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First initiated in Washington State in 1979, CDTM agreements permit pharmacists, without the direct approval of a physician, to initiate, modify, or discontinue drug therapy, order and interpret laboratory tests, and advise patients on control of chronic conditions. In July 2018, Well-Ahead Louisiana launched an initiative to increase use of CDTM to treat heart disease and diabetes in rural areas. Because Louisiana has the fourth-highest diabetes prevalence and fifth-highest heart disease prevalence in the nation, our team targeted 4 geographic regions of the state, primarily rural, where the burden of these diseases was greatest (6). According to Louisiana Board of Pharmacy records, only 75 (<1%) of the 9,087 licensed pharmacists in Louisiana participate in an active CDTM. The nurse practitioner is not considered an eligible provider for a CDTM agreement in Louisiana. [...]the agreement could not be pursued.

Scientists and managers of natural resources have recognized an urgent need for improved methods and tools to enable effective adaptation of management measures in the face of climate change. This paper presents an Adaptation Design Tool that uses a structured approach to break down an otherwise overwhelming and complex process into tractable steps. The tool contains worksheets that guide users through a series of design considerations for adapting their planned management actions to be more climate-smart given changing environmental stressors. Also provided with other worksheets is a framework for brainstorming new adaptation options in response to climate threats not yet addressed in the current plan. Developed and tested in collaboration with practitioners in Hawai’i and Puerto Rico using coral reefs as a pilot ecosystem, the tool and associated reference materials consist of worksheets, instructions and lessons-learned from real-world examples. On the basis of stakeholder feedback from expert consultations during tool development, we present insights and recommendations regarding how to maximize tool efficiency, gain the greatest value from the thought process, and deal with issues of scale and uncertainty. We conclude by reflecting on how the tool advances the theory and practice of assessment and decision-making science, informs higher level strategic planning, and serves as a platform for a systematic, transparent and inclusive process to tackle the practical implications of climate change for management of natural resources.

The interactive and cumulative impacts of climate change on natural resources such as coral reefs present numerous challenges for conservation planning and management. Climate change adaptation is complex due to climate-stressor interactions across multiple spatial and temporal scales. This leaves decision makers worldwide faced with local, regional, and global-scale threats to ecosystem processes and services, occurring over time frames that require both near-term and long-term planning. Thus there is a need for structured approaches to adaptation planning that integrate existing methods for vulnerability assessment with design and evaluation of effective adaptation responses. The Corals and Climate Adaptation Planning project of the U.S. Coral Reef Task Force seeks to develop guidance for improving coral reef management through tailored application of a climate-smart approach. This approach is based on principles from a recently-published guide which provides a framework for adopting forward-looking goals, based on assessing vulnerabilities to climate change and applying a structured process to design effective adaptation strategies. Work presented in this paper includes: (1) examination of the climate-smart management cycle as it relates to coral reefs; (2) a compilation of adaptation strategies for coral reefs drawn from a comprehensive review of the literature; (3) in-depth demonstration of climate-smart design for place-based crafting of robust adaptation actions; and (4) feedback from stakeholders on the perceived usefulness of the approach. We conclude with a discussion of lessons-learned on integrating climate-smart design into real-world management planning processes and a call from stakeholders for an “adaptation design tool” that is now under development.

Wetlands are known to provide a myriad of vital ecosystem functions and services, which may be under threat from a changing climate. However, these effects may not be homogenous across ecosystem functions, wetland types, ecoregions, or meso‐scale watersheds, making broad application of the same management techniques inappropriate. Here, we present a relative wetland vulnerabilities framework, applicable across a range of spatial and temporal scales, to assist in identifying effective and robust management strategies in light of climate change. We deconstruct vulnerability into dimensions of exposure and sensitivity/adaptive capacity, and identify relevant measures of these as they pertain to the attributes of wetland extent and plant community composition. As a test of the framework, we populate it with data for three primary hydrogeomorphic wetland types (riverine, slope, and depression) in seven small watersheds across four ecoregions (Ridge and Valley, Piedmont, Unglaciated Plateau, and Glaciated Plateau) in the Susquehanna River watershed in Pennsylvania. We use data generated from the SRES A2 emissions experiment and MRI‐CGCM2.3.2 climate model as input to the Penn State Integrated Hydrologic Model to simulate future exposure to altered hydrologic conditions in our seven watersheds, as expressed in two hydrologic metrics: % time groundwater levels occur in the upper 30 cm (rooting zone) during the growing season, and median difference between spring and summer mean water levels. We then examine the spatial and temporal scales at which each of the components of vulnerability (exposure and sensitivity/adaptive capacity) shows significant relative differences. Overall, we find that relative differences in exposure persist at a very fine spatial grain, exhibiting high variability even among individual watersheds in a given ecoregion. For temporal scale, we find strong seasonal but weak annual relative differences in exposure resulting from a magnification of summer dry‐down combined with winter and spring wet periods becoming wetter. Sensitivities/adaptive capacities show significant differences among wetland types. A comparison between our anticipated hydrologic alterations under climate change and historical changes in hydrology due to anthropogenic disturbance indicates potential shifts in hydrologic patterns that are far beyond anything that wetland managers have experienced in the past.

