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Scope of Practice for Extension Agents Delivering Health Programs

Extension Agents charged with delivering preventive and chronic disease self-management programs have become increasingly common as the national Cooperative Extension System seeks to meet the current and trending needs of citizens across the country. As agents with varying credentials are secured, a common set of guidelines for how that expertise will be utilized through the Extension system is needed. This set of guidelines, or “scope of practice,” will define a niche for health Extension Agents within the broader healthcare system, will set clear expectations for the agents, administration, and partner organizations, and will provide a framework for identifying clear measures of success for agents and their programs. The suggested scope-of-practice that is outlined here has helped to guide our workforce recruitment, training, and health program delivery in the state of South Carolina.

While access, use, and quality of healthcare are responsible for only about 10% of the overall health of an individual, the United States continues to allocate approximately 90% of the national health budget to healthcare.1 The other 90% of a person’s health is the result of lifestyle, environment, and genetics. Lifestyle factors are the habits and behaviors that shape the way a person or group lives.2 In the context of health, a healthy lifestyle includes a healthy diet, physical activity, maintenance of healthy body weight, smoking cessation, and limited alcohol consumption.3 A person’s environment often reinforces lifestyle behaviors and includes things like the availability of healthy food and access to health and social resources. People from underserved communities are especially vulnerable to these environmental determinants of health and are often faced with food deserts and unreliable sources of transportation making lifestyle behavior change challenging.4 Furthermore, traditional healthcare systems do not have the capacity for extended reach into the community to address these lifestyle and environmental challenges,5 resulting in increased health disparity in people from low resource and rural communities.

In 2014, the Extension Council on Policy (ECOP) published the Cooperative Extension’s National Framework for Health and Wellness.1 The ECOP suggested that land-grant universities have the knowledge and expertise to address national health trends, and Cooperative Extension Services (CES) has a demonstrated history of reaching and engaging individuals in low-resource, rural communities.6 There is a potential to apply the CES model to health and improve health-related self-care and outcomes. ECOP concluded that the national health needs, combined with the assets of CES, make it a “critical time to create a new programmatic focus” in CES.1 In SC, we have responded to this by creating the Rural Health and Nutrition Extension Program Team to take on a new programmatic focus for the prevention and management of chronic disease.

Health and nutrition programs in SC have been developed in alignment with the university CES mission: “to improve the lives of SC citizens.” Programs address chronic disease prevention and self-management through education and support and have been designed to work in partnership with healthcare providers and community organizations. Health Extension Agents deliver research-based education while assisting participants with social determinants of health such as food access, health literacy, and resource navigation in their communities. Agents address long-term behavior change that can lead to the prevention of chronic disease or disease co-morbidities. In cases where participants have already been diagnosed with a chronic disease, education efforts focus on reinforcement of medical advice received from their health care providers or following general, professional authority recommendations for disease prevention or self-management.

With this programmatic focus, questions about the role of Extension Agents relative to other healthcare professionals have been raised. All healthcare professions have a scope of practice that has been established to outline what kind of procedures, actions, and processes a health professional may perform. This ensures that patients are receiving the right information from the right person as they progress through the healthcare system. However, Dubay-Persaud et al. (2019) reported that 49% of healthcare workers were asked to perform outside of their scope of training.7 The most common reasons for this included a mismatch of skills with host expectations and a perceived lack of alternative options. When health professionals are asked to perform outside of their scope of practice, they are at increased risk for experiencing moral distress that could persist over time.7 As sources of reliable, research-supported information, Extension Agents delivering health programs are often asked for medical advice with current, previous, or newly diagnosed diseases.

“Medical advice” is advice given by a doctor about an individual’s specific needs related to an illness or injury.8 Providing medical advice that is not verified and supported by prescribed clinician recommendations puts individuals at risk for medical liability. In general, medical advice should only be given by licensed healthcare professionals who have the knowledge, training, and skills, as well as the overall patient medical history and treatment history to provide individualized assessment, intervention, and follow-up care as appropriate.9 Extension Agents should encourage compliance with medical advice that individuals have already received and help participants navigate resources needed to maintain that compliance. To assist Extension Agents with providing appropriate information that does not cross the line into medical advice, we have outlined a clear scope of practice with alternative responses for addressing questions and requests that fall outside of this framework.

