What motivates us to work as nurse case managers? Is it the sense of accomplishment we feel when we work through a challenging issue and achieve that coveted win-win outcome? Is it the pleasure of working with colleagues who share our passion for providing quality case management services? Perhaps it is the simple desire to provide for our families. Perhaps it is all of the above. What ever it may be, it is safe to say it is not our plan to place ourselves at legal risk.

However, it is an undeniable fact for those who work in telephonic health care settings that our work is putting us at risk. Nurse case managers (NCM) providing services to patients who live in states other than the nurse’s home state must be licensed in the state the patient resides in. If this is not so, the NCM is working without a valid license to practice.

Considering that thousands of NCMs work in telenursing or telehealth settings across the country, this scenario needs to be resolved. It would be an expensive and altogether onerous requirement for telephonic nurse case managers to obtain and maintain multiple nursing licenses as a requirement to perform their day-to-day activities.

There is, in fact, a process in place that allows case managers providing telephonic services to practice within a legal framework. It is the Nurse Licensure Compact (NLC), also known as multistate licensure.

Multistate licensure is a mutual-recognition model that enables a nurse licensed in a “compact state” to practice legally in all other compact states. Developed and implemented in the late 1990s by the National Council State Boards of Nursing (NCSBN), the concept of one license for each nurse is similar in a broad sense to an automobile driver’s license — as long as state laws are acknowledged and followed, a driver licensed in one state can legally drive in all other states in the U.S. Nurses residing in NLC states have a “privilege to practice” in all other states belonging to the NLC. See the list below.

PRIVILEGE TO PRACTICE
Currently, 23 states participate in the compact: Arizona, Arkansas, Colorado, Delaware, Idaho, Iowa, Kentucky, Maine, Maryland, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, South Carolina, South Dakota, Tennesee, Texas, Utah, Virginia and Wisconsin.

The fact that fewer than half of our states honor other states’ nursing licenses is of grave concern to nurses practicing across state lines. Why? Because the stakes are very high. When a nurse provides case management or telehealth services without a valid nursing license to practice in the patient’s state of residency, the case manager is in violation of the law. Practicing without a license is a serious offense that carries legal and financial consequences, including permanent loss of nursing licensure, up to $1,000 in fines, and up to one year in jail.

Adding to an NCM’s burden is the fact that no professional liability carrier will cover a nurse practicing without a valid license. This leaves the individual open to personal liability should legal action lead to an assessment of damages. In a 2006 Case In Point interview, Michael Loughran, the executive vice president of Healthcare Providers Service Organization (HPSO), reminds case managers to “be sure to protect their license. The best way to do that is not to practice in a state where they’re not licensed, either performing traditional or telephonic services.” A new HPSO professional liability insurance program for case managers covers only those activities sanctioned under individual state’s Nurse Practice Acts. Practicing without a valid nursing license is never permissible and would therefore be excluded from coverage under this new NCM policy.

WHAT CAN I DO?

Case managers can increase their knowledge of this important issue in several ways. The new CMSA website has a page dedicated to multistate licensure within the “policy makers” tab. The CMSA position statement provides valuable background information on the issue. Links to other sources of information are provided, including the National Council of State Boards of Nursing (www.ncsbn.org). Here are some specific actions you can take to move the issue of multistate
licensure toward resolution:

1. Review the CMSA website (www.cmsa.org) for additional background information, template letters, and a detailed list of
contacts. Discuss this issue with colleagues and employers to increase general awareness.

Suggestion for NCMs in compact states:

• Personalize and send “support of the NLC” letter to NCSBN.

Suggestions for NCMs in non-compact states:

• Determine SNA executive director and state board of nursing contact.
• Personalize and send “support of the NLC” letter to SNA with copies to organizations listed on letter.
• Determine state health care legislators and/or legislators from your state’s website.
• Personalize and send “support for legislation requiring state to join NLC” letter to appropriate contacts.

2. Review the American Nurses Association (www.ana.org) website. Details of ANA’s stance can be found on the ANA website by entering “MSL” in the search field on the home page. Of particular interest is a document titled Nursing Regulation for the New Millennium: The Mutual Recognition Model, which was posted last December. ANA members should ask their state nurses association to request that ANA reinvigorate discussions about this important issue.

3. If you live in one of the 27 non-compact states and are interested in learning more about presenting NLC model rules to your state legislation, contact your local CMSA Legislative Committee, or the national CMSA Public Policy Committee for
assistance. Case managers excel at advocating for our patients. We assess a problem, develop a strategy to affect a positive change, implement our plan, reassess outcomes and adjust our strategy until positive outcomes are achieved. Now is the time to advocate for ourselves and our NCM colleagues regarding multistate licensure. Our strength is in numbers.

Carol K. Smith, RN-BC, MSN, a telephonic case manager based in Phoenix, Ariz., is certified as a nurse case manager through ANCC and has served as an NCM Content Expert for the same organization. Carol is active in CMSA and welcomes comments. [carolsmithaz@gmail.com]