assistant 4 year Undergraduate Bachelor's (BSN) 4 year Undergraduate Bachelor's (BA/BS) Psychiatric Nurse Practitioner Psychiatric Physician Assistant Advanced Health Assessment Advanced Pathophysiology General Medical Science Courses Graduate - Number of Years Discipline Psychologist Psychiatrist General Practitioner Year 1 Scientific & Clinical Coursework General Medical Science Courses General Medical Science Courses Year 2 Research Coursework Clinical Practicum General Medical Science Courses General Medical Science Courses Year 3 Master's Degree Clinical Practicum Coursework Clerkships Clerkships Year 4 Advanced Scientific & Clinical Courses & Practicum/Research Electives M.D. Awarded Electives M.D. Awarded Year 5 Specialized Courses Research Clinical Practicum Psychiatric Residency General Practice Residency Year 6 Internship Psychiatric Residency General Practice Residency Psychiatric Residency General Practice Residency Psychiatric Residency Board Eligible General Practice Residency Board Eligible Year 7 Year 8 Year 9 Year 10 Completion of Dissertation and Supervised Clinical Experience Doctoral Degree One year PostDoctoral Supervised Clinical Experience Licensure Pharmcotherapeutics Master's Degree 2,000 hours supervision Board Certification General Medical Science Courses Psychiatric Specialty Training Postdoctoral training clinical psychopharmacology One year practicum Year 11 Prescribing Psychologist – Emphasis behavioral health clinical training, graduate level, included in blue color years. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –32– Appendix E BY ORDER OF THE SECRETARY OF THE AIR FORCE AIR FORCE INSTRUCTION 44-119 24 SEPTEMBER 2007 Medical MEDICAL QUALITY OPERATIONS COMPLIANCE WITH THIS PUBLICATION IS MANDATORY ACCESSIBILITY: Publications and forms are available for downloading or ordering on the e-Publishing website at: http://www.e-publishing.af.mil. RELEASABILITY: There are no releasability restrictions on this publication. OPR: AFMOA/SG3OQ Supersedes AFI44-119, 4 June 2001 Certified by: AFMOA/CC (Col Lawrence M. Riddles) Pages: 244 This instruction implements AFPD 44-1, Medical Operations, DoDD 6025.13-R, Clinical Quality Management Program(CQMP) in the Military Health Services System (MHS), which incorporated DoDD 6025.14, Department of Defense Participation in the National Practitioner Data Bank (NPDB), DoDI 6040.37, Confidentiality of Medical Quality Assurance (QA) Records, DoDI 6025.15 Implementation of Department of Defense Participation in the National Practitioner Data Bank; DoDI 6025.16, Portability of State Licensure for Health Care Professionals; DoDI 6025.17, Department of Defense (DoD) Patient Safety Program (PSP). It outlines medical treatment facility (MTF) roles and responsibilities in the area of clinical performance improvement (PI), explains patient safety and risk management (RM) programs, PI/accreditation/ self-inspection requirements, credentials and privileging processes, and scope of practice in order to provide optimal healthcare delivery. This instruction applies to all Air Force Medical Service (AFMS) personnel to include units of the Air Reserve Components (ARC) with the exception that the ARC are exempt from the requirement for Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation and the annual PI/RM Summary. ARC Aeromedical Evacuation Squadrons (AES) participating in actual patient care will comply with applicable ARC guidance. The reporting requirement in paragraph 2.8.7. is exempt from licensing in accordance with (IAW) paragraph 2.11.12. of AFI 33-324, The Information Collections and Reports Management Program; Controlling Internal, Public, and Interagency Air Force Information Collections. This instruction directs collecting and maintaining information protected by the Privacy Act of 1974 authorized by Title 10, United States Code (U.S.C.), Section 8013, Secretary of the Air Force. Privacy Act system notice F044 AF SG K, Medical Professional Staffing Records, applies. Ensure that all records created as a result of processes prescribed in this publication are maintained in accordance with AFMAN 37-123 (will convert to AFMAN 33-363), Management of Records, and disposed of in accordance with the Air Force Records Disposition Schedule (RDS) located at https://afrims.amc.af.mil/. Implementing publications do not need to be forwarded to higher headquarters for review and coordination before publishing. Refer recommended changes and questions about this publication to the Office of Primary Responsibility (OPR) using the AF IMT 847, Recommen- Appendix E — Continued Next Page Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –33– 104 Appendix E – Continued AFI44-119 24 SEPTEMBER 2007 7.8. Clinical Psychologists: 7.8.1. Background. Clinical psychology is the discipline of professional psychology dedicated to the scientific understanding of factors operating in the etiology, maintenance, and potential change of human behavior, habits, and lifestyles. Clinical psychologists are trained in providing health and mental health promotion programs for individuals and groups experiencing ongoing mental and physical problems. 