Existing law, the Physical Therapy Practice Act, provides for the licensure and regulation of physical therapists by the Physical Therapy Board of California, which is within the Department of Consumer Affairs, and defines physical therapy as the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise.

Existing law, the Veterinary Medicine Practice Act, provides for the licensure and regulation of veterinarians and the practice of veterinary medicine by the Veterinary Medical Board, which is within the Department of Consumer Affairs. That act makes it unlawful for any person to practice veterinary medicine in this state without a license and provides that the practice of veterinary medicine includes, among other things, the treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of an animal.

This bill would authorize a licensed physical therapist with a certificate in animal physical rehabilitation to provide animal physical rehabilitation to an animal if certain requirements are met, including that the animal physical rehabilitation is performed on a veterinary premise registered with the Veterinary Medical Board, in an animal physical rehabilitation facility registered with the Veterinary Medical Board, or in a mobile or range setting. in certain settings and under the supervision of a supervising veterinarian. The bill would authorize unlicensed assistants to perform an animal physical rehabilitation assistant to assist with delegated animal physical rehabilitation tasks under the direct supervision of a licensed physical therapist with a certificate in animal physical rehabilitation. The bill would define an animal physical rehabilitation facility and would require an animal physical rehabilitation facility to register with the Veterinary Medical Board and pay specified registration fees. if certain conditions are met. The bill would require the Veterinary Medical Board to create an application form and determine the application process for the certificate. The bill would require the Veterinary Medical Board and the Physical Therapy Board of California, in cooperation, to determine the qualifications necessary for a physical therapist to receive a certificate issued by the Veterinary Medical Board, as provided, and would authorize the Veterinary Medical Board to charge a fee for issuance and renewal of a certificate. The bill would provide that a physical therapist with a certificate in animal physical rehabilitation or an animal physical rehabilitation assistant is solely liable for any delegated animal physical rehabilitation tasks provided under the certificate. a direct order. The bill would authorize the Veterinary Medical Board to discipline a physical therapist with a certificate in animal physical rehabilitation. The bill would also define various terms for these purposes

Existing law, the Physical Therapy Practice Act, provides for the licensure and regulation of physical therapists by the Physical Therapy Board of California, which is within the Department of Consumer Affairs, and defines physical therapy as the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise.

Existing law, the Veterinary Medicine Practice Act, provides for the licensure and regulation of veterinarians and the practice of veterinary medicine by the Veterinary Medical Board, which is within the Department of Consumer Affairs. That act makes it unlawful for any person to practice veterinary medicine in this state without a license and provides that the practice of veterinary medicine includes, among other things, the treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of an animal.

This bill would authorize a licensed physical therapist with an advanced a certificate in animal physical rehabilitation to provide animal physical rehabilitation to an animal if certain conditions requirements are met, including that the animal physical rehabilitation is performed on a veterinary premise registered with the Veterinary Medical Board, in an animal physical rehabilitation facility registered with the Veterinary Medical Board, or in a mobile or range setting. The bill would authorize unlicensed assistants to perform animal physical rehabilitation tasks under the direct supervision of a licensed physical therapist with a certificate in animal physical rehabilitation. The bill would define an animal rehabilitation facility animal physical rehabilitation facility and would require an animal physical rehabilitation facility to register with the Veterinary Medical Board and pay specified registration fees. The bill would require the Veterinary Medical Board to create an application form and determine the application process for the certificate. The bill would require the Veterinary Medical Board and the Physical Therapy Board of California, in cooperation, to determine the qualifications necessary for a physical therapist to receive the advanced a certificate issued by the Veterinary Medical Board Board, as provided, and would authorize the Veterinary Medical Board to charge a fee for issuance and renewal of the advanced a certificate. The bill would provide that a physical therapist with an advanced a certificate in animal physical rehabilitation is solely liable for any animal physical rehabilitation provided under the certificate. The bill would also redefine physical therapy to include the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of an animal if practicing under the above-described advanced certificate. authorize the Veterinary Medical Board to discipline a physical therapist with a certificate in animal physical rehabilitation.

Existing law, the Physical Therapy Practice Act, provides for the licensure and regulation of physical therapists by the Physical Therapy Board of California, which is within the Department of Consumer Affairs, and defines physical therapy as the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise.

Existing law, the Veterinary Medicine Practice Act, provides for the licensure and regulation of veterinarians and the practice of veterinary medicine by the Veterinary Medical Board, which is within the Department of Consumer Affairs. That act makes it unlawful for any person to practice veterinary medicine in this state without a license and provides that the practice of veterinary medicine includes, among other things, the treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of an animal.

