Variance for Recognizing the Practice and Role of a Physician Assistant in Certified Mental Health Programs

PDF Version of DQA 08-004 (PDF, 52 KB)

Date:  March 4, 2008 -- DQA Memo 08-004

To:      Area Administrators/Assistant Administrators 01
          Bureau Directors 01
          County Departments of Human Services
          Directors 01
          Tribal Chairpersons/Human Services
          Coordinators 01
          Community Mental Health Providers 01
           Hospitals HOSP 02

From:  Otis Woods, Administrator
           Division of Quality Assurance

Via:     Mark Hale, Division of Quality Assurance
           Behavioral Health Certification Section

           Dan Zimmerman, Division of Mental Health
           and Substance Abuse Services
           Bureau of Mental Health and Substance
           Abuse Services

Variance for Recognizing the Practice and Role of a Physician Assistant in Certified Mental Health Programs

In advance of the rewrite of administrative rules, the Department is issuing a statewide variance to provide immediate regulatory relief regarding the roles of physician assistants (PAs) in certified mental health programs, including:

• Emergency mental health services programs (HFS 34);
• Comprehensive community services programs (HFS 36);
• Mental health day treatment services for children (HFS 40);
• Inpatient mental health, adult day treatment;
• Outpatient mental health clinics (HFS 61); and
• Community support programs (HFS 63).

This variance does not limit the scope and practice of the PAs. Their practice continues to be governed by the credentialing requirements found in Wisconsin Administrative Code Chapters Med 8 and 10, and is under the jurisdiction of the Wisconsin Department of Regulation and Licensing. The variance provides the flexibility for certified mental health programs to use PAs to serve their clients.

PAs Not Recognized by Chapters HFS 34, 36, 40, 61 and 63

Chapters HFS 34, 36, 40, 61 and 63, Wisconsin Administrative Code, do not list PAs as program personnel. Chapter Med 8 outlines the education, training, and experience requirements that a PA must meet, and Chapter Med 10 provides the criteria for determining unprofessional conduct (see Attachment 1, which contains ss. Med 8.07, 8.08, and 8.10).

The conditions for approval of a variance request to permit a PA to supplement the services of a psychiatrist in a certified mental health program are predicated on the following criteria. Note: For comprehensive community services programs and outpatient mental health clinics only, a physician whose scope of practice includes the assessment and treatment of mental illness may function as the supervising physician; for all other programs, a psychiatrist must be the supervising physician.

Conditions of Variance

1. PAs included as Program Personnel will practice as allowed in ss. Med 8.07, 8.08, and 8.10. Notification of the beginning date of PA services must be provided to the Behavioral Health Certification Section surveyor, prior to the provision of services by a PA, but subsequent to the approval of the variance request.
   
2. The program shall develop and implement a policy detailing the relationship between the psychiatrist and the PA to ensure that the PA is supplementing, not supplanting, the psychiatrist. The policies and procedures must address the provisions of Med 8.08 (2), the assessments and services the PA may perform in the clinic (in accordance with Med 8.07 (2)). In CSPs, the psychiatrist will be responsible for the initial in-depth psychiatric assessment of all CSP clients, including the development of a working diagnosis and assuring the need for CSP services. 
   The CSP psychiatrist will also be responsible for assessing the need for further medical evaluation, and for making the initial determination for medical/pharmacological treatment. The PA may conduct the aforementioned activities in collaboration with a psychiatrist and in accordance with Med 8.07, 8.08, and 8.10. A copy of the policy must be submitted to the Behavioral Health Certification Section surveyor with the variance request letter for review to determine if the variance should be granted.
   
3. Documentation, in keeping with the provisions of the applicable provider requirements and Med 8.07, 8.08, and 8.10, must be completed and available for review when requested, by DQA staff.
   All remaining requirements in HFS 36, HFS 63 and HFS 61 remain unchanged, unless the Department previously issued a variance or waiver.
   
4. The Behavioral Health Certification Section surveyor must be notified immediately if the psychiatrist or PA no longer provides services for the CCS program, CSP, or outpatient mental health clinic. If the PA no longer provides services, the variance will cease to be effective on the last date of employment or contracted services from the PA.

Note: Granting of any of these variances does not constitute granting a variance s. 49.45 (2) (b) 6. f., Stats., of the Medical Assistance (Title XIX) requirements. The Bureau of Quality Assurance does not have the authority to grant waivers or variances for Medical Assistance rules. Please contact Christine Wolf at (608) 266-9195 for further information about requirements for Medical Assistance.

