1. MEDICAL ASSISTANTS IN CALIFORNIA SCOPE OF PRACTICE: Laws, Regulations,….

2. …and OPPORTUNITIES!

3. Today, we’ll discuss…

4. THE “WHAT?”

5. The Medical Assistant Scope of Practice

6. THE “WHAT?” “SO WHAT??”

7. What is the PROBLEM?...and what can we do about it?

8. and…

9. THE “WHAT?” “SO WHAT??” “NOW WHAT???”

10. An Innovative program to address these issues.

11. SCOPE OF PRACTICE: WHERE TO GET QUESTIONS ANSWERED:

12. CA. MEDICAL ASSISTANTS SCOPE American Association of Medical Assistants: http://www.aama-ntl.org/employers/laws.aspx California Medical Board: http://www.mbc.ca.gov/Licensees/Physicians_and _Surgeons/Medical_Assistants/Medical_Assistan ts_FAQ.aspx

13. CA Medical Assistants Laws, Regulations and Governance CA Business and Professions: (B&P) Code §§ (Sections) 2069-2071 CA Code of Regulations: Title 16 §§ 1366–1366.4; 1366.31-33 Medical Board of California (www.mbc.ca.gov/allied)www.mbc.ca.gov/allied California Board of Registered Nursing

14. California Medical Assistants (MAs): Unlicensed Work in MD, podiatrist or optometrist offices; and clinics – (not for inpatient care in licensed general acute care hospitals) Regulated by CA Board of Medicine Must be over 18 Must be trained May be certified

15. MA Certification Multiple national & state-based options Usually states don’t require certification CA requires certification of MAs who are training other MAs – (16 CA ADC §1366.3) Employers may require certification

16. In a Community Health Center Provide technical support services … …Upon: the specific authorization and supervision of a licensed physician and surgeon or a licensed podiatrist, OR…

17. In a Community Health Center …Upon the specific authorization of a physician assistant, a nurse practitioner, or a nurse- midwife, with a physician maintaining supervisory function unless delegated in standardized procedure or protocol. SO…Supervising MD/DO/podiatrist may provide in writing that NP or PA may assign MD- authorized tasks to the MA.

18. Technical Support Services CA MAs may perform: As authorized by supervising physician or designee: Collect “anthropomorphic data” (VITAL SIGNS) Collect basic information about the presenting conditions (HPI) and past history. Perform simple laboratory and screening tests customarily performed in a medical office. Provide patient information and instructions.

19. In a Community Health Center: A California Medical Assistant may: Administer medication only by intradermal, subcutaneous, or intramuscular injections; Perform skin tests; and…

20. Other Technical Support: Electrocardiograms, Pulmonary function testing, Apply and remove bandages and dressings, Apply orthopedic appliances such as knee immobilizers, envelope slings, orthotics, Remove casts, splints and other external devices, Obtain impressions for orthotics, padding and custom molded shoes, Select and adjust crutches for patients, Instruct patient in proper use of crutches.

21. Other Technical Support (cont.): Remove sutures or staples from superficial incisions or lacerations Perform ear lavage Collect by non-invasive techniques, and preserve specimens for testing Assist patients in ambulation and transfers Prepare patients for and assist the physician, podiatrist, PA or RN in exams or procedures including positioning, draping, shaving, disinfecting treatment sites, prepare patients for gait analysis testing

22. MA’s Can’t: Set I.V.s or given medication intravenously Administer chemotherapy. Interpret skin test results. (BUT, may measure the test). Administer anesthetics, including medications containing local anesthetics, such as lidocaine.

23. Questions to ask yourselves What are MAs doing now at your site? (Or, how are you educating/training MAs?) What MA role changes do you want to see? What is driving this need to change?

24. Questions to ask yourselves What are you planning to do? What challenges or barriers do you face? How do you think they can be overcome? What resources do you need to make the changes?

25. Why Innovate? Flagging productivity Long patient wait times Staff dissatisfaction / infighting Difficulty in recruiting & affording RN staff Difficulty in recruiting & retaining providers Distance from urban centers & training programs

26. Innovative Models THREE MODELS LEADING TO EXPANDED ROLES:

27. 3 Models 1.Ambulatory Intensive Caring-Unit (A-ICU) MA health coaches for high risk patients with chronic conditions. Frequent encounters and care management.

28. 3 Models 2.Cross-trained MA Team Model Cross-trained teams of MAs handle both nursing and clerical roles. High MA to provider ratio.

29. 3 Models 3. Integrated Multi-disciplinary Care Team (care coordination model) Team-based model, MAs conduct daily hands-on clinical tasks, nurses serve as care coordinators.

30. Medical Assistant Selection and Training “Hire for attitude; train for skill” Relational skills and bilingual competency BFOQ Weekly core competency training Active participation in plan of care for center patient population (huddle) Daily precepting with providers at each patient encounter - 12 encounters a day

31. Health Coach: Roles and Responsibilities Help with individualized patient care plan Continual follow-up by phone and email Meet patients individually (panel of 80-150) Conduct health education classes MA role to support provider visits/exams Stay with patient through exam – Call for lab results, schedule follow up visits, glucometer readings, help with referrals, help document patient history, follow up on medication adherence, etc.

32. MA-team Model [rural] Increase MA/Provider ratio to 3:1 Don’t move the patient; move the care – MAs Take co-pay in the room – MAs conduct tests in-room – MAs print visit summary in-room --MAs as scribes with EMR.

33. Outcomes New positions: Health Coach, CHW, Pharm Tech, – Health Coaches earn approximately 42% more than MAs Wait time reduced for patients Provider productivity increased - 2000 to 2013 – From 1.82 patients per hour to 2.8 per hour Cost savings– Up to $67K per team per year

34. Changing Roles: RNs Nurses challenged by MAs trained to roles they would traditionally have. BUT RNs have expertise and judgment to do higher level activities: CARE MANAGEMENT and TRIAGE.

35. Changing Roles: Providers COMMON COMPLAINTS “I am on a never-ending treadmill!” “My colleagues and I are always at the edge of burn-out!” “EMRs and population health add a ton more work!”

36. Changing Roles: Providers BUT— Giving up work to the team is difficult!

37. Changing Roles: Providers AT FIRST: “The responsibility is on me!” “It’s MY license at stake!” “No one else understands the work!”

38. AFTER TRAINING OF HEALTH COACHES: “Many tasks can come off my plate!”: – Including: Entering data-even having a scribe. Many phone calls. Preventive care and alerts. Etc.!