This bill would authorize a licensed physical therapist with an advanced certificate in animal physical rehabilitation to provide animal physical rehabilitation to an animal if certain conditions are met, including that the animal physical rehabilitation is performed on a veterinary premise registered with the Veterinary Medical Board, an animal rehabilitation facility registered with the Veterinary Medical Board, or a range setting. The bill would define an animal rehabilitation facility and would require an animal rehabilitation facility to register with the Veterinary Medical Board and pay specified registration fees. The bill would require the Veterinary Medical Board to create an application and determine the application process for the certificate. The bill would require the Veterinary Medical Board and the Physical Therapy Board of California, in cooperation, to determine the qualifications necessary for a physical therapist to receive the advanced certificate issued by the Veterinary Medical Board and would authorize the Veterinary Medical Board to charge a fee for issuance and renewal of the advanced certificate. The bill would provide that a physical therapist with an advanced certificate in animal physical rehabilitation is solely liable for any rehabilitation provided under the certificate. The bill would also redefine physical therapy to include the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of an animal if practicing under the above-described advanced certificate.

Date of Hearing: May 9, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 3013

Author:(Chu) – As Amended Ver:April 17, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill establishes an animal physical rehabilitation certificate at the Veterinary Medical Board (VMB). Specifically, this bill:

1. Requires the VMB to establish a certificate for animal physical rehabilitation for a licensed physical therapist (PT), as specified.
2. Requires animal physical rehabilitation facilities to register with the VMB and allows certified PTs to register such facilities.
3. Establishes associated fees.
4. Allows a supervising veterinarian to determine the appropriate level of supervision for the certified PT performing animal rehabilitation.

FISCAL EFFECT:

1. Costs to the Physical Therapy Board within the Department of Consumer Affairs (DCA) in the range of $100,000 for two years for licensing, enforcement, and administrative workload (Physical Therapy Fund).
2. Costs to the Veterinary Medical Board as follows, assuming about 250 individuals register (all costs are VMB Contingent Fund):
   1. One-time costs in the range of $600,000 for examination development, information technology, and potential facilities costs to house additional staff.
   2. Ongoing costs in the range of $125,000 annually for registration, enforcement, examinations, and information technology.
   3. Fee revenue is uncertain. If 250 individuals registered, the fee would be $1,000 every two years to support ongoing costs. One-time costs could be covered by a special fund loan if funds area available, but fees would need to increase even further to pay back the loan.

COMMENTS:

1. Purpose. This bill is sponsored by the Animal Physical Therapy Coalition to codify recommendations of a task force convened by the Veterinary Medical Board to study the issue of animal physical therapy.
2. Background. Animal physical rehabilitation is a specialized application of physical therapy to animals. It is performed largely, though not solely, on horses and dogs, and focuses mostly on rehabilitating the animal's legs. During the VMB's 2016 Sunset Review hearing, the staff background paper noted the VMB was concerned about the welfare of the animals being treated by unlicensed personnel and had found evidence of animal harm. Staff recommended the development of a task force, which convened over a period of 9 months in 2016 and 2017. The task force issued recommendations to the VMB, which this bill attempts to codify. However, at the VMB's April 19, 2017, board meeting, the VMB approved a motion to modify the task force's final recommendation to specify that a PT may offer animal physical rehabilitation under direct supervision, rather than allowing the degree of supervision to be determined by the supervising veterinarian.
3. Support. The Animal Physical Therapy Coalition supports this bill, explaining it will increase access to animal PT services by removing barriers to care.
4. Opposition. A number of veterinary stakeholders oppose this bill, including California Registered Veterinary Technician Association, California Veterinary Medical Association, and the VMB, among others. Opponents cite risks to animal safety, liability, and a status quo model of care that is in the interests of animals.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 10, 2018

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Evan Low, Chair

ABPCA Bill Id:AB 3013

Author:(Chu) – As Amended Ver:April 2, 2018

SUBJECT: Veterinary medicine: animal physical rehabilitation.

SUMMARY: Authorizes a licensed physical therapist (PT) with a certificate in animal physical rehabilitation (APR), as determined by the Veterinary Medical Board (VMB) in collaboration with the Physical Therapy Board of California (PTBC), to provide APR to an animal patient if certain requirements are met, including that the APR is performed on specified premises registered with the VMB and that the PT works under the indirect supervision of a licensed veterinarian who has an established veterinarian-client-patient relationship with the animal, among other things.

EXISTING LAW:

1. Provides for the regulation of veterinary medicine under the Veterinary Medicine Practice Act, and prohibits the unlicensed practice of veterinary medicine. (Business and Professions Code (BPC) §§ 4800-4917)
2. Establishes the VMB within the Department of Consumer Affairs (DCA) to implement and enforce the Act, including to license and regulate veterinarians, registered veterinary technicians (RVTs), unlicensed veterinary assistants, and veterinary premises. (BPC § 4800-4811)
3. Defines the practice of "veterinary medicine, surgery, and dentistry, and the various branches thereof" as the following:
   1. Representing engagement in the practice of veterinary medicine, veterinary surgery, or veterinary dentistry in any of its branches. (BPC § 4826(a))
   2. Diagnosing or prescribing a drug, medicine, appliance, application, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of animals. (BPC § 4826(b))
   3. Administering a drug, medicine, appliance, application, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of animals, as specified. (BPC § 4826(c))
   4. Performing a surgical or dental operation upon an animal. (BPC § 4826(d))
   5. Performing any manual procedure for the diagnosis of pregnancy, sterility, or infertility upon livestock or Equidae. (BPC § 4826(e))
   6. Using words, letters, or titles that may induce the belief that the person using them is engaged in the practice of veterinary medicine, veterinary surgery, or veterinary dentistry, as specified. (BPC § 4826(f))
4. Makes it unprofessional conduct for a veterinarian to administer, prescribe, dispense or furnish a drug, medicine, appliance, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture or bodily injury or disease of an animal without having first established a veterinarian-client-patient relationship (VCPR) with the animal patient or patients and the client, except where the patient is a wild animal or the owner is unknown. (California Code of Regulations (CCR), Title 16, § 2032.1)
5. Specifies that a VCPR must be established through all three of the following:
   1. The client has authorized the veterinarian to assume responsibility for making medical judgments regarding the health of the animal, including the need for medical treatment. (CCR, tit. 16, § 2032.1(b)(1))
   2. The veterinarian has sufficient knowledge of the animal to initiate at least a general or preliminary diagnosis of the medical condition of the animal. This means that the veterinarian is personally acquainted with the care of the animal by virtue of an examination of the animal or by medically appropriate and timely visits to the premises where the animals are kept. (CCR, tit. 16, § 2032.1(b)(2))
   3. The veterinarian has assumed responsibility for making medical judgments regarding the health of the animal and has communicated with the client a course of treatment appropriate to the circumstance. (CCR, tit. 16, § 2032.1(b) (3))
6. Authorizes RVTs and veterinary assistants to perform specified animal health care services under the supervision of a veterinarian licensed or authorized to practice in this state. (BPC § 4840)
7. Requires the VMB to adopt regulations establishing animal health care tasks and an appropriate degree of supervision required for those tasks that may be performed only by a RVT or a licensed veterinarian; authorizes the VMB to adopt regulations for veterinary assistants; requires the VMB to establish an appropriate degree of supervision by a RVTs or a licensed veterinarian over a veterinary assistant for any tasks established; and requires the degree of supervision for any of those tasks to be higher than, or equal to, the degree of supervision required when an RVT performs the task. (BPC § 4836)
8. Defines “direct supervision” to mean: (1) the supervisor is physically present at the location where animal health care job tasks are to be performed and is quickly and easily available; and (2) the animal has been examined by a veterinarian at such time as good veterinary medical practice requires consistent with the particular delegated animal health care job task. (CCR, tit. 16, § 2034(e))
9. Defines “indirect supervision” to mean: (1) that the supervisor is not physically present at the location where animal health care job tasks are to be performed, but has given either written or oral instructions (“direct orders”) for treatment of the animal patient; and (2) the animal has been examined by a veterinarian at such times as good veterinary medical practice requires, consistent with the particular delegated animal health care task and the animal is not anesthetized, as defined. (CCR, tit. 16, § 2034(f))
10. Lists specific animal health care tasks an RVT may or may not perform and the required level of supervision, provides that an RVT may perform health care tasks not listed under the direct or indirect supervision of a licensed veterinarian, and requires the degree of supervision by the licensed veterinarian over the RVT to be consistent with standards of good veterinary medical practices. (CCR, tit. 16, § 2036)
11. Authorizes licensed chiropractors to perform musculoskeletal manipulation (MSM) under direct supervision by a veterinarian, as specified. (CCR, tit. 16, § 2038)
12. Provides for the licensure and regulation of physical therapy under the Physical Therapy Practice Act. (BPC §§2600-2696)
13. Establishes the PTBC within the DCA to administer and enforce the Physical Therapy Practice Act, including licensing PTs, physical therapist assistants, and physical therapy aides and technicians. (BPC § 2602)
14. Defines "physical therapy" as "the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise," which includes "physical therapy evaluation, treatment planning, instruction and consultative services" and "the promotion and maintenance of physical fitness to enhance the bodily movement related health and wellness of individuals through the use of physical therapy interventions," but excludes "use of roentgen rays and radioactive materials, for diagnostic and therapeutic purposes, and the use of electricity for surgical purposes, including cauterization," and "the diagnosis of disease." (BPC § 2620)
15. Provides that a PT is not authorized to practice medicine, surgery, or any other form of healing except as described under the definition of "physical therapy." (BPC § 2621)
16. Authorizes the PTBC to take action against a PT license for unprofessional conduct through citation, discipline, denial of a license, or issuance of a probationary license. (BPC § 2660)
17. Specifies that unprofessional conduct includes, among other things:
    1. Practicing or offering to practice beyond the scope of practice of physical therapy. (BPC § 2660(d))
    2. Failure to maintain adequate and accurate records relating to the provision of services to his or her patients. (BPC § 2660(g))
    3. Gross negligence or repeated acts of negligence in practice or in the delivery of physical therapy care. (BPC § 2660(h))
    4. Aiding or abetting any person to engage in the unlawful practice of physical therapy. (BPC § 2660(i))
    5. The commission of any fraudulent, dishonest, or corrupt act that is substantially related to the qualifications, functions, or duties of a PT or physical therapist assistant. (BPC § 2660(j))
    6. Permitting a physical therapist assistant or physical therapy aide under a PT's supervision or control to perform, or permitting the physical therapist assistant or physical therapy aide to advertise competence to perform, professional services beyond the level of education, training, and experience of the physical therapist assistant or aide. (BPC § 2660(n))
    7. The revocation, suspension, or other discipline, restriction, or limitation imposed by another state upon a license or certificate to practice physical therapy issued by that state, or the revocation, suspension, or restriction of the authority to practice physical therapy by any agency of the federal government. (BPC § 2660(o))

