Collaborative practice agreement

A collaborative practice agreement (CPA) (also called a consult agreement, collaborative pharmacy practice agreement, physician-pharmacist agreement, standing order or standing protocol, or physician delegation)[1] is a legal document in the United States that establishes a formal relationship between pharmacists (often clinical pharmacy specialists) and collaborating physicians for the purpose of establishing a legal and ethical basis for pharmacists to participate in collaborative drug therapy management (CDTM).[2][3] CDTM is sometimes also referred to as clinical pharmacy services, pharmaceutical care, disease state management, or comprehensive medication management.[4] CDTM is an expansion of the traditional pharmacist scope of practice, allowing for pharmacist-lead management of drug related problems (DRPs) with an emphasis on a collaborative, interdisciplinary approach to pharmacy practice in the healthcare setting. Legal guidance and requirements for the formation of CPAs are established on a state by state basis.[2] The terms of a CPA are decided by the collaborating pharmacist and physician, though templates exist online. CPAs can be specific to a patient population of interest to the two parties, a specific clinical situation or disease state, and/or may outline an evidence-based protocol for managing the drug regimen of patients under the CPA. CPAs have become the subject of intense debate within the pharmacy and medical professions.

History

According to Karen E. Koch, PharmD, the first coining of the term "collaborative drug therapy management" can be traced back to William A. Zellmer's 1995 publication in the American Journal of Health-System Pharmacy.[5] In it, Zellmer advocates for using the term "collaborative drug therapy management" instead of "prescribing," arguing that it will not only make legislation that expands the authority of pharmacists more palatable to lawmakers (and physician stakeholders), but also to center the discussion on 'why' the profession is interested in expanding that authority: for the betterment of patient care, through interdisciplinary collaboration.[6] The notion of "dependent prescribing authority" would later evolve into the modern concept of "collaborative practice agreements."

The first state to pass legislation allowing for the formal formation of CPAs was Washington. In 1979, Washington amended the Practice of Pharmacy--Requirements, act No. 2141 of 1979 (in English) providing for the formation of "collaborative drug therapy agreements."[7] As of February 2016, 48 states and the District of Columbia have approved laws that allow for the provision of CPAs.[8] The federal government approved CPAs in 1995.[9]

As of February 2016, the only two states that do not allow for the provision of CPAs are Oklahoma and Alabama.[10] Alabama pharmacists had hoped to see a CPA law, HB 494, pass in 2015. The bill was introduced by Alabama House Representative Ron Johnson, but the bill died in committee.[11]

Below is a list of US states that have approved CPAs and the year that they were approved (and/or later updated), as of February 2016:

State Year
Alabama Not approved[10]
Alaska 2002[9]
Arizona 2000[9]
Arkansas 1997[9]
California 1981, 2002[9]
Colorado 2007,[12] 2016[13]
Connecticut 2002[9]
Delaware N/A
Florida 1986, 1997[9]
Georgia 2000[9]
Hawaii 1997, 2002[9]
Idaho 1998[9]
Illinois Unregulated[9]
Indiana 1996,[9] 2011[10]
Iowa 1996[9]
Kansas 1996,[9] 2014[10]
Kentucky 1996[9]
Louisiana 1999[9]
Maine 2013[10]
Maryland 2002[9]
Massachusetts 2009[10]
Michigan 1991[9]
Minnesota 1998[9]
Mississippi 1987[9]
Missouri 2012[10]
Montana 2001[9]
Nebraska 1998[9]
Nevada 1990[9]
New Hampshire 2006[10]
New Jersey 2004[10]
New Mexico 1993, 2002[9]
New York 2011[10]
North Carolina 1999[9]
North Dakota 1995, 2001[9]
Ohio 1999[9]
Oklahoma Not Approved[10]
Oregon 1980[9]
Pennsylvania 2002[9]
Rhode Island 2001[9]
South Carolina 1998[9]
South Dakota 1993[9]
Tennessee 2014[10]
Texas 1995[9]
Utah 2001[9]
Vermont 1992[9]
Virginia 1999,[9] 2013[10]
Washington 1979[9]
West Virginia 2008[10]
Wisconsin 2000[9]
Wyoming 1999[9]

Pharmacy services

Pharmacists involved in CPAs may participate in clinical services that are outside of the traditional scope of practice for pharmacists. Notably, pharmacists do not need to participate in CPAs to provide many pharmacy practice services that are already covered by their traditional scope of practice, such as performing medication therapy management, providing disease prevention services (e.g. immunizations), engaging in public health screenings (e.g. screening patients for depressive disorders, such as major depressive disorder, via administering the PHQ-2), providing disease-state specific education (e.g. as a certified diabetes educator), and counseling patients on information regarding their medications.[14]