There is both a fundamental and applied need to define expectations of changes in aquatic ecosystems due to global changes. It is clear that programs using biological indicators and reference-based comparisons as the foundation for assessments are likely to make increasingly erroneous decisions if the impacts of global change are ignored. Global changes influence all aspects of water resource management decisions based on comparisons to reference conditions with impacts making it increasingly problematic to find an “undisturbed” water body to define acceptable conditions of ecological integrity. Using a more objective scale for characterizing reference conditions that is anchored in expectations for what would be attainable under undisturbed conditions, such as the Biological Condition Gradient (BCG) is one approach that maintains consistent definitions for ecosystem conditions. In addition, protection of reference stations and of unique or undisturbed aquatic resources is imperative, though the scope of protection options is limited. Projections indicate that encroaching land use will affect 36-48% of current reference surface waters by the year 2100. The interpretation of biological indicators is also at risk from global changes. Distinguishing taxonomic attributes based on temperature or hydrologic preferences can be used to enhance the ability to make inferences about global change effects compared to other stressors. Difficulties arise in categorizing unique indicators of global changes, because of similarities in some of the temperature and hydrologic effects resulting from climate change, land use changes, and water removal. In the quest for biological indicators that might be uniquely sensitive to one global stressor as an aid in recognizing probable causes of ecosystem damage, the potential similarities in indicator responses among global and landscape-scale changes needs to be recognized as a limiting factor. Many aspects of global changes are not tractable at the local to regional scales at which water quality regulations are typically managed. Our ability to implement water policies through bioassessment will require a shift in the scale of assessment, planning, and adaptations in order to fulfill our ultimate regulatory goals of preserving good water quality and ecological integrity. Providing clear expectations of effects due to global change for key species and communities in freshwater ecosystems will help water quality programs achieve their goals under changing environmental conditions.

The author's Florida childhood was muddy, awash in alligators, salt spray, and briny oysters. The author grew up on—and in—northeast Florida’s Matanzas River, a marshy estuary snaking from St. Augustine in St. Johns County southward into Flagler County. Layers of history are imprinted on the Matanzas, from shell middens of early indigenous people, Spanish landmarks, and the sites of bloody battles, to remnants of 1900s homesteaders, hunting clubs, and kitschy 1950s attractions. The river supports robust commercial and recreational fishing, thanks to efforts of conservationists in the 1990s. It is one of the last places in only a handful on Florida’s east coast where we can still harvest oysters. But to live in Florida today is to live in a paradox. The climate warms, sea levels rise, and storms batter us with increasing frequency, yet nearly 1,000 people move to Florida each day. The ramifications are a tired but dire story: subdivisions subsume floodplains, coasts erode, corals bleach, fresh water dwindles, species extinguish. This is the backdrop of Matanzas Voices, an oral history initiative whose goal is to suss out this tension playing out in the author's northeast Florida home. Matanzas Voices documents the dynamic of a changing river and a changing populace by framing the Matanzas as a commons uniting disparate communities. It is equal parts oysterman, fisherman, park service employee, scientist, entrepreneur. For coastal southerners like us, the debate over climate change’s human provenance is a luxury we can no longer afford; the reality has already set in. Matanzas Voices is motivated by a belief that storytelling is inherently activist, that making smart decisions for communities necessitates harnessing the narrative from the ground up. One of the goals is to understand the importance of the river and associated natural areas from a local level, so that we might inform and fuel smart policymaking and planning decisions. Perhaps most importantly, Matanzas Voices positions itself as a documentary model for assessing how coastal communities react and adapt to the pressures of climate change. At best, the project is a study in nostalgia, belonging, and sense(s) of place(s), capturing the lamentations of a community changing and growing. At worst, it is bearing witness to the last gasps of an overwhelmed organism—one unable to support human activity in the foreseeable future. When the author was first drumming up support for Matanzas Voices, someone asked them, “How will a project like this save our oysters?” It’s a good question: the river suffers the impacts of major storm events, population growth, and pollution. Their hope is that Matanzas Voices joins the wider conversation about the value of localized knowledge in managing the South’s ecosystems. By turning inward, perhaps we’ll find solutions we didn’t know we had