THIS BILL:

1. Defines “animal physical rehabilitation facility” (APR facility) as a facility where a licensed PT with a certificate in APR performs APR on an animal.
2. Authorizes a licensed PT with a certificate in animal physical rehabilitation issued by the VMB may provide APR to an animal if all of the following requirements are met:
   1. The PT is working under the indirect supervision of a licensed veterinarian who has an established veterinarian-client-patient relationship (VCPR) with the animal, the veterinarian makes a referral to the PT, and the veterinarian is available for immediate consultation by telephone or other electronic means if immediate veterinary medical care is necessary.
   2. The APR is performed on a veterinary premise registered with the VMB, in an APR facility registered with the board, or in a mobile or range setting.
   3. The PT applies to the VMB, on an application form approved by the VMB, and pays the fee for a certificate in APR.
3. Requires an animal physical rehabilitation facility shall register with the board, on a form approved by the board, and pay the registration fee described in Section 4905 and specifies that:
   1. A licensed physical therapist with a certificate in animal physical rehabilitation may register an animal rehabilitation facility with the board.
   2. The board may inspect an animal rehabilitation facility for safety and compliance with this chapter.
4. Requires the VMB and the PTBC to cooperatively determine what qualifications are necessary for a PT to receive a certificate in APR issued by the VMB. When making this determination, the VMB and the PTBC shall ensure that the qualifications provide for safe and efficacious treatment of an animal and are consistent with the VMB’s Animal Rehabilitation Task Force findings and approved motions.
5. Requires the VMB to create the application form and determine the application process for the certificate and specifies that the certificate shall expire two years after the date of issuance and may be renewed.
6. Provides that a PT with a certificate in animal physical rehabilitation shall be solely liable for any animal physical rehabilitation provided under the certificate and the veterinarian that referred the animal for animal physical rehabilitation shall not be liable for any animal physical rehabilitation provided by the physical therapist.
7. Authorizes the VMB to discipline a PT with a certificate in APR.
8. Authorizes unlicensed assistants to perform animal physical rehabilitation tasks under the direct supervision of a PT with a certificate in APR.
9. Requires the VMB to set the fee for the issuance and renewal of a certificate in APR in an amount not to exceed the reasonable regulatory costs to the VMB.
10. Requires the VMB to set the fee for the initial and annual renewal fees for registration of an APR facility in an amount not to exceed the reasonable regulatory costs to the VMB.

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the Animal Physical Therapy Coalition. According to the author, “[a]s demand for animal physical rehabilitation increases, we must continue to expand healthcare choices and protect animals and consumers from unqualified practitioners. That is why [this bill] provides direction for statewide standards and qualifications for [PTs] to become certified in animal physical rehabilitation. This bill codifies the Animal Physical Rehabilitation Taskforce recommendation, both safeguarding animals and their owners and removing barriers for qualified professionals to serve animals.”

Background. In California, only licensed veterinarians may provide veterinary medicine to an animal for a wound, fracture, and bodily injury, which includes all treatment, including physical therapy, except that RVTs and unlicensed veterinary assistants may treat animals under a veterinarian’s supervision.

Like other licensing requirements, practice restrictions on veterinary medicine serve to protect consumers of professional services and the public from practices that present a high risk of harm when performed by unqualified practitioners. As a result, those who wish to practice a licensed profession must demonstrate a minimum level of competency that reduces the risk of harm to an acceptable level. Licensing requirements vary by profession, but usually include specific education, examination, and experience. Specific training and education may also be supplemented with or substituted for additional supervision by a licensee with the proper level of training.

Currently, a licensed PT who wants to perform physical therapy on an animal must pursue additional licensure as a veterinarian, pursue registration as RVT, or work under the direct supervision of a licensed veterinarian as a veterinary assistant. Direct supervision means the supervising veterinarian is on-site, is readily available, and performs necessary examinations on the animal patient.

RVTs work under the indirect supervision of a licensed veterinarian, which means the licensed veterinarian is not on-site but has provided written or oral instructions, has established a VCPR with the animal patient, and performs examinations as necessary under the veterinary standard of care. This bill seeks to also authorize PTs who are certified in APR, as determined by the VMB and PTBC, to work under the indirect supervision of a licensed veterinarian.

