The Dr. Lorna Breen Heroes’ Foundation led the Virginia ALL IN: Caring for Our Caregivers initiative to remove questions about past mental health conditions from the licensing and credentialing applications for health professionals. Through informational resources and an audit process, the initiative encouraged hospitals to change their credentialing applications to remove overly broad and invasive questions about health workers’ mental health. The initiative successfully championed legislation eliminating similar questions from the state licensing process for all licensed health care workers.
State licensing and hospital credentialing applications seek to protect patients by confirming that clinicians are fully trained and practice professionally. Questions on licensing and credentialing applications that ask about a history of any diagnosis or treatment, as opposed to current impairment, are stigmatizing and can deter clinicians from receiving care. For example, the question, “Have you been diagnosed with, and/or have you received treatment for a physical, mental, chemical dependency or emotional condition which could impair your ability to practice?” includes an unlimited timeframe and conjecture about the future impact through the use of “could.” This question was changed to “Are you diagnosed with or receiving treatment for any condition (physical, mental, emotional or substance dependence related) that currently impairs your ability to practice medicine?” Change needs to happen at both the hospital credentialing and state licensing levels; therefore, the goal of ALL IN: Caring for Our Caregivers was to advocate for legislation in Virginia affecting state licensing and provide support for credentialing change at hospitals.
Through the Virginia Hospital & Healthcare Association (VHHA), hospitals committed to using the ALL IN Licensure and Credentialing Toolkit to audit and change the language on credentialing applications and peer reference forms.1 Hospitals verified the change by submitting their materials for a third-party review by lawyers trained to identify concerning language and suggest alternatives. Once verified, hospitals were identified as “WellBeing First Champions” and given tools to communicate the change.
Additionally, the Medical Society of Virginia provided language for HB1573, a bill in the Virginia House of Delegates, and SB970, a companion bill in the state Senate, to direct the Department of Health Professions to amend its licensure, certification, and registration applications to remove questions about mental health conditions and impairment for all licensed health workers, including physicians, nurses, and pharmacists.
The Dr. Lorna Breen Heroes’ Foundation led the initiative, which came together through joint support by the Virginia Hospital & Healthcare Association (VHHA), the Virginia Nurses Association, and the Medical Society of Virginia, to make Virginia a “best place to work” for health care. The population for the intervention was hospitals in Virginia, as well as state government.
ALL IN: Caring for Virginia’s Caregivers launched in December 2022, through the initiation of a steering committee representing 12 hospitals or health systems, and a webinar that included all hospitals through the VHHA. In addition, a launch event occurred during the VHHA annual meeting. Advocacy efforts for the state licensing law culminated in the signing of HB1573 into law on March 16, 2023. Phase 1 lasted through April 2023, with a focus on hospital credentialing change. The VHHA issued reminder e-mails throughout the process and hosted a webinar on March 31, 2023, announcing the hospitals that were confirmed as WellBeing First Champions during the first five-month period. After the initial period, change efforts continued for an additional five-month period, ending September 2023.
The Federation of State Medical Boards,2 the American Medical Association,3 and the American Psychiatric Association4 recommend against overly broad and invasive mental health questions. Such questions on licensing and credentialing applications are shown to be ineffective at protecting the public and may violate the Americans With Disabilities Act.5 Moreover, these disclosures result in a pervasive and well-documented stigma that prevents clinicians from seeking mental health care.6
This first phase focused on changing state licensure and hospital credentialing applications because this change is a “linchpin” to dismantle a culture in which health workers fear to seek treatment. This work paves the way for subsequent efforts to support the well-being of health workers; future phases of the initiative focus on evidence-informed actions that leaders can take to support workers and build a long-term well-being strategy.
In the first five months, the following hospitals or hospital systems verified that their applications were consistent with recommendations: Children’s Hospital of the King’s Daughters, Inova Health System, Sentara Healthcare, and University of Virginia Health System. These systems represent 26 (24%) of the 110 hospitals in Virginia. In the next five months, Bon Secours Mercy Health, Valley Health, Mary Washington Health, Centra Health, and Augusta Health systems were verified, representing an additional 26 hospitals, bringing the total to 47% of Virginia hospitals. After the initial two periods, an additional 22 hospitals are in the process of change and verification. Upon completion, 67% of Virginia hospitals will have changed their questions (Figure 1). Individual organizations in the “laggard” phase may need additional outreach to affect change. The initiative only has access to credentialing applications that were voluntarily submitted for verification after audit and change, so it is unknown which remaining hospitals are eligible for verification without change. Changes made by the involved hospitals occurred both before and after the initial application. Most applying hospitals needed to change their credentialing application or peer reference form to be eligible.
FIGURE 1— Credentialing Best Practice Uptake During 10 Months of Effort in Virginia, as Mapped to the Rodgers Adoption Curve, Beginning December 2022
Note. The All IN initiative confirmed change in the innovator and early adopter categories and initiated progress through the early majority and into the late majority. Adopter categorization was on the basis of innovativeness. The sample size was n = 110 hospitals.
Source. Diffusion of Innovations, fifth edition by Everett M. Rogers. Copyright 2003 by The Free Press. New York.
On March 16, 2023, Virginia Governor Glenn Youngkin signed into law HB1573 and SB970 to require the Department of Health Professions to amend its licensure, certification, and registration applications to remove any existing questions pertaining to mental health conditions and impairment for all licensed health care workers. This action readied Virginia to amend its state licensure application, and this change is in progress (Figure 2). Through advocacy, eight additional states changed their physician licensing applications during this time. Virginia is unique in its inclusion of all licensed health care workers.
FIGURE 2— State Medical Boards in the United States That Have Audited and Changed Intrusive Language Regarding Mental Health in Licensure Applications, as of October 5, 2023
The removal of overly broad and invasive mental health questions is cost-free and evidenced-based, and it positively affects the mental health and well-being of health workers. All US states, hospitals, and health systems can implement the ALL IN: Caring for Our Caregiver’s framework to become WellBeing First Champions and create environments in which every health worker can freely seek care. To help replicate the process, ALL IN: WellBeing First for Healthcare provides a toolkit, available on the organization’s Web site.
Additionally, Dr. Lorna Breen Heroes’ Foundation asks all hospitals and health systems to voluntarily reverify that changes remain in place on an annual basis for continued recognition as a “WellBeing Champion.” This annual step helps to inform health workers that it remains safe for them to seek care.
As of 2019, more than one physician in the United States dies by suicide every day.7 The COVID-19 pandemic has only magnified these challenges; record-high levels of physician burnout (over 60%) were reported in 2022.8 Nevertheless, many US health workers still face unique barriers to receiving mental health care.
Public health, health care, and legislators must work together to remove these barriers to health workers receiving care. Interventions that target root causes have enormous potential to positively affect the lives of health workers, and the patient population also benefits from a healthier workforce and more sustainable health care system.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
