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profession is not only authorized to provide a service, but also should be reimbursed for that service, have done so through separate legislation such as “vendorship” or “freedom of choice” laws (Frank, 1989; Fairbank, 1989; Lieberman et al., 1989). The lack of an explicit reimbursement mandate may differentially affect providers trying to locate in rural areas because independent third-party billing is particularly critical for these providers. Without an agency to provide a salary or another professional under whose authority a rural practitioner can provide reimbursable services, barriers to direct reimbursement are also barriers to rural mental health practice.

Supervision and Rural Practice

The language that licensure laws use to describe the clinical supervision required to qualify for independent practice may create barriers to entry into a profession, or barriers to practice, that differentially affect rural areas. States (and even professions within states) vary in the degree to which they require supervision to be performed exclusively by a member of the profession being entered, and the extent to which this supervision must be obtained on a one- to-one, face-to-face basis. These variations are relevant in that they can make it easier or more difficult for a newly trained practitioner to move quickly into independent practice, thereby meeting the need for mental health practitioners in many rural areas. In cases where independent practice is not the immediate goal, as with a practitioner working in a community mental health center, limitations on who may supervise may also be relevant, as many rural CMHCs may not have a full complement of experienced practitioners in all professions.

In practice, if a non-independent practitioner works in a clinical setting with his or her independently licensed counterpart, weekly or bi-weekly clinical supervision sessions are easy to arrange and meet the supervision requirement. Moreover, the non-independently licensed worker is typically salaried, not able to bill directly for services, and has the support of the agency or institution. In a rural area, where a mental health center may be operating outreach services or satellite clinics staffed by a social worker, psychologist or counselor who is not licensed to practice independently, licensure laws do not specifically address the interpretation of supervised practice. Thus, state licensing boards have delegated the oversight of these practitioners to the agencies that employ them.

In general, a more restrictive approach to the question of who may supervise may affect the ability of new professionals to move into rural areas. However, further research is needed to determine the extent of that effect.


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