Veterinary Medicine Education. Applicants for licensure as a veterinarian must graduate with a Doctor of Veterinary Medicine (DVM) degree from a four-year program at an accredited college of veterinary medicine or its equivalent, as determined by the VMB. Graduates must take and pass the North American Veterinary Licensing Exam and a California-specific law and ethics examination. The national exam covers all aspects of veterinary medicine and contains visual materials designed to test diagnostic skills.

Licensed veterinarians may also seek board certification by completing a 3-to-4-year residency program. The residency program provides intensive training in one of the 39 specialties recognized by the American Veterinary Medical Association (AVMA). The specialties include internal medicine, oncology, pathology, dentistry, nutrition, radiology, surgery, dermatology, anesthesiology, neurology, cardiology, ophthalmology, preventive medicine, and exotic-small-animal medicine.

Applicants for registration as a RVT must be at least 18 years of age, complete a two-year minimum veterinary technology program at a VMB-approved college or postsecondary institution or the equivalent, as determined by the VMB. The VMB may also consider a combination of education and clinical experience of the RVT as equivalent of the graduation requirement. The RVT must also pass a national examination and state-specific examination.

Veterinary assistants are not required to meet any specific requirements for education or examination. RVTs and veterinary assistants may perform animal health care services and tasks as prescribed by law or regulation under the supervision of a veterinarian. However, RVTs may perform animal health care services on impounded animals pursuant to direct, written, or telephonic order of a veterinarian and may directly purchase sodium pentobarbital for performance of euthanasia without the supervision or authorization of a veterinarian.

Physical Therapy Education. Applicants for licensure as a PT must complete a post- baccalaureate (master's) degree in physical therapy from an accredited postsecondary institution or an institution approved by the PTBC. The educational requirements must include instruction in the subjects prescribed by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association or Physiotherapy Education Accreditation Canada and must include a combination of didactic and clinical experiences.

Generally, PT programs cover basic science courses, including biology, chemistry, and physics as well as specialized courses in biomechanics, neuroanatomy, human growth and development, manifestations of disease, examination techniques, and therapeutic procedures. In addition to classroom and laboratory instruction, students must complete at least 18 weeks of full-time clinical experience with a variety of patients.

Graduates must also take and pass the National Physical Therapy Examination (NPTE) and a California- specific law and ethics examination. The NPTE PT exam consists of 250 multiple choice questions that are designed to assess basic entry-level competence after graduation from an accredited program or from an equivalent non-accredited program.

Animal Physical Rehabilitation Task Force. During the VMB's 2016 Sunset Review hearing, the staff background paper noted that the VMB was becoming increasingly concerned about the welfare of the animals being treated by unlicensed personnel and found evidence of animal harm. As a result, the staff recommendation was for the VMB to "create a task force comprised of stakeholders including veterinarians, RVTs, animal rehabilitation and related animal industry professionals, consumers, and representatives from the legislature to further examine the issue and present a recommendation to the [VMB] by January 1, 2017."

The specific recommendations approved at each meeting are as follows:

First meeting on June 20, 2016:

1. Animal Physical Rehabilitation is defined as the treatment of injury or illness to address pain and improve function by means of physical corrective treatment.
2. Animal Physical Rehabilitation does not include relaxation, recreational or wellness modalities, including but not limited to, massage, athletic training or exercise.
3. Any proposed changes to existing law and regulations are not an attempt to restrict or amend section 2038 of the California Code of Regulations regarding the provision of Musculoskeletal Manipulation modalities.
4. Prior to performing or authorizing Animal Physical Rehabilitation, a veterinarian shall establish a valid veterinarian-client-patient relationship as defined in sections 2032.1 or 2032.15 of the California Code of Regulations.

Second meeting on October 4, 2016:

1. Veterinarians have sufficient education and training to provide Animal Physical Rehabilitation.
2. Registered Veterinary Technicians (RVTs) may provide Animal Physical Rehabilitation under the direct supervision of a veterinarian unless in a range setting in which case the veterinarian may provide the appropriate level of supervision.
3. Veterinary Assistants may provide Animal Physical Rehabilitation under the direct supervision of a veterinarian or an RVT.

Third and final meeting on February 2, 2017:

California licensed physical therapists with advanced certification in Animal Physical Rehabilitation (with such certification to be defined by the Veterinary Medical Board and Physical Therapy Board working cooperatively) may provide animal physical rehabilitation under the degree of supervision to be determined by the veterinarian who has established a veterinarian-client-patient relationship, on a veterinary premises or an Animal Physical Rehabilitation premises (as defined in regulation by the Veterinary Medical Board and the Physical Therapy Board working cooperatively), or a range setting.

However, at the VMB's April 19, 2017, board meeting, the VMB approved a motion to modify the task force's final recommendation to specify that a PT may offer APR under direct supervision, rather than the degree of supervision to be determined by the supervising veterinarian. This bill seeks to codify the taskforce’s original recommendations.

Other States. According to the American Veterinary Medical Association, thirty states are silent regarding APR. Thirteen states specifically include APR in their practice acts, with some allowing direct supervision of PTs: Florida, Georgia, Illinois, Iowa, Maine, Mississippi, Tennessee, Indiana, Louisiana, New Mexico, Oklahoma, Pennsylvania and South Carolina.

Seven states allow for an indirect model similar to this bill: Oregon, Colorado, Nebraska, Utah, Virginia, Nevada and New Hampshire. Oregon has authorized PTs to practice APR since 1975.

ARGUMENTS IN SUPPORT:

The Animal Physical Therapy Coalition (sponsor) writes in support, "[w]e are pleased to endorse [this bill] as we are familiar with the unique skillset and services provided by a licensed physical therapist certified in animal rehabilitation. We have personally benefitted from rehabilitation services rendered by an animal physical therapist and many of our member's dogs have made excellent gains in both performance and injury recovery. These services have also been critical for the prevention of injury. We therefore, recognize the important role these professionals play in the care and well-being of animals and we also recognize the lack of access to these practitioners due to the outdated laws prohibiting them to practice on their own premises. By increasing access to animal physical therapists in California, more animals will be better served."

ARGUMENTS IN OPPOSITION:

The American Animal Hospital Association (AAHA) writes in opposition, "AAHA is very concerned about and opposes [this bill] as we believe if passed, it will undermine the safety of veterinary patients. AAHA hospitals are all about excellence in patient care, and nothing should interfere with that."

The California Registered Veterinary Technicians Association writes in opposition, "[u]nlike human patients, animals cannot tell us about their complaints. Veterinary professionals are trained to recognize animal pain and disease. The Veterinary Medicine Practice Act specifically authorizes RVTs to administer life saving aid and treatment in an emergency when a veterinarian is not present. PTs have no such authority or training. RVTs believe that some PTS have skills that can be beneficial for veterinary patients, but that due to the limitations in their training, they must be under the Direct Supervision of a veterinarian in order to practice safely. If PTS want to be able to practice under Indirect Supervision, they can go back to school and become RVTs as some have already done.

RVTs have recently formed a national specialty academy for [APR]. As RVTs, we are required to work under the supervision of a veterinarian. RVTs who specialize in animal rehabilitation want to be able to work along side of PTs with specialized training, but can only do so if they are both under the supervision of a veterinarian."

The California Veterinary Medical Association (CVMA) writes in opposition, "The CVMA is strongly opposed to the referral model and believes that existing laws and regulations are in the best interest of consumer protection and animal safety…. Under indirect supervision, the veterinarian determines if the patient requires a re-examination and changes or additions to treatment. With a referral, the patient would be seen by a physical therapist over a period of visits and the physical therapist would determine whether there were health issues, if the animal is in pain and whether they should send the animal back to the veterinarian. This is a diagnosis that only a veterinarian has the education, skill, and experience to perform. This proposed model puts the animal at risk and places undue liability on the referring veterinarian.

There are many successful veterinary practices with veterinarians, certified registered veterinary technicians and physical therapists providing animal rehabilitation under the current supervision model. The CVMA believes this is best for the animal patient and the client.

Physical therapists are educated in human medicine. A certification in animal physical therapy does not give them the necessary education or experience to make independent decisions regarding the care and treatment of an animal patient."

The Veterinary Medical Board writes in opposition, "Over the past seven-plus years, the Board and its Multidisciplinary Advisory Committee (MDC) have diligently researched and received public and stakeholder input on the issue of [APR] including multiple public hearings both at the MDC level and Board level….

The Veterinary Medicine Practice Act (VMPA) requires that a [VCPR] is established by a California licensed veterinarian. This ensures veterinary oversight and responsibility by the veterinarian. This can only occur at a premises where veterinary medicine is practiced which must be registered with the Board and have a veterinarian licensee manager. In the VMPA, direct supervision does not mean that the veterinarian must be in the same room watching the PT do the animal rehabilitation, but rather the veterinarian is on the premises and is '…quickly and easily available.' Direct supervision aligns with the Board's mandate for protection of the consumer and the patient.

Direct supervision of APR is the best medical approach for the animal patient. The veterinary medical team: the veterinarian, [RVT], and veterinary assistant will be able to collaborate on the total medical picture with the veterinarian, who has established the VCPR, and has the ultimate responsibility for the patient. The fundamental basis of [this bill] is flawed as it undermines the need for licensure, regulation, and consumer protection."

POLICY ISSUES FOR CONSIDERATION:

Client-patient healthcare decisions. One point of disagreement among proponents and opponents is whether clients can safely consent to APR on behalf of animal patients, even if a veterinarian provides sign off, due to the possibility of latent conditions or other difficult to observe risk-factors. In human healthcare, a patient or guardian can in most circumstances provide well-informed consent and assume the risk of healthcare procedures. However, in veterinary healthcare, a veterinarian's duties extend to both the client and the animal patient. Because concepts like risk and recovery outcomes cannot be effectively communicated to an animal patient, it is often up to the client to decide whether the risk to an animal patient is acceptable. However, if the provider is unable to explain or the client does not fully understand the risks, then neither the animal patient nor human client can consent. This bill attempts to reduce the chance of that situation by requiring the licensed veterinarian with a VCPR to use professional judgment before authorizing a PT to provide APR to an animal patient off-site.

AMENDMENTS:

1. To include the APR Task Force's recommended definition, clarify undefined terms, supervision requirements, veterinarian responsibilities, and the steps needed before delegating APR tasks to a PT the author should amend the bill as follows:

On page 4, line 22, after subdivision (a), insert:

4828.5. (a) For purposes of this section, the following definitions apply:

(1) "Animal physical rehabilitation" means the treatment of injury or illness to address pain and improve function by means of physical or corrective treatment, as defined under Section 2620. Animal physical rehabilitation does not include relaxation, recreational or wellness modalities, including but not limited to, massage, athletic training, or exercise.

(2) “Animal Physical Rehabilitation Facility” means a facility where a supervised physical therapist performs delegated animal physical rehabilitation tasks on an animal patient.

(3) "Delegated animal rehabilitation task" means animal physical rehabilitation treatments, functions, or services delegated to a supervised physical therapist or animal physical rehabilitation assistant by a supervising veterinarian under direct orders.

(4) "Direct order" means oral or written instruction from a supervising veterinarian authorizing physical rehabilitation of an animal patient, including communication and safety protocols or procedures specific to the animal patient, consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task.

(5) "Supervised physical therapist" means a physical therapist licensed under Chapter 5.7 (commencing with Section 2600) with a certificate in animal physical rehabilitation issued by the board who works under a supervising veterinarian pursuant to this section.

(6) "Supervision" or "degree of supervision" means one of the following:

(A) “Direct supervision” means all of the following:

(i) The supervising veterinarian is physically present at the location where delegated animal rehabilitation tasks are to be performed and is quickly and easily available.

(ii) For purposes of supervision of animal physical rehabilitation assistants, the supervised physical therapist is physically present at the location where delegated animal rehabilitation tasks are to be performed and is available as specified by the supervising veterinarian.

(iii)The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task.

(B) “Indirect supervision” means both of the following:

(i) The supervising veterinarian is not physically present at the location where delegated animal rehabilitation tasks are to be performed but is otherwise available, consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task..

(ii) The animal has been examined by the supervising veterinarian within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task.

(7) "Supervising veterinarian" means a veterinarian licensed pursuant to this chapter who is responsible for the following:

(A) Determining the competency of a supervised physical therapist to perform delegated animal physical rehabilitation tasks and supervise an animal physical rehabilitation assistant.

(B) Determining the competency of an animal physical rehabilitation assistant to perform delegated animal physical rehabilitation tasks under direct supervision of the supervised physical therapist.

(C) Determining the appropriate degree of supervision of a supervised physical therapist or an animal physical rehabilitation assistant necessary for the performance of the particular delegated animal physical rehabilitation task consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task.

(D) Making all decisions relating to the diagnosis, treatment, management, and future disposition of the animal patient.

(E) Examining the animal patient prior to authorizing a supervised physical therapist or animal physical rehabilitation assistant to perform a delegated animal physical rehabilitation task. The examination of the animal patient shall be conducted within the period of time consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task.

(8) "Animal physical rehabilitation assistant" means an unlicensed person who is not a licensed veterinarian, registered veterinarian, or supervised physical therapist and who assists a supervised physical therapist with delegated animal physical rehabilitation tasks pursuant to this section.

1. To clarify that the supervising veterinarian determines the appropriate level of supervision and make conforming changes, the author should amend the bill as follows:

On page 4, line 22 through page 5, line 2:

(b) Notwithstanding any other law, a supervised physical therapist licensed under Chapter 5.7 (commencing with Section 2600) with a certificate in animal physical rehabilitation issued by the board may provide animal physical rehabilitation to an animal if all of the following requirements are met:

(1) The supervised physical therapist is working under the supervision of a supervising veterinarian indirect supervision of a licensed veterinarian who has an established veterinarian-client-patient relationship with the animal, the veterinarian makes a referral to the physical therapist with a certificate in animal physical rehabilitation, and the veterinarian is available for immediate consultation by telephone or other electronic means if immediate veterinary medical care is necessary.

(2) The degree of supervision is consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task as determined by the supervising veterinarian. Unlicensed assistants may perform animal physical rehabilitation tasks under the direct supervision of a licensed physical therapist with a certificate in animal physical rehabilitation pursuant to this chapter.

(3) The delegated animal physical rehabilitation task is performed on a veterinary premise registered with the board, in an animal physical rehabilitation facility registered with the board, or in a mobile or range setting.

(4) The supervised physical therapist applies to the board, on an application form approved by the board, and pays the fee for a certificate in animal physical rehabilitation described in Section 4905.

1. To clarify that the unlicensed assistant works under the supervision of both a supervised PT and the supervising veterinarian and the supervising veterinarian determines the appropriate level of supervision and make conforming changes, the author should amend the bill as follows:

On page 5, after line 10, insert:

(c) An animal physical rehabilitation assistant may assist with delegated animal physical rehabilitation tasks if all of the following requirements are met:

(1) The animal physical rehabilitation assistant is working under the direct supervision of a supervised physical therapist in compliance with subdivision (b) of this section.