7.8.2. Education and Licensure Requirements: Clinical psychologists must demonstrate appropriate skills, training, and experience to be considered for clinical privileges. Minimum educational requirements include: 7.8.2.1. A doctor of philosophy (PhD) or a doctor of psychology (PsyD) degree in clinical, counseling, or combined professional-scientific psychology from a program accredited by the American Psychological Association (APA). Waiver of this requirement (i.e., for graduates of regionally accredited universities or schools of professional psychology) must be staffed through AFMOA/ SG3OQ. 7.8.2.2. An APA-accredited predoctoral internship in professional psychology (This 1-year internship is part of an APA-accredited doctoral program. The AF accepts this internship from any APA-accredited site including designated AF sites). 7.8.2.3. An optional postdoctoral fellowship allows for subspecialization in Operations/Aviation psychology, child/adolescent psychology, health psychology, or neuropsychology. 7.8.2.4. Valid license to practice psychology from a US jurisdiction. 7.8.3. Scope of Practice. Clinical Psychologists: 7.8.3.1. Conduct clinical interviews and interpret psychological tests/assessments. 7.8.3.2. Diagnose mental disorders and formulate treatment plans. 7.8.3.3. Provide individual and group psychotherapy, hypnosis (See AFI 44-102), formal sex therapy (See AFI 44-102), and biofeedback (chief of the medical staff should review the provider’s credentials with the consultant for clinical psychology if they are unfamiliar with the credentials requirements). 7.8.3.4. Recommend administrative and medical dispositions. 7.8.3.5. Perform neuropsychological screening. 7.8.3.6. Perform comprehensive neuropsychological evaluations (must have postdoctoral fellowship training as described above). 7.8.3.7. Admit, treat, and discharge patients (with physician oversight) to/from inpatient units with mental health capability. 7.8.3.8. Admit/discharge patients to/from substance abuse rehabilitation centers. 7.8.3.9. Makes recommendations to medical evaluation boards when requested. 7.8.3.10. Determine the degree of impairment for military service and for civilian social and industrial adaptability due to mental disorders. 7.8.3.11. Perform safety and risk assessments. Appendix E — Continued Next Page Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –34– Appendix E – Continued AFI44-119 24 SEPTEMBER 2007 105 7.8.3.12. Serve on competency and sanity boards. 7.8.3.13. Certify stability for the sensitive duty programs such as PRP, security clearances, and special access. 7.8.3.14. Assess for mental competency when administrative or legal matters arise. 7.8.3.15. Perform commander-directed mental health evaluations (CDEs) and act as behavioral health consultants to commanders and first sergeants. 7.8.3.16. Serve on aircraft mishap investigation boards (must have completed appropriate training program such as Air Force Aircraft Mishap Investigation and Prevention Course). 7.8.3.17. Those clinical psychologists designated by the HQ USAF/SG, who participated in the DoD Psychopharmacology Demonstration Project (PDP) and were thereby granted prescriptive authority, may continue to have prescriptive authority for the remainder of their tenure with the AFMS. Prescriptive authority may also be granted to fully qualified psychologists who have completed a Master’s Degree in clinical psychopharmacology, successfully passed the Psychopharmacology Exam for Psychologist (PEP), and who have received a minimum of one year of documented supervision. Supervision must be provided by a psychiatrist or a psychologist with prescriptive authority. 7.8.3.18. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code “1” on their privileges list. 7.8.4. Supervision: 7.8.4.1. As with any privileged provider, an ongoing, proactive peer review process (as outlined in Chapter 8) is required. Periodic review of performance is required at least biennially as part of the competency-based privileging process. Examples of competency assessment include periodic review of a representative sample of medical records, direct observation of performance, and verbal/written assessment of clinical knowledge/skills. 7.8.4.2. Unlicensed clinical psychologists who have completed their doctorate: 7.8.4.2.1. May be granted supervised privileges. 7.8.4.2.2. Are supervised by a fully qualified licensed provider who will establish a plan of supervision based on the unlicensed psychologist’s skills and needs. As a minimum, the supervisor will meet with the unlicensed psychologist for at least one hour every week. 7.8.4.2.3. Supervision can be obtained from any one of the following (listed in order of preference): 7.8.4.2.3.1. A privileged mental health provider at the MTF, including a reservist, if assigned, or 7.8.4.2.3.2. A licensed provider at a nearby VA facility or a nearby MTF, or 7.8.4.2.3.3. A licensed civilian psychologist in the local community. 