ACN 095/21 - OCT 2021 ADVANCED PRACTICE PROVIDER POLICY UPDATE

R 141256Z OCT 21
FM COMDT COGARD WASHINGTON DC
TO ALCOAST COMDT NOTICE
BT
UNCLAS
ACN 095/21
SSIC 6000
SUBJ: ADVANCED PRACTICE PROVIDER POLICY UPDATE
A. COMDT COGARD WASHINGTON DC 061253Z OCT 20/ACN 119/20
B. COMDT COGARD WASHINGTON DC 180954 JUN 19/ACN 063/19
C. Coast Guard Medical Manual, COMDTINST M6000.1 (series)
1. This ACN cancels REF (A) and (B).
2. This ACN establishes updated policy regarding utilization and
scope of practice of advanced practice providers (APPs) which
include physician assistants (PAs) and nurse practitioners (NPs).
3. This ACN applies to active duty and reserve Coast Guard personnel
and other Uniformed Services personnel detailed to the Coast Guard,
as well as contracted civilians and GS civilians.
4. Updated Department of Defense directives, Veterans Affairs
policies, and civilian APP laws and regulations over the past 10-15
years have broadly increased the use and scope of practice of these
medical providers. Historic use of supervisory language and practice
are being replaced. Many recently revised standards of APP practice
emphasize collaborative team practice in lieu of supervision. These
APP supervisory policies have placed an unnecessary administrative
burden on physicians and APPs. Updated policy and practice are
necessary to enable all APPs to provide clinical care to the full
extent of their education, training, and experience.
5. Chapter 1B of REF (C) will reflect the below updates in the next
revision.
     a. Supervised, assigned PAs and NPs and its definition is no
longer part of this policy and will now read "Supervise assigned
MOs. To ensure the competence and skill of those providing health
care and services to every category of Coast Guard medical
beneficiaries, all health care personnel are provided supervision of
their clinical performance, as appropriate. Supervisory activities
are performed in the context of the relationship that exists between
supervisor (senior staff member) and employee (subordinate staff
member). The assessment and ongoing validation of the employee's
ability to perform various privileged tasks or patient care
activities, as applicable, substantiates the competency of both
privileged and non-privileged health care personnel. A Clinical
Appraisal Report will be completed for all MOs at the beginning
of the privilege renewal process. The Credentialing Verification
Office (CVO) will ensure this is completed prior to Level 1
privileging reviews.
     b. Duties of Medical Officers (MO) and its definition is no
longer a part of this policy and will now read "Duties of Medical
Officers (MOs). The principal mission of MOs is to support the
operational missions of the CG. MOs include physicians and physician
assistants who are members of the CG or PHS detailed to the CG,
and Nurse Practitioners (NPs) who are Public Health Service (PHS)
officers detailed to the CG. MOs are required to have appropriate
certification and/or licensure while assigned to the CG. Except for
DOD physician assistants, all non-DoD MOs must have an active,
unrestricted state license to practice medicine. PAs and NPs are
collectively termed Advanced Practice Providers (APPs), and must be
nationally certified by their respective organizational bodies.
Civilian medical practitioners (under contract to the CG or GS
employees) assigned to a medical treatment facility are considered
MOs to the limits defined by the language of their contract and/or
job description. Civilian medical practitioners who have a contract
with the CG to see patients in their private offices are not
considered MOs for the purpose of this Manual. All MOs, except those
serving as volunteers pursuant to a gratuitous services agreement or
those in the CG Auxiliary, must have a federal Drug Enforcement
Administration (DEA) registration number. A fee exempt Federal DEA
registration meets the requirement, and may be obtained by
contacting Commadant (CG-1121), CG Pharmacy Force Manager. Providers
will collaborate with other providers as often as needed when
additional medical advice is necessary or required by the
jurisdiction that issued their credentials. APPs will inform their
respective supervisors of any specific state license requirements.
Health care personnel employed by the federal government will abide
by the practice requirements imposed by their state of licensure
when practicable. However, compliance with state requirements must
not interfere with the individual's performance of assigned
duties/responsibilities in the specified discipline within the
federal sector. Commandant (CG-11) will determine if and when other
privileging requirements need to be implemented."
     c. Physician Assistants (PA) and Nurse Practitioners (NP) and
its definition is no longer part of this policy and will now read
"Physician Assistants (PAs) and Nurse Practitioners (NPs) are
Advanced Practice Providers (APPs)."
         (1) Not certified or licensed. APPs will not normally be hired
without current national certification and active, unrestricted
state licensure. DoD PAs detailed to the CG are required to be
nationally certified but they are not required to be state licensed
per DoD policy, and will not be required to obtain a license while
detailed to the CG. Recent Interservice Physician Assistant
Program (IPAP) graduates who are not yet certified by the National
Commission on Certification of Physician Assistants (NCCPA) must
practice in CG facilities only under the following conditions:
               (a) All health record entries shall be co-signed by a
licensed physician by the end of the next working day;
               (b) When a physician is not present at the unit,
non-certified APPs must be restricted to providing medical care,
except for emergencies, to active duty members only;
               (c) Non-certified APPs may stand clinic watches providing
a standby licensed physician is available via telephone to discuss
any questions or concerns;
               (d) With the exception of operational emergencies, these
providers are not eligible for independent TDY assignments at
locations where a licensed physician is not present.
         (2) Junior APP assignment and TDY restrictions.
               (a) New IPAP graduates will be assigned to a clinic with a
physician, and preferably also a senior APP, for the first two years
to ensure proper clinical mentorship, development, and oversight.
               (b) APPs in the first year of practice will not deploy on
solo TDY medical support missions unless approved by HSWL SC OPMED.
               (c) Other CG facilities may honor CG physician assistants'
and nurse practitioners' refills (for other than controlled
substances) if the patient presents his or her health care record
containing the original entry is no longer part of this policy.
               (d) APPs are licensed and privileged practitioners, and as
such, co-signature by a physician or other privileged provider of
APP entries in the patient's medical record, prescriptions, and so
forth, is not required, except where noted in their privilege or as
otherwise required by policy.
6. These changes will be implemented into the next revision of
REF (C), which will be released within the year.
7. This message will be cancelled on 13 OCT 2022.
8. POC: LCDR Bridget Metcalf, Physician Assistant (PA)
Force Manager, COMDT (CG-1121), (202) 475-5183,
Bridget.A.Metcalf@uscg.mil.
9. Released by RADM Dana Thomas, Director of Health, Safety and
Work-Life (CG-11).
10. Internet release is authorized.