(2) The unlicensed assistant is working under the degree of supervision consistent with standards of good veterinary medical practice and the particular delegated animal physical rehabilitation task, as determined by the supervised physical therapist's supervising veterinarian pursuant to subparagraph (A) of paragraph (6) of subdivision (a) of this section.

1. To clarify that PTs and unlicensed APR assistants may not perform anything not authorized by the supervising veterinarian, the author should amend the bill as follows:

On page 5, immediately following the previous insertion after line 10, insert:

(d) Unless specifically authorized by this section, a supervised physical therapist or animal physical rehabilitation assistant shall not perform any activity which represents the practice of veterinary medicine or requires the knowledge, skill and training of a licensed veterinarian or registered veterinary technician, including the following:

(1) Surgery.

(2) Diagnosis and prognosis of animal diseases.

(3) Prescription of drugs, medicines or appliances.

(4) Anesthesia.

(5) Application of casts or splints, except temporary cast molding for purposes of fitting custom or prefabricated orthotics or prosthetics if authorized by a supervising veterinarian.

(6) Dental extraction.

(7) Suture.

(8) Administration of controlled substances.

(9) Any other veterinary medicine function, tasks, or activities not specifically authorized by a supervising veterinarian as a delegated animal rehabilitation task.

1. The author should amend the bill to make the following conforming changes:

On page 5, lines 11 through 30:

(e)(1) An animal physical rehabilitation facility shall register with the board, on a form approved by the board, and pay the registration fee described in Section 4905.

(2) A licensed supervised physical therapist with a certificate in animal physical rehabilitation may register an animal rehabilitation facility with the board.

(3) The board may inspect an animal rehabilitation facility for safety and compliance with this chapter.

(c)  (f)(1) The board and the Physical Therapy Board of California, in cooperation, shall determine what qualifications are necessary for a physical therapist licensed under Chapter 5.7 (commencing with Section 2600) to receive a certificate in animal physical rehabilitation issued by the board. When making this determination, the board and the Physical Therapy Board of California shall ensure that the qualifications provide for safe and efficacious treatment of an animal and are consistent with the Veterinary Medical Board’s Animal Rehabilitation Task Force findings and approved motions.

(2) The board shall create the application form and determine the application process for the certificate.

1. To clarify the renewal process and clarify that, while the veterinarian is not responsible for the services themselves, it is unprofessional conduct subject to discipline to agree to supervise or authorize APR without ensuring the safety of the animal patient, the author should amend the bill as follows:
   
   On page 5, line 31 through page 6, line 7:

(d) (g) A certificate shall expire two years after the date of issuance and may be renewed in a manner approved by the board and consistent with Article 5 of this Chapter (commencing with Section 4900).

(e) (h) A supervised physical therapist or an animal physical rehabilitation assistant with a certificate in animal physical rehabilitation shall be solely liable for any delegated animal physical rehabilitation tasks provided in compliance with paragraph (4) of subdivision (a) of this section, and the supervising veterinarian that referred the animal for animal physical rehabilitation shall not be liable for any animal physical rehabilitation provided by the supervised physical therapist or animal physical rehabilitation assistant. Failure to comply with paragraph (7) of subdivision (a) of this section shall be deemed unprofessional conduct.

(f) (i) Consistent with this chapter, the board shall have the authority to discipline a supervised physical therapist, up to revocation of the supervised physical therapist's certificate. with a certificate in animal physical rehabilitation .

(g) For purposes of this chapter, “animal physical rehabilitation facility” means a facility where a licensed physical therapist with a certificate in animal physical rehabilitation performs animal physical rehabilitation on an animal.

(j) The board shall report final disciplinary actions against a supervised physical therapist pursuant to subdivision (i) of this section to the Physical Therapy Board of California.

REGISTERED SUPPORT:

Animal Physical Therapy Coalition (sponsor):

A Heart Performance Horses

A Well Adjusted Pet

Atlas Rehabilitation for Canines

Bark Magazine

C.A.R.E. 4 Paws

Chrissie's Fund

Dog Adoption and Welfare Group (DAWG)

Hearts Therapeutic Equestrian Center

Paws'itive Teams

Santa Maria Valley Humane Society

Santa Barbara Supersonic Flyball Racing Team

Shadow's Fund

Shorty's Charities

The Inquisitive Canine, LLC

Veterinary Medical and Surgical Group

1 former VMB and APR Task Force member

3 former APR Task Force members
8 veterinarians

3 PTs

Over 100 individuals

REGISTERED OPPOSITION:

American Animal Hospital Association

California Registered Veterinary Technician Association

California Veterinary Medical Association

Veterinary Medical Board

1 current VMB member, on behalf of Social Compassion in Legislation

3 current VMB members, individually

3 former APR Task Force members

Over 100 veterinarians

16 RVTs

27 veterinary students

Over 50 individuals

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301