ACN 029/21 - MAR 2021 POLICY UPDATE TO EXPAND CLINICAL CAPABILITIES OF COAST GUARD PROVIDERS

R 171129Z MAR 21
FM COMDT COGARD WASHINGTON DC
TO ALCOAST COMDT NOTICE
BT
UNCLAS
ACN 029/21
SSIC 6000
SUBJ:  POLICY UPDATE TO EXPAND CLINICAL CAPABILITIES OF COAST GUARD
PROVIDERS
A. Coast Guard Medical Manual, COMDTINST M6000.1 (series)
B. Health, Safety, and Work-Life Service Center Technical Directive
2016-005, Provider Peer Review
C. Coast Guard Substance Abuse Prevention and Treatment Manual,
COMDTINST M6320.5 (series)
D. Physical Disability Evaluation System, COMDTINST M1850.2 (series)
E. Military Separations, COMDTINST M1000.4 (series)
F. U.S. Coast Guard Auxiliarist Support to Coast Guard Health Care
Facilities, COMDTINST 6010.2 (series)
G. Mental Health Evaluations of Members of the Military Services,
DoDI 6490.04
H. Active Duty Mental Health Conditions and Emergencies,
COMDTPUB 6520.1
I. Administrative Investigations Manual, COMDTINST M5830.1 (series)
J. Military Drug and Alcohol Policy, COMDTINST M1000.10 (series)
1. REF (A) authorizes COMDT (CG-11) to ensure all Coast Guard (CG)
health care providers are qualified through proper credentialing and
privileging, and outlines policies regarding all aspects of these
functions. Credentialing and privileging files are developed and
maintained by the CG’s Central Verification Office (CVO), now housed
in COMDT (CG-1121). There is no specific additional privileging
required to perform clinical care via telemedicine. Health care
services may only be provided in CG facilities by CG credentialed
and privileged personnel. As national clinical standards are
improved and expanded, and additional provider types are becoming
skilled in additional types of clinical care, the Coast Guard can
capitalize on these opportunities within the organic health care
system. Health Information Systems (HIS) will help increase access
to care, decrease gaps in care, improve both command and personnel
support related to health care needs, and maximize personnel
readiness. There are multiple fitness for duty, accession,
retention, benefits determination, and line of duty determinations
that can be completed by additional providers than are noted in
current policy guidance. This update expands the clinical provider
pool to complete these evaluations and other clinical services,
and will help expedite important administrative processes.  REF (B)
provides procedural guidance to ensure quality care is provided by
various provider types.
2. This policy update applies to all uniformed active and reserve
providers, federal service civilians, contractors, Department of
Veterans Affairs (VA) providers in CG clinics, and Auxiliarists
providing care to CG beneficiaries. Policy updates will not impact
bargaining unit employees until all negotiable matters pertaining
to changes in conditions of employment are handled through the
statutory process pursuant to 5 U.S.C. 71. All other CG personnel
pertinent to this policy must comply upon publication of this ACN. 
3. The following updated policies are effective immediately:
    a. REF (A) paragraph 13.B.3.t is amended to add the following
provider types: clinical pharmacists, licensed marriage and family
therapists, licensed mental health counselors, and licensed clinical
mental health counselors. 
    b. REF (C) paragraph 3.C.2.b is amended by adding "or a trained
CG BH Provider in consultation with a CG MO" after "CG MO" in the
first sentence.
    c. REF (D) is amended as follows:
        1) Paragraph 3.C.1:  Replace the third sentence with:
“A military employed and privileged psychiatrist or a military
employed and privileged psychologist must be a Medical Evaluation
Board member when considering an evaluee with psychological
impairments.”
        2) Paragraph 3.G.6.t: Add the following text at the end of
the paragraph:  “Due to the logistics and the geographic challenges
encountered with mental health providers as members of the MEB,
signature or electronic signature on the psychiatric or psychologic
evaluation is an acceptable substitute to a signature on the
CG-5684 [Medical Board Report Cover Sheet]."
    d. REF (E) will replace references to “physician” with
“licensed medical provider” in paragraphs 1.B.15.h, 1.C.3.a,
1.C.9.c, 1.C.11.c, and 1.D.3. 
    e. REF (F) is amended as follows:
        1) Paragraph 4.b, replace with this language “For the purpose
of this Instruction, Auxiliary health care professionals include all
provider types as defined in the Medical Manual. These health care
professionals are authorized to volunteer in CG clinics or sickbays,
as well as provide telehealth services as approved by HSWL SC OPMED.”
        2) Paragraph 4.c is replaced with this: “c. This Instruction
also applies to Auxiliary health care personnel who are not
considered privileged (but may be credentialed and/or certified)
providers. These include but are not limited to Registered
Nurse (RN), emergency medical technicians (EMTs), and paramedics.”