Expanded pharmacy services under a CPA are described as collaborative drug therapy management (CDTM). While the traditional scope of practice for pharmacists provides for the legal authority to detect drug related problems (DRPs) and provide suggestions for solving DRPs to prescribers (such as physicians), pharmacists that provide CDTM directly solve DRPs when they detect them. This may involve prescribing activities, which include selecting and initiating medications for the treatment of a patient's diagnosed illnesses (as outlined in the CPA), discontinuing the use of prescription or over-the-counter medications, modifying a patient's drug therapy (e.g. changing the strength, frequency, route of drug administration, or duration of therapy), evaluating a patient's response to drug therapy (which may include ordering and performing laboratory tests, such as a basic metabolic panel), and continuing drug therapy (providing a new prescription).[2] Other services may include administering medications, especially those administered parenterally (e.g. long-acting, injectable antipsychotics).[3] It is important to note that CPAs do not allow pharmacists to diagnose and treat patients as fully independent providers; rather, the focus and intent of CPAs is to allow pharmacists to practice as semi-autonomous providers with an emphasis on forming collaborative, interdisciplinary relationships with physicians.

Variation by state

The legal provisions of CPAs vary on a state-by-state basis. This affects the specific services that pharmacists are allowed to perform pursuant to a CPA, as well as the terms of the arrangement (e.g. requirements for CPA renewal). Wisconsin's "Wisconsin Act 294," for example, has been described by the American Pharmacists Association (APhA) as granting some of the most expansive powers to pharmacists in any state CPA law.[1][15]

Alaska

Regulations for CPAs in Alaska are found in the Alaska Administrative Code, title 12, chapter 52, section 240 (12 AAC 52.240). Pharmacists must submit a CPA application to the Alaska Board of Pharmacy for approval. Collaborating physicians must get approved from the Alaskan Medical Board (pursuant to 12 AAC 40.983). A notable difference from other state CPA laws is that Alaskan pharmacists may enter into CPAs with all practitioners that prescribe medications (pursuant to Alaska Statute title 8).

Alaskan CPAs may involve multiple pharmacists and multiple practitioners (e.g. one pharmacist entering into a CPA with a group of staff physicians, multiple pharmacists entering into a CPA with one physician, or multiple pharmacists entering into a CPA with multiple pharmacists), though a "principal prescribing practitioner" must be named. The CPA must specify the disease states, medications (or medication classes) that the pharmacists are allowed to make decisions on, as well as a procedure/protocol in place for making those decisions. Decisions must be reviewed at least every 3 months together with the covered entities, and the protocols are only effective for a maximum of 2 years at a time. Alaskan CPAs allow pharmacists to "monitor drug therapy" pursuant to 12 AAC 52.995, which includes conducting a full patient history, measuring vital signs, and ordering/evaluating CPA covered laboratory tests.

Pharmacist advocacy

CPAs are a focus of advocacy efforts for professional pharmacy organizations.

American Pharmacists Association Foundation

In January 2012, the American Pharmacists Association (APhA) Foundation convened a consortium composed of pharmacy, medicine, and nursing stakeholders representing 12 states to discuss the integration of CPAs into everyday clinical practice.[16] The consortium published a white paper titled "Consortium Recommendations for Advancing Pharmacists’ Patient Care Services and Collaborative Practice Agreements," summarizing their recommendations.[14]

National Alliance of State Pharmacy Associations

In July of 2015, the National Alliance of State Pharmacy Associations (NASPA) convened a working group composed of appointees from the CEOs of Joint Commission of Pharmacy Practitioners (JCPP) member organizations, the National Association of Chain Drug Stores, and individual states.[17] The 18 member working group's report made recommendations towards what state lawmakers should include in CPA laws.[17][18]

American College of Clinical Pharmacy

In 2015, the American College of Clinical Pharmacy (ACCP) published an updated white paper on the subject of collaborative drug therapy management.[10] The ACCP periodically publishes updates on the subject, with previous publications in 2003 and 1997.[10] The paper describes the recent history of CPAs, the legislative progress, and discusses payment models for collaborative drug therapy management activities.

Physician perspective

CPAs have been met with mixed reviews by physicians and physician advocacy groups.