7.8.4.2.4. NOTE: As described in Chapter 6, the clinical supervisor must be a provider who has regular privileges in the scope of practice for which he or she is supervising. EXCEPTION: A VA provider or civilian psychologist shall have full credentials review as a consultant, as described in paragraph 6.20. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –35– Appendix F Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –36– Appendix G Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –37– Appendix H Expanding Psychiatric Prescribers in Nebraska Psychiatric Prescribers Psychiatrists (1) Nurse Practitioner Specialized in Psychiatry (1) Physician Assistant Specialized in Psychiatry (1) Prescribing Psychologists (2) Provide psychotherapy and medication management Percentage increase with prescribing psychologists Number 156 75 12 58 24% 19% (1) 2012 data from Behavioral Health Education Center of Nebraska – BHECN (2) Estimate for Nebraska based on percentage of licensed psychologists in Louisiana and New Mexico that completed medical training and qualified for prescriptive authority Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –38– Appendix I Dr. Mikel Merritt Dr. Merritt is prescribing psychologist with the United States Air Force. He earned his PhD from the University of Nebraska-Lincoln in August of 2006. The final year of his doctoral studies, he commissioned with the US Air Force to complete an internship and has gone on to serve for nearly ten years as an Active Duty psychologist, deploying once in support of Operation Enduring Freedom to Afghanistan. He is currently stationed at Whiteman AFB, MO where he serves as the Mental Health Flight Commander, supervising a team of mental health providers including active duty and civilian Social Workers, Psychologists and Psychiatrists. Dr. Merritt’s first regular duty assignment after internship was at Holloman AFB, NM. It was during this assignment that Dr. Merritt began the process of becoming a prescribing psychologist. He applied and was accepted into the Master’s program in psychopharmacology at New Mexico State University. Through this program he completed two years of didactic work, and an 80 hour practicum with a primary care physician, as well as a 400 hour practicum working with a psychiatrist specifically in the realm of psychopharmacology. He also passed the Psychopharmacology Examination for Psychologists and went to complete a year of supervised prescribing practice. During this period he was relocated to Yokota Air Base, in Japan, where he conducted the year of supervised practice, working closely with a psychiatrist and family practice providers including physicians, Nurse Practitioners, and Physician Assistants. Dr. Merritt was credentialed with independent prescriptive authority in June of 2011 by the USAF, allowing him to prescribe in any Department of Defense medical facility where he is privileged, and has served as a prescribing provider since that time. As the Mental Health Flight Commander at Whiteman AFB, Dr. Merritt continues to carry a full caseload with approximately one-half of his patient’s receiving only psychotherapy. The patient’s he does see for both therapy and medication report that it is easier for them to see only one provider for all of their mental health needs. His capabilities have dramatically reduced the wait time for clinic patrons to be seen by a prescribing provider when indicated. Prior to his arrival it was not uncommon for patients to wait as long as a month to be seen, now most are seen in a week or less. This has served to greatly enhance the mental health care available to the beneficiary population. As a prescribing psychologist, Dr. Merritt routinely orders and interprets laboratory studies, primarily these studies relate to medication levels, liver and kidney function, as well as screening out other potential causes of disorders (such as thyroid screening). Dr. Merritt also collaborates with the primary care providers responsible for the medical care of patients. This includes a variety of activities ranging from requesting studies that Dr. Merritt does not perform (i.e. EKG, or ordering CT scans or MRI’s) to simply discussing how the mental health diagnoses and treatment may interact with any other medical concerns. In the time since earning independent prescriptive authority, Dr. Merritt has treated a wide variety of disorders including depression, anxiety, psychosis, and Bipolar disorder. He has successfully met the needs of the patient population and in many instances been able to reduce the number of medications and even eliminate the need for medication in a number of his patients. His expertise in the integration of medication with psychotherapy has been recognized by the Nebraska Psychological Association, who invited Dr. Merritt to present a three-hour continuing education program on the topic, and by his peers whom he collaborates with regularly. Dr. Merritt is a native Nebraskan from North Platte. Ψ NPA Credentialing Review Application — Prescribing Psychologist Permit Page –39–