General Guidelines

  • Discuss with CES agents, university administration, healthcare and community organization partners and program participants that health Extension Agents are not medical doctors and that they cannot tailor the content of their programs or lessons to individual needs
  • Use only approved content, information, and curriculum for the delivery of health and nutrition programs.
  • In general, beyond guidelines that have been published by national professional organizations like the American Heart Association or the American Diabetes Association, Extension Agents should not:
    • prescribe diets
    • give out individualized medical nutrition therapy advice
    • recommend prescribed medication changes (type, time or frequency)
    • recommend individualized blood glucose monitoring times or frequency
    • recommend individualized target blood glucose or blood pressure levels
    • recommend individualized methods for treating low or high blood glucose or blood pressure levels
    • provide advice about the clinical care of co-morbidities (like foot ulcers or neuropathy)
  • Even if an agent knows the answer to a question out of scope, agents should refer an individual to his or her primary health care provider for any of these concerns or questions.
  • For clients who do not have ready access to a health care provider, Extension Agents should not provide medical advice but can emphasize general recommendations made by professional authorities (such as the American Diabetes Association, American Heart Association, USDA guidelines, etc.).
  • Agents may assist participants with finding a local primary healthcare provider for further recommendations, clinical care, and services.
  • Extension Agents should discuss this scope of practice with clinical partners, other agents, Extension supervisors, and participants, to ensure that everyone understands these expectations and agrees on who should be referred to Extension health programs.
  • Agents should utilize the most up-to-date community needs assessments and community asset mapping to maintain knowledge of available health and social resources in their county or community. Resources might include primary care physicians, certified diabetes educators, and registered dietitians through local hospitals/clinics as well as emergency food assistance facilities, SNAP, WIC, and other public assistance programs and offices.
  • Agents should contact their Extension supervisor if assistance is needed in deciding how to respond to a request that may involve medical or medical nutrition therapy advice.

A detailed description of allowable and unallowable responses with alternatives is outlined in table 1.

Conclusion

Extension Agents are expert educators and trusted sources of research-supported information. Defining a scope of practice for Extension Agents delivering health and nutrition programs allows agents to focus their area of expertise, protects them from medical liability, and encourages outside organizational partnerships for reciprocal referral and services.

Table 1. Allowable and unallowable actions within the scope of practice for health Extension Agents in SC.

Allowable Unallowable with Alternative responses
Do encourage a whole diet approach: using the USDA food icon/dietary Guidelines or condition-specific guidelines outlined by national program/professional topic authorities. Do use approved curriculum for information transfer of these guidelines. Do not individualize diets with calorie or nutrient recommendations for managing disease-specific conditions. Do not recommend diets based on personal bias that are unsupported by research and do not have “significant scientific agreement” as outlined by the FDA for health claims (such as vegan or paleo diets).
Do provide recommendations outlined in approved curriculum vetted in best-practices and standards of care for prevention and self-management of conditions (i.e., yearly dilated eye exam for someone with diabetes). Do not provide biased advice or personal opinions about preventive practices. Do not provide recommendations from unauthorized sources.
Do teach individuals how to read Nutrition Facts and ingredient information on food labels and apply the information to prevention or self-management of chronic diseases like hypertension and diabetes. Do not provide instruction or answer questions about specific amounts of nutrients, foods, and/or recipes that may or may not be eaten on a specific diet. For example, do not recommend that someone “eat 30 grams of carbohydrate per meal.” (alternative: provide national (ADA) recommendations for a range of grams of carbohydrate in a snack or meal)
Do teach menu planning using approved curriculum methods for self-management of conditions and the USDA food icon/current Dietary Guidelines for prevention. Do not plan menus for individuals on a special diet. Do not adjust your teaching or stray from the approved curriculum guidelines. (alternative: “check with your dietitian/let me get you a list of dietitians”)
Do teach individuals to prepare recipes in accordance with approved guidelines and curriculum. For example, demonstrate how to prepare recipes using low-fat ingredients. Do not label recipes as “appropriate” or “inappropriate” for a medically prescribed diet. For example, do not state, “this recipe is good for low sodium diets.” (alternative: “this is a recipe that is lower in sodium than the original recipe”)
Do encourage individuals to ask their health care providers when they have questions about individual labs or modifying their diets, medications, monitoring schedules, or medical devices for any medical condition such as diabetes or hypertension. Do not interpret or explain an individual’s labs or logging data. (alternative: “these are the guidelines. How do you think your labs compare?”). If pressed further with questions, refer to a clinician.
Do respond to medical or nutritional myths and misinformation by reviewing whole diet, condition-specific guidelines with a group, and encouraging individuals to check with their health care providers who can give them individualized accurate information. Do not provide medical or nutrition therapy advice, even if you believe that learners or others have offered or shared medical or nutrition therapy information that is inaccurate. For example, do not state, “oranges are fine on a diabetic diet” after an individual has told you their healthcare provider told them not to eat oranges. (alternative: “check back with your physician or dietitian”)
Do suggest individuals contact their health care providers when they want advice about their symptoms. Do not diagnose conditions or diseases. For example, do not tell an individual that he/she has lactose-intolerance or an allergy based on their description of symptoms. (alternative: “let your doctor know you’re experiencing these symptoms”)
Do emphasize that nutrient needs should be met primarily through consuming foods. Do not recommend specific brands or amounts of vitamin or mineral supplements. Do not recommend herbal supplements, meal replacement products such as weight-loss beverages, and “energy” or sports products such as protein bars or sports drinks. Do not advise on drug-supplement-nutrient interactions. (alternative: “check with your doctor before you use any nutritional supplements”)
Do measure weight and height as outcome indicators with participant permission. Do encourage participants to measure and log blood pressure using an individual home blood pressure monitoring device. Do not measure blood pressure of participants. (alternative: ask participants to take their own BP measurement and self-report their reading.)
Do recommend self-tracking of bioindicators. Do provide or recommend curriculum-approved tracking tools or nutrition/activity devices for self-monitoring (such as logs or pedometers). Do recommend participants share results with medical professionals. Do not assess participant bioindicator tracking records. (Alternative, provide normal ranges/guidelines and refer to clinical partner to set up an appointment or triage).
Do refer to local resources that can provide clinical services, supplies, medications, or other needs to participants for prevention and self-management. Do provide an all-inclusive, local resource list and assist with navigating those resources to participants enrolled. Do not recommend specific brands of glucometers or blood pressure monitors. Do not bias referrals for healthcare or social services to specific partners or organizations (include all local options).
Do recommend physical activity based on general Physical Activity Guidelines for Americans or professional practice group guidelines. Do encourage walking and active transportation. Do encourage participants to get clearance by their physicians prior to starting a physical activity program. Do utilize the “Move Your Way” Department of Health and Human Services campaign materials. Do not provide individualized training sessions for physical activity (personal training) (alternative: encourage or lead walking groups with personal or physician waiver).
Do provide unbiased referrals and contact information for all participant concerns outside of this established “Scope of Practice.” Do not provide information outside of this “Scope of Practice” for health Extension Agents in SC. (alternative: “Individual needs may vary slightly from these guidelines, but providing individual recommendations is outside of my expertise. I will gladly refer you to someone who can answer your questions.”)

References Cited

  1. Braun B, Bruns K, Kronk L, Fox LK, Kukel S, Le Menestrel S, Llyod LM, Reeves C, Rennekamp R, Rice R, Rodgers M, Samuel J, Vail A, Warren T. Cooperative extension’s national framework for health and wellness. Issue brief. Extension Committee on Organization & Policy (ECOP), Association of Public Land Grant Universities. 2014 [accessed 2020 Feb]. http://www.aplu.org/members/commissions/food-environment-and-renewable-resources/CFERR_Library/national-framework-for-health-and-wellness/file?id=5134.
  2. Citation [def. 2]. (n.d.). Merriam Webster Online. http://www.merriam-webster.com/dictionary/citation.
  3. World Health Organization. Regional Office for Europe. Healthy living: what is a healthy lifestyle? Copenhagen: WHO Regional Office for Europe. 1999 [accessed 2020 Feb 21]. https://apps.who.int/iris/handle/10665/108180.
  4. James CV, Moonesinghe R., Wilson-Frederick SM, Hall JE, Penman-Aguilar A, Bouye K. Racial/ethnic health disparities among rural adults – United States, 2012-2015. Morbidity and mortality weekly report. Surveillance summaries (Washington, DC: 2002). 2017:66(23), 1–9.
  5. Pinto AD, Bloch G. Framework for building primary care capacity to address the social determinants of health. Canadian Family Physician. 2017 Nov 1;63(11):e476-82. doi:10.15585/mmwr.
  6. Warner P, Christenson J. The Cooperative extension service. New York (NY): Routledge; 1984 [accessed 2020 Feb 21]. doi:10.4324/9780429309809.
  7. Doobay-Persaud A, Evert J, DeCamp M, Evans CT, Jacobsen KH, Sheneman NE, Goldstein JL, Nelson BD. Extent, nature and consequences of performing outside scope of training in global health. Globalization and health. 2019 Dec 1;15(1):60. doi:10.1186/s12992-019-0506-6.
  8. FindLaw. Thomson Reuters; 2020 [accessed 2020 Mar 2]. https://healthcare.findlaw.com/patient-rights/what-is-the-unauthorized-practice-of-medicine.html.
  9. The role of nutrition in maintaining health in the nation’s elderly: evaluating coverage of nutrition services for the Medicare population. Institute of Medicine (US) Committee on Nutrition Services for Medicare Beneficiaries. Washington (DC): National Academies Press (US); 2000 [accessed 2020 Feb 21]. https://www.ncbi.nlm.nih.gov/pubmed/25077252.

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