Praise

In a 2011 commentary for the American College of Clinical Pharmacy, Terry McInnis, MD, MPH stresses the need for pharmacist-physician collaboration to improve positive patient outcomes and to decrease healthcare costs. In the final paragraph, she makes an appeal towards pharmacists that are interesting in pursuing CPAs:

“For pharmacists, I believe that you have come to one of the rare crossroads that will define the future of your profession. You will either take your place as providers of care, or your numbers will dwindle as most dispensing activities are replaced by robotics and pharmacy technicians. I am a physician, and I say our profession and the patients that we serve need you ‘on the team’ as clinical pharmacist practitioners. But, will you truly join us?”[19]

In the keynote address of the 2015 APhA annual meeting, Reid Blackwelder, MD, FAAFP (president of the American Academy of Family Physicians, 2013-2014)[20] advocated for a "collaborative view of health care,"[21] though it is unclear if Blackwelder was referring to CPAs specifically, or if he specifically supports CPAs.

Criticism

In 2012, the American Academy of Family Physicians (AAFP) produced a position paper[22] that expressed support for CPAs, but stressed the risk of "fragmenting" care if pharmacists were given fully autonomous prescribing privileges.[23]

In 2010, the American Medical Association (AMA) published a series of reports called the "AMA Scope of Practice Data Series."[24] One of the reports was focused on the profession of pharmacy, titled, "AMA Scope of Practice Data Series: Pharmacists," which criticized the formation of CPAs as an attempt to encroach upon the physician's scope of practice by pharmacists. In response to the report, a collaboration of seven national professional pharmacy associations drafted a response to the AMA's report on pharmacists.[25] In 2011, the House of Delegates of the AMA adopted what was seen as a softer tone by APhA in response to input from it and other professional pharmacy associations, ultimately passing the following resolution that refocused attention on opposing independent (rather than collaborative, or dependent) practice agreements:

"That our AMA develop model state legislation to address the expansion of pharmacist scope of practice that is found to be inappropriate or constitutes the practice of medicine, including but not limited to the issue of interpretations or usage of independent practice arrangements without appropriate physician supervision and work with interested states and specialties to advance such legislation (Directive to Take Action)."[26]

References

  1. 1 2 Weaver, Krystalyn. "Policy 101: Collaborative practice empowers pharmacists to practice as providers". pharmacist.com. The American Pharmacists Association. Retrieved 28 April 2017.
  2. 1 2 3 Carmichael, Jannet (2003). Encyclopedia of Clinical Pharmacy. New York, NY: Marcel Dekker, Inc. pp. 199–206. ISBN 0-8247-0752-4.
  3. 1 2 Koch, Karen. "Trends in Collaborative Drug Therapy Management". Medscape.com. WebMD LLC. Retrieved 6 May 2017.
  4. ↑ Kim Jun, Jeany (2017). "The Role of Pharmacy Through Collaborative Practice in an Ambulatory Care Clinic". American Journal of Lifestyle Medicine. doi:10.1177/1559827617691721.
  5. ↑ Koch, Karen. "Trends in Collaborative Drug Therapy Management". medscape.com. WebMD LLC. Retrieved 8 May 2017.
  6. ↑ Zellmer, William A. (August 1, 1995). "Collaborative Drug Therapy Management". Am J Health-Sys Pharm. 52: 1732.
  7. ↑ Hecox, Nancy (July 14, 2014). "Collaborative Drug Therapy Agreement Topics in the State of Washington: From Dispensing Pills to Managing Ills". SOJ Pharm Pharm Sci. 1 (2): 1–2. Retrieved 28 April 2017.
  8. ↑ Gilchrist, Allison. "Collaborative Practice Agreements Open Opportunities, Liabilities for Pharmacists". pharmacytimes.com. Pharmacy & Healthcare Communications, LLC. Retrieved 28 April 2017.
  9. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Hammond, RW; Schwartz, AH; Campbell, MJ; Remington, TL; Chuck, S; Blair, MM; Vassey, AM; Rospond, RM; Herner, SJ; Webb, CE (2003). "Collaborative Drug Therapy Management by Pharmacists--2003". Pharmacotherapy. 23 (9): 1210–1225.
  10. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 McBane, SE; Dopp, AL; Abe, A; Benavides, S; Chester, EA; Dixon, DL; Dunn, M; Johnson, MD; Nigro, SJ; Rothrock-Christian, T; Schwartz, AH; Thrasher, K; Walker, S (2015). "Collaborative Drug Therapy Management and Comprehensive Medication Management―2015". Pharmacotherapy. 35 (4): e39–e50. doi:10.1002/phar.1563.
  11. ↑ Traynor, Kate. "Alabama Pharmacists Push for State Collaborative Therapy Law". ashp.org. American Society of Health-System Pharmacists. Retrieved 8 May 2017.
  12. ↑ State Board of Pharmacy. "Pharmacy Rules and Regulations". Retrieved 7 May 2017.
  13. ↑ "Statewide Protocol Continuing Education On-Demand Webinar". copharm.org. Colorