[Federal Register Volume 89, Number 49 (Tuesday, March 12, 2024)]
[Notices]
[Pages 17898-17900]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-05237]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs

    Peer Specialist Standard of Practice
AGENCY: Department of Veterans Affairs.

ACTION: Request for information.

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SUMMARY: The Department of Veterans Affairs (VA) is requesting 
information to assist in developing a national standard of practice for 
VA Peer Specialists. VA seeks comments on various topics to help inform 
VA's development of this national standard of practice.

DATES: Comments must be received on or before May 13, 2024.

ADDRESSES: Comments must be submitted through http://www.regulations.gov. Except as provided below, comments received before 
the close of the comment period will be available at http://www.regulations.gov for public viewing, inspection, copying, including 
any personally identifiable or confidential business information that 
is included in a comment. We post the comments received before the 
close of the comment period on the following website as soon as 
possible after they have been received: http://www.regulations.gov. VA 
will not post on http://www.regulations.gov public comments that make 
threats to individuals or institutions or suggest that the commenter 
will take actions to harm the individual. VA encourages individuals not 
to submit duplicative comments. We will post acceptable comments from 
multiple unique commenters even if the content is identical or nearly 
identical to other comments. Any public comment received after the 
comment period's closing date will not be accepted.

FOR FURTHER INFORMATION CONTACT: Ethan Kalett, Office of Regulations, 
Appeals and Policy (10BRAP), Veterans Health Administration, Department 
of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, 202-
461-0500. This is not a toll-free number.

SUPPLEMENTARY INFORMATION:

Authority

    Chapters 73 and 74 of 38 U.S.C. and 38 U.S.C. 303 authorize the 
Secretary to regulate VA health care professions to make certain that 
VA's health care system provides safe and effective health care by 
qualified health care professionals to ensure the well-being of those 
veterans who have borne the battle.
    On November 12, 2020, VA published an interim final rule confirming 
that VA health care professionals may practice their health care 
profession consistent with the scope and requirements of their VA 
employment, notwithstanding any State license, registration, 
certification, or other State requirements that unduly interfere with 
their practice. 38 CFR 17.419; 85 FR 71838. Specifically, this 
rulemaking confirmed VA's current practice of allowing VA health care 
professionals to deliver health care services in a State other than the 
health care professional's state of licensure, registration, 
certification, or other State requirement, thereby enhancing 
beneficiaries' access to critical VA health care services. The 
rulemaking also confirmed VA's authority to establish national 
standards of practice for its health care professionals which would 
standardize a health care professional's practice in all VA medical 
facilities, regardless of conflicting State laws, rules, regulations, 
or other State requirements.
    The rulemaking explained that a national standard of practice 
describes the tasks and duties that a VA health care professional 
practicing in the health care profession may perform and may be 
permitted to undertake. Having a national standard of practice means 
that individuals from the same VA health care profession may provide 
the same type of tasks and duties regardless of the State where they 
are located or the State license, registration, certification, or other 
State requirement they hold. We emphasized in the rulemaking and 
reiterate here that VA will determine, on an individual basis, that a 
health care professional has the proper education, training, and skills 
to perform the tasks and duties detailed in the national standard of 
practice, and that they will only be able to perform such tasks and 
duties after they have been incorporated into the individual's 
privileges, scope of practice, or functional statement. The rulemaking 
explicitly did not create any such national standards and directed that 
all national standards of practice would be subsequently created via 
policy.

Preemption of State Requirements

    The national standard of practice will preempt any State laws, 
rules, regulations, or requirements that both are and are not listed in 
the national standard as conflicting, but that do in fact conflict with 
the tasks and duties as authorized in VA's national standard of 
practice. In the event that a State changes their requirements and 
places new limitations on the tasks and duties it allows in a manner 
that would be inconsistent with what is authorized under the national 
standard of practice, the national standard of practice will preempt 
such limitations and authorize the VA health care professional to 
continue to practice consistent with the tasks and duties outlined in 
the national standard of practice.
    In cases where a VA health care professional's license, 
registration, certification, or other State requirement allows a 
practice that is not included in a national standard of practice, the 
individual may continue that practice so long as it is permissible by 
Federal law and VA policy, is not explicitly prohibited by the national 
standard of practice, and is approved by the VA medical facility.

[[Page 17899]]

Need for National Standards of Practice

    It is critical that VA, the Nation's largest integrated health care 
system, develops national standards of practice to ensure, first, that 
beneficiaries receive the same high-quality care regardless of where 
they enter the system and, second, that VA health care professionals 
can efficiently meet the needs of beneficiaries when practicing within 
the scope of their VA employment. National standards are designed to 
increase beneficiaries' access to safe and effective health care, 
thereby improving health outcomes. The importance of this initiative 
has been underscored by the coronavirus disease 2019 (COVID-19) 
pandemic. The increased need for mobility in VA's workforce, including 
through VA's Disaster Emergency Medical Personnel System, highlighted 
the importance of creating uniform national standards of practice to 
better support VA health care professionals who practice across State 
lines. Creating national standards of practice also promotes 
interoperability of medical data between VA and the Department of 
Defense (DoD), providing a complete picture of a veteran's health 
information and improving VA's delivery of health care to the Nation's 
veterans. DoD has historically standardized practice for certain health 
care professionals, and VA has closely partnered with DoD to learn from 
their experience.