        3) Paragraph 14.e, replace “Commandant (CG-112)” with
“HSWL SC OPMED”.
    f. REF (G) replaces policy in REF (H). REF (H) is cancelled.
4. As described in REF (A), Chapter 1.B., specific privileges and
scopes of practice immediately expanded include:
    a. Clinical psychologists will be signature authorities on
the following evaluations:
        1) Line of duty evaluations relating to behavioral or
mental health conditions, including those related to substance
use/abuse; and
        2) CG substance abuse screenings in accordance with
REF (C) in collaboration with a CG medical officer. The CG Addiction
Orientation for Health Care Providers (AOHCP) course must have been
completed prior to performing these screenings.
    b. Licensed Social Workers. LCSWs/LICSWs will be signature
authorities on the following evaluations:
        1) Command directed mental health evaluations as described
in REF (G);
        2) Fitness for duty evaluations not related to aviation or
dive/undersea medicine;
        3) Security clearance evaluations;
        4) Line of duty evaluations relating to behavioral or mental
health conditions, including those related to substance use/abuse
as described in REF (I);
        5) Statements relating to officer resignations as described
by REF (E);
        6) Substance abuse screenings, in collaboration with a
qualified CG Medical Officer per REF (C) and REF (J);
        7) Medical advisory opinions in response to CG Board of
Correction of Military Records with mandatory review by a
psychiatrist or clinical psychologist pursuant to 10 USC 1552(g);
        8) Advisor to Discharge Review Boards pursuant to
10 USC 1553(d)(1)(B);
        9) Evaluations of patients suspected of having eating
disorders;
       10) Mental health assessments (MHAs) associated with periodic
health assessments (PHAs), pre-separation/retirement assessments, and
all types of deployment related assessments as described by REF (A);
       11) Signature authority on the VA mental health related
disability benefit questionnaires (DBQs) with required collaboration
with a psychiatrist or clinical psychologist (doctoral level
LCSW/LICSW only).
    c. Psychiatry privileged PAs and NPs will be signature
authorities on the following evaluations:
        1) Fitness for duty evaluations not related to aviation or
dive/undersea medicine as described in REF (A) generally;
        2) Security clearance evaluations;
        3) Statements relating to officer resignations per REF (E); and
        4) Evaluations of patients suspected of having eating disorders
as described in REF (A). 
    d. Clinical pharmacists. CG credentialed pharmacists are
authorized to be privileged with core privileges to perform the
following functions in conjunction with a collaborating physician,
as well as supported supplemental privileges as approved by the
Privileging Authority:
        1) Evaluation, consultation and management of medication
therapy;
        2) Medication reconciliation;
        3) Individual medical readiness review;
        4) Prescriptive authority for medication renewals; and
        5) Administer vaccinations.
5. Behavioral Health (BH) Providers-This is a new designation that
will be added to REF (A), Chapter 1.B. 
    a. Behavioral Health (BH) Providers will be defined as follows: 
BH Providers include psychiatrists, psychiatry trained PAs and NPs,
clinical psychologists, licensed clinical social workers or licensed
independent clinical social workers with highest independent license
from the state they are licensed in, licensed marriage and family
therapists, licensed mental health counselors, and licensed clinical
mental health counselors. These providers may place referrals for
BH related care in the Tricare system when indicated.
6. Behavioral Health Technician (BHT) -This is a new designation that
will be added to REF (A), Chapter 1.B.: 
    a. BHTs are Health Services Technicians (HSs) who have
successfully completed BHT training through CG or DoD sponsored
courses. BHTs may perform these BH specific duties once a
supervising CG privileged BH Provider has been designated in writing. 
Scope of practice will be standardized to the extent possible based
on BHT curriculum, and approved by the supervisor. This new BH
provider supervising role will be the Designated Behavioral Health
Advisor (DBHA).
7. HSWL SC Registered Nurse (RN) Field Technical Manager-: This
is a new designation that will be added to REF (A), Chapter 1.B.
    a. Under the general direction and supervision of the Chief,
Operational Medicine Branch, HSWL SC, the HSWL SC Field Technical
Manager must:
        1) Care Coordination/Case Management: Assume duties as the
Chief of Complex Case Management.
        2) Serve as a leader in the coordination of care thus
ensuring the provision of appropriate care for complex cases across
the Coast Guard.
        3) Provide guidance, process development, and training to
assist in developing the Coast Guard’s Case Management/Care
Coordination process.
        4) Prepare reports to leadership regarding complex cases
within the Coast Guard. Quality Improvement Program: Work with other
divisions to develop strong quality improvement processes to aid the
field in ensuring a strong quality program.
        5) Monitor and track quality by reviewing corrective actions
following surveys.
        6) Monitor Patient Event Reporting Template (PERT) submissions.
        7) Report outcomes of quality measures to leadership.
        8) Technical Manager: Serve as the nursing consultant on
nursing care issues, quality improvement, infection control, and
clinical practice guidelines affecting nursing service to COMDT
(CG-11) and Command elements.
        9) Provide guidance and advice: Regarding the evaluation,
training, hiring, and credentialing of nursing personnel to meet
operational needs of the clinics and regional practice. Acts as the
technical authority for nursing practice within the Coast Guard.
       10) Liaison: Act as a liaison regarding care coordination/case
management to other government organizations, civilian partners,
clinics, and families as needed.
8. Registered Nurse (RN)-This is a new designation that
will be added to REF (A), Chapter 1.B.:RNs are state-licensed
professionals who support the care continuum within a variety
of settings. Within the Coast Guard, the RN is utilized in support
of care coordination, ambulatory care, quality improvement, and
training. An active state RN license must be maintained, and the
RN will be centrally credentialed.
    a. Scope of practice includes, but is not limited to, providing
support as an Ambulatory Care RN to Coast Guard clinics. These 
duties can include but are not limited to:
        1) Disease Management and Wellness instruction in 
coordination with the medical team.
        2) Care Coordination on a clinic and regional basis.
        3) Participation in staff education and training as an 
attendee and instructor.
        4) Utilizing the nursing process to assess and address 
patient needs.
        5) Providing education and direction to patients regarding
health care needs, promoting safe and effective patient outcomes, 
and properly documenting encounters by creating an individualized
education/care plan.
        6) Communicating with patients addressing aspects of care
including but not limited to Provider feedback, communication of
lab results, and population health issues.
        7) Participating in treatment team, complex and high risk
case discussions, and Clinical Case Staff Meetings (CCSM) as
assigned with appropriate documentation.
        8) May serve as the Quality Improvement Coordinator and/or
Infection Control Coordinator as determined by the Clinic
Administrator/Regional Manager.
        9) Functions as a liaison to local partners in health care in
coordination with clinic leadership.
       10) Demonstrates leadership within the treatment team by
providing support and guidance on the nursing process and patient
needs.
       11) Performs tasks as assigned by clinic administrator to
support clinic operations.
       12) Provides instruction in support of the continuing education
of the HS staff.
       13) Aids in updating clinic/regional practice SOPs as needed. 
9. The designation memorandum will follow a similar procedure
currently used for a Designated Medical Officer Advisor (DMOA) per
REF (A). BHTs will have 100 % record review per the same policy
standard as all other HSs. These HSs will also have a separate DMOA
if continuing to provide non-BHT duties and care.
10. Care Coordination and Case Management. Clinical Case Management
will be provided in coordination with our care partners
(i.e. TRICARE, DHA, other civilian partners) by Care Coordinators,
BHTs, and privileged providers as appropriate. HSWL SC will provide
guidance on required training and appropriate designation of care
coordinators and case managers.
11. Documentation. All types of health care providers must document
all care provided or coordinated to CG beneficiaries in their CG
health care record. Replace REF (A) paragraph 4.G with: 
“Mental Health (MH) Records. All clinical MH evaluations will be
completed in the Disability Evaluation System or in traditional
mental health format using standard CG health care record forms. 
Initial and follow-up evaluations will be recorded in the electronic
health record, or using the Chronological Record of Care, Form
SF-600, in SOAP format. A separate record of mental health care may
be created and maintained by the privileged provider in a system of
records approved by the local QI Committee in compliance with all
Privacy Act and HIPAA regulations. These remain the property of the
CG. The patient’s CG health care record must at a minimum include
the diagnosis(es), treatment plan, current psychiatric medications,
and pertinent laboratory and imaging studies. MH diagnoses will
follow Diagnostic and Statistical Manual of Mental Disorders
(current edition) language and format. Psychotherapy notes must not
be placed into a CG health care record.”
12. Peer review. Per REF (A), all privileged CG providers will
participate in a peer review program with similar providers. BH
Providers will generally perform peer review with and for other BH
Providers. Procedures for performing peer reviews are outlined
in REF (B). 
13. POC: CAPT Shane Steiner, Chief, Operational Medicine,
COMDT (CG-1121), at: 202-475-5256, Shane.C.Steiner@uscg.mil and
CAPT Jerald Mahlau-Heinert, Mental Health Integrator,
at: 202-475-5155, Jerald.L.Mahlau-Heinert@uscg.mil.
14. Released by RADM Dana L. Thomas, Direct of Health, Safety,
and Work-Life (CG-11) and RADM Joanna M. Nunan, Assistant Commandant
for Human Resources (CG-1).
15. Internet release is authorized.