If you have questions about this memo, please contact Dan Zimmerman, Bureau of Mental Health and Substance Abuse Services (608-266-7072), or your Behavior Health Certification Section surveyor. Contact phone numbers are attached.

cc: Joyce Allen, Director, Bureau of Mental Health
     and Substance Abuse Services
     Mark Hale, Section Chief, Behavioral Health
     Certification Section, DQA
     Cremear Mims, Director, Bureau of Health
     Services, DQA
     Dan Zimmerman, Contract Administrator, Bureau
     of Mental Health & Substance Abuse Services

Attachment 1

Med 8.07 Practice. 

    (1)  SCOPE AND LIMITATIONS. In providing medical
          care, the entire practice of any physician
          assistant shall be under the supervision of
          a licensed physician. The scope of practice
          is limited to providing medical care specified
          in sub. (2). A physician assistant's practice
          may not exceed his or her educational training
          or experience and may not exceed the scope of
          practice of the supervising physician. A medical
          care task assigned by the supervising physician
          to a physician assistant may not be delegated
          by the physician assistant to another person.

   (2)   MEDICAL CARE. Medical care a physician
          assistant may provide include:
   (a)   Attending initially a patient of any age in
          any setting to obtain a personal medical
          history, perform an appropriate physical
          examination, and record and present pertinent
          data concerning the patient in a manner
          meaningful to the supervising physician.
   (b)   Performing, or assisting in performing, routine
          diagnostic studies as appropriate for a specific
          practice setting.
   (c)   Performing routine therapeutic procedures,
          including, but notlimited to, injections,
          immunizations, and the suturing and care of
          wounds.
   (d)   Instructing and counseling a patient on
          physical and mental health, including diet,
          disease, treatment and normal growth and
          development.
   (e)   Assisting the supervising physician in a
          hospital or facility, as defined in s. 50.01
          (1m), Stats., by assisting in surgery, making
          patient rounds, recording patient progress
          notes, compiling and recording detailed
          narrative case summaries and accurately
          writing or executing orders under the
          supervision of a licensed physician.
   (f)    Assisting in the delivery of medical care
          to a patient by reviewing and monitoring
          treatment and therapy plans.
   (g)   Performing independently evaluative and
          treatment procedures necessary to provide
          an appropriate response to life-threatening
          emergency situations.
   (h)   Facilitating referral of patients to other
          appropriate community health-care facilities,
          agencies and resources.
    (i)   Issuing written prescription orders for drugs
          under the supervision of a licensed physician
          and in accordance with procedures specified in
          s. Med 8.08 (2).

Med 8.08 Prescribing limitations. 

  (1)   A physician assistant may not prescribe or
         dispense any drug independently.
  (2)  A physician assistant may issue a prescription
         order only if all the following conditions apply:
   (a)  The physician assistant issues the prescription
         order only in patient situations specified and
         described in established written guidelines.
         The guidelines shall be reviewed at least
         annually by the physician assistant and his or her
         supervising physician.
   (b)  The supervising physician and physician assistant
         determine by mutual agreement that the
         physician assistant is qualified through
         training and experience to issue a prescription
         order as specified in the established written
         guidelines.
   (c)  The supervising physician is available for
         consultation as specified in s. Med 8.10 (3).
   (d)  The prescription orders prepared under procedures
         in this section contain all information required
         under s. 450.11 (1), Stats.
   (e)  The supervising physician either:
         1. Reviews and countersigns the prescription order
             prepared by the physician assistant, or
         2. Reviews and countersigns within 72 hours the
             patient record prepared by the physician
             assistant practicing in the office of the
             supervising physician or at a facility or a
             hospital in which the supervising physician has
             staff privileges, or
         3. Reviews by telephone or other means, as soon
             as practicable but within a 72-hour period, and
             countersigns within one week, the patient
             record prepared by the physician assistant
             who practices in an office facility other than
             the supervising physician's main office of a
             facility or hospital in which the supervising
             physician has staff privileges.

Med 8.10 Employment requirements; supervising physician responsibilities.

  (1)  No physician may concurrently supervise more
        than 2 physician assistants unless the physician
        submits a written plan for the supervision of
        more than 2 physician assistants and the board
        approves the plan. A physician assistant may be
        supervised by more than one physician.
 (2)  Another licensed physician may be designated by
        the supervising physician to supervise a physician
        assistant for a period not to exceed 8 weeks per
        year. Except in an emergency, the designation
        shall be made in writing to the substitute
        supervising physician and the physician assistant.
        The supervising physician shall file with the
        board a copy of the substitution agreement
        before the beginning date of the period of his or
        her absence.
 (3)  The supervising physician or substitute supervising
        physician shall be available to the physician
        assistant at all times for consultation either
        in person or within 15 minutes of contact by
        telephone or by 2-way radio or television
        communication.
 (4)  A supervising physician shall visit and conduct
        an on-site review of facilities attended by the
        physician assistants at least once a month.
        Any patient in a location other than the location
        of the supervising physician's main office shall be
        attended personally by the physician
        consistent with his or her medical needs.

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