Process to Develop National Standards of Practice

    As authorized by 38 CFR 17.419, VA is developing national standards 
of practice via policy. There will be one overarching national standard 
of practice directive that will generally describe Veterans Health 
Administration (VHA) policy; each individual national standard of 
practice will be an appendix to the directive. The directive and all 
appendices will be accessible on the VHA Publications website at 
https://vaww.va.gov/vhapublications/ (internal) and https://www.va.gov/vhapublications/ (external) once published.
    To develop these national standards, VA is using a robust, 
interactive process that adheres to the requirements of Executive Order 
(E.O.) 13132 to preempt conflicting State laws, rules, regulations, or 
other requirements. The process includes consultation with internal and 
external stakeholders, including State licensing boards, VA employees, 
professional associations, Veterans Service Organizations, labor 
partners, and others. For each VA occupation, a workgroup comprised of 
VA health care professionals in the identified occupation conducts 
research to identify internal best practices that may not be authorized 
under every State license, certification, or registration, but would 
enhance the practice and efficiency of the profession throughout VA. If 
a best practice is identified that is not currently authorized by every 
State, the workgroup determines what education, training, and skills 
are required to perform such tasks and duties. The workgroup then 
drafts a proposed VA national standard of practice using the data 
gathered during the research and incorporates internal stakeholder 
feedback into the standard. The workgroup may consult with internal or 
external stakeholders at any point throughout the process.
    The proposed national standard of practice is then internally 
reviewed, to include by an interdisciplinary VA workgroup consisting of 
representatives from Quality Management, VA medical facility Chief of 
Staff, Academic Affiliates, Veterans Integrated Services Network (VISN) 
Chief Nursing Officer, Ethics, Workforce Management and Consulting, 
Surgery, Credentialing and Privileging, VISN Chief Medical Officer, and 
Electronic Health Record Modernization.
    Externally, VA hosts listening sessions for members of the public, 
professional associations, and VA employees to provide comments on the 
variance between State practice acts for a specific occupation and what 
should be included in the national standard of practice for that 
occupation. The Listening Session for Peer Specialists was held on 
September 21, 2023. No professional associations presented comments on 
the Peer Specialist scope of practice.
    VA has developed a robust process to engage with partners, members 
of the public, States, and employees on the proposed national standard 
of practice. VA provides the proposed national standard of practice to 
our DoD partners as an opportunity to flag inconsistencies with DoD 
standards. VA also engages labor partners informally as part of a pre-
decisional collaboration. Consistent with E.O. 13132, VA sends a letter 
to each State board and certifying organization or registration 
organization, as appropriate, which includes the proposed national 
standard and offers the recipient an opportunity to discuss the 
national standard with VA. After the State boards, certifying 
organizations, or registration organizations have received 
notification, the proposed national standard of practice is posted in 
the Federal Register for 60 days to obtain feedback from the public, 
professional associations, and any other interested parties. At the 
same time, the proposed national standard is posted to an internal VA 
site to obtain feedback from VA employees. Responses received through 
all vehicles--from State boards, professional associations, unions, VA 
employees, and any other individual or organization who provides 
comments via the Federal Register--will be reviewed. VA will make 
appropriate revisions in light of the comments, including those that 
present evidence-based practice and alternatives that help VA meet our 
mission and goals. VA will publish a collective response to all 
comments at https://www.va.gov/standardsofpractice.
    After the national standard of practice is finalized, approved, and 
published in VHA policy, VA will implement the tasks and duties 
authorized by that national standard of practice. Any tasks or duties 
included in the national standard will be properly incorporated into 
individual health care professionals' privileges, scope of practice, or 
functional statement once it has been determined by their VA medical 
facility that the individual has the proper education, training, and 
skills to perform the task or duty. Implementation of the national 
standard of practice may be phased in across all VA medical facilities, 
with limited exemptions for health care professionals as needed.

Format for National Standard for Peer Specialists

    The proposed format for national standards of practice when there 
are State certifications is as follows. The first paragraph provides 
general information about the profession and a broad list of tasks and 
duties these health care professionals can do. For this national 
standard, Peer Specialists are United States military veterans who 
self-identify with a lived experience of recovery from a mental health 
condition and have been professionally trained to help other veterans 
with similar experiences to identify and achieve specific life and 
recovery goals. This is an evolving profession both in and outside of 
VA. We reiterate that the proposed standard of practice does not 
contain an exhaustive list of every task and duty that each VA health 
care professional can perform. Rather, it is designed to highlight 
generally what tasks and duties the health care professionals perform 
and how this they will be able to practice within VA notwithstanding 
their State license, certification, registration, or other State 
requirements.

[[Page 17900]]

    The second paragraph references the training and certification 
needed to practice this profession at VA. Qualification standards for 
employment of health care professionals by VA are outlined in VA 
Handbook 5005, Staffing, dated November 8, 2023. VA follows the 
requirements outlined in the VA qualification standards even if the 
requirements conflict with or otherwise differ from a State 
requirement. National standards of practice do not affect those 
requirements. This includes, but is not limited to, when a State 
requires a license to practice a specific occupation, but VA does not 
require a State license as part of the qualification standards. For 
Peer Specialists, VA qualification standards require an active, 
current, full, and unrestricted certification from a State or a not-
for-profit entity with Peer Specialist training.
    The third paragraph confirms that this profession can perform all 
the duties set by the State certification bodies. For Peer Specialists, 
VA reviewed State certification requirements and State-recognized non-
profit organization certification requirements. VA found that 48 States 
certify Peer Specialists through a State certification or a non-profit 
entity and seven States do not regulate Peer Specialists. However, VA 
found no variance in how Peer Specialists practice in any State. VA 
thus proposes to adopt a national standard of practice for Peer 
Specialists that is consistent with what is permitted in all States. As 
previously noted, this VA national standard of practice is the first 
attempt at creating a comprehensive standard for Peer Specialists.
    This national standard of practice does not address training 
because it will not authorize VA Peer Specialists to perform any tasks 
or duties not already authorized under their State certifications.
    Following public and VA employee comments and revisions, each 
national standard of practice that is published into policy will also 
include the date for recertification of the standard of practice and a 
point of contact for questions or concerns.

Proposed National Standard of Practice for Peer Specialists

    1. Peer Specialists are United States military Veterans who self-
identify with a lived experience of recovery from a mental health 
condition and have been professionally trained to help other Veterans 
with similar experiences to identify and achieve specific life and 
recovery goals. Peer Specialist is an evolving profession both in and 
outside of VA, and a national scope of practice for this profession has 
not been previously developed or implemented. VA is the largest single 
employer of Peer Specialists in the United States. This VA national 
standard of practice is the first uniform set of guidelines to which 
Peer Specialists practice. Peer Specialists are actively engaged in 
their own recovery and wellness and provide individual and group-based 
peer support services to other veterans who use VA health care 
services. Peer Specialists share aspects of their personal recovery 
story and wellness strategies, when and where it is appropriate to do 
so, to be of help to others. They collaborate with other health care 
professionals on interdisciplinary treatment teams as the teams work 
toward shared goals to provide quality health care services for 
Veterans. Peer Specialists' tasks and duties include, but are not 
limited to:
    a. Assisting Veterans to explore, identify, and make progress on 
their self-directed personal recovery and wellness goals.
    b. Being role models and sharing elements of their personal 
experience, including their recovery stories, coping techniques, and 
self-help strategies to be of service to others.
    c. Collaborating with Veterans and their treatment providers to 
identify and cultivate Veterans' skills and strengths that support 
their recovery goals.
    d. Helping Veterans to learn new coping skills and self-help 
strategies to overcome fears and barriers that could inhibit the 
Veteran's personal recovery. This does not include facilitating 
psychotherapy protocols.
    e. Advocating for Veterans when needed and supporting Veterans in 
learning to self-advocate for their own needs and interests.
    f. Supporting Veterans in distress and collaborating with 
colleagues to connect Veterans with clinical providers' services and 
community services when needed.
    g. Assisting Veterans to connect to available VA and community 
resources, including conducting outreach calls to educate and engage 
Veterans to connect with available VA services.
    h. Facilitating peer support groups and co-facilitating with 
clinicians on other types of health and personal wellness groups. This 
does not include facilitating or co-facilitating psychotherapy groups.
    i. Assisting Veterans with integration activities into their 
community, as consistent with Veterans' stated goals.
    2. Peer Specialists in the Department of Veterans Affairs (VA) 
possess the training and peer specialist certification required by VA 
qualification standards. See VA Handbook 5005, Staffing Part II, 
Appendix F3, dated July 17, 2012.
    3. VA Peer Specialists can, in collaboration with their 
supervisors, practice all duties covered by their peer specialist 
certification. VA reviewed certification requirements for this 
occupation in May 2023 and confirmed there is no variance in what is 
permitted by the state-issued peer specialist certifications. As of May 
2023, the VA standard of practice is consistent with what is permitted 
in any state.

Request for Information

    1. Are there any factors that would inhibit or delay the 
implementation of the aforementioned tasks and duties for VA health 
care professionals in any states?
    2. Is VA's assessment of what tasks or duties States allow and do 
not allow accurate?
    3. Are there any areas of variance between State certifications 
that VA should preempt that are not listed?
    4. Is there anything else you would like to share with us about 
this VA national standard of practice?

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved and signed 
this document on February 13, 2024, and authorized the undersigned to 
sign and submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
General Counsel, Department of Veterans Affairs.
[FR Doc. 2024-05237 Filed 3-11-24; 8:45 am]
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