On Jan. 1, California Assembly Bill 2348 took effect as law, allowing RNs to dispense hormonal birth control independently. The law expands the scope of practice for nurses in California, giving RNs who work in clinics the authority to conduct a patient/family history, vital sign assessment and then dispense or administer hormonal contraception without a physician’s order or pelvic exam.
Patients may obtain hormonal medication from RNs for up to three consecutive years. After that, a visit with a physician, nurse practitioner, certified nurse-midwife or physician assistant is required. The law also allows RNs to dispense medication ordered by an NP, CNM or PA, when practicing in a specified clinic. Before the law took effect, RNs only could dispense hormonal birth control ordered by an MD. The law applies only to RNs working in clinics that have medications in-house for the RN to physically hand to the patient. RNs cannot issue prescriptions for hormonal contraceptives.
The standardized procedure includes RN training, competency evaluation and use of the Centers for Disease Control and Preventions most recent version of the United States Medical Eligibility Criteria for Contraceptive Use. Use of the USMEC determines which hormonal contraceptives can be dispensed and under what circumstances.
Pro, con and neutral
Planned Parenthood Affiliates of California was one of the bill’s supporters. President and CEO Kathy Kneer said the organization’s goal was to expand access to birth control for women in California. She said that because of the shortage of healthcare providers — particularly in rural areas where shortages may be more pronounced — it made sense to enable RNs to provide this type of service. Kneer’s organization believes RNs are integral to healthcare and she said the law incorporates skills that fall within nurses current scope of practice, such as conducting a patient history and assessment.
The California Nurses Association opposed the bill. “The CNA fully supports the expansion of the availability of birth control for all women, but we want safe legislation,” said Stephanie Roberson, a legislative advocate with the CNA.
The association is concerned that the law may have the opposite effect of what it was designed to do. Roberson said clinics may hire more RNs to dispense contraceptives and have fewer MDs and NPs on hand to screen patients for cervical cancer and STDs.
The association said it would prefer that patients be required to first see a provider with more credentials for all appropriate exams, tests and prescriptions.
Seeing a provider can be even more important for rural patients who may face logistical difficulties traveling to a clinic, the association said. Having to return for additional care from a higher-level provider will make comprehensive care more ambiguous, Roberson said.
The California Association for Nurse Practitioners initially opposed the bill. Beth Haney, RN, DNP, FNP-C, president of CANP, said two of its early concerns were the legality of RNs dispensing medications ordered by an NP and the issue of delegated authority. The earlier version of the bill also excluded college health centers and physician’s offices as covered locations. The CANP worked with the bill’s sponsors to iron out their differences and now holds a position of neutrality toward the law.
Haney said that while CANP supports increased access to birth control, its position was that the same outcome could have been achieved under current law through standard orders or protocols written by medical directors of clinics.
Awaiting billing codes
Even though the law has taken effect, California’s Medicaid program, known as Medi-Cal, has not issued billing codes for RN services for dispensing hormonal contraceptives, Kneer said. Consequently, California’s Planned Parenthood has not yet implemented the use of nurses for this service. A survey of four college and university student health centers in Southern California revealed that they have not implemented the law either, but plan to do so soon.
Training of RNs at Planned Parenthood is forthcoming. According to Kneer, Planned Parenthood has eight affiliates in California operating multiple sites. Each affiliate’s medical director will oversee the establishment of standardized procedures. However, each clinic’s administrator will determine which RNs meet their threshold for practicing under the new law as well as the training, evaluation and quality assurance of the RN and service after the law is implemented.
For information on the law, visit www.CA.gov and search the terms “Assembly Bill 2348.”