[Federal Register Volume 89, Number 82 (Friday, April 26, 2024)]
[Notices]
[Pages 32527-32529]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-09033]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs; Marriage and Family Therapist 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 Marriage and Family Therapists. 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 June 25, 2024.

ADDRESSES: Comments must be submitted through https://www.regulations.gov Except as provided below, comments received before 
the close of the comment period will be available at https://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: https://www.regulations.gov/. 
VA will not post on https://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 
considered.

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 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,

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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.

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 is one overarching directive to describe 
Veterans Health Administration (VHA) policy on national standards of 
practice. The directive is accessible on the VHA Publications website 
at https://vaww.va.gov/vhapublications/ (internal) and https://www.va.gov/vhapublications/ (external). As each individual national 
standard of practice is finalized, it is published as an appendix to 
the directive and accessible at the same websites.
    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 specific occupations and what 
should be included in the national standard of practice for that 
occupation. The listening session for Marriage and Family Therapists 
was held on September 21, 2023. At the listening session, there was one 
presenter who represented the American Association of Marriage and 
Family Therapy. The presenter supported the Marriage and Family Therapy 
national standard of practice and urged VA to allow all providers to 
practice to the full extent of their license and education. The 
presenter stated that maximizing utilization of provider skills would 
make access to care more efficient and would lower costs. VA 
appreciates the thoughtful presentation and considers the information 
presented at the listening session when drafting the proposed VA 
national standard 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 with 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 the Proposed National Standard for Marriage and Family 
Therapist

    The format for the proposed national standards of practice when 
there are

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State licenses is as follows. The first paragraph provides general 
information about the profession and what the health care professionals 
can do. For this national standard, Marriage and Family Therapists are 
licensed professionals who provide psychotherapy to couples, families, 
individuals, and groups. 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 they will be able to practice within VA 
notwithstanding their State license, certification, registration, or 
other State requirements.
    The second paragraph references the education and State license, or 
other requirement, 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 differ from a State 
requirement. National standards of practice do not affect those 
requirements. For Marriage and Family Therapists, VA qualification 
standards require an active, current, full, and unrestricted State 
license.
    The second paragraph also notes whether the national standard of 
practice explicitly excludes individuals who practice under 
``grandfathering'' provisions. Qualification standards may include 
provisions to permit employees who met all requirements prior to 
revisions to the qualification standards to maintain employment at VA 
even if they no longer meet the new qualification standards. This 
practice is referred to as grandfathering. Marriage and Family 
Therapists have grandfathering provisions included within its 
qualification standards, and VA proposes to have those individuals be 
authorized to follow the Marriage and Family Therapist national 
standard of practice. Therefore, there would be no notation regarding 
grandfathered employees in the national standard of practice as they 
would be required to adhere to the same standard as any other VA 
Marriage and Family Therapist who meets the current qualification 
standards.
    The third paragraph describes what tasks and duties the profession 
will be able to perform within the scope of their VA employment. It 
includes whether the profession can practice all duties covered by 
their State license. For Marriage and Family Therapists, VA reviewed 
State license requirements and found no variance in how VA Marriage and 
Family Therapists practice in any State.
    This national standard of practice does not address training 
because it will not authorize VA Marriage and Family Therapists to 
perform any tasks or duties not already authorized under their State 
license.
    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 Marriage and Family 
Therapist

    1. Marriage and Family Therapists provide psychotherapy to couples, 
families, individuals, and groups. These professionals are licensed to 
diagnose and treat mental health disorders such as depression, post-
traumatic stress disorder, anxiety, and other mental health disorders. 
Marriage and Family Therapists have specialized training in family 
systems theory and are well qualified to treat relationships issues, 
including marriage or couples counseling, and child-parent challenges.
    2. Marriage and Family Therapists in the Department of Veterans 
Affairs (VA) possess the education and license required by VA 
qualification standards. See VA Handbook 5005, Staffing, Part II, 
Appendix G44, dated April 18, 2018.
    3. VA Marriage and Family Therapists can practice all duties 
covered by their license. VA reviewed license requirements for this 
occupation in February 2024 and confirmed there is no variance in how 
VA Marriage and Family Therapists practice in any State.

Request for Information

    1. Is VA's assessment of what States allow and do not allow 
accurate?
    2. Are there any other areas of variance between State licenses, 
certification, or registration that VA should preempt that are not 
listed?
    3. 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 April 5, 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.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2024-09033 Filed 4-25-24; 8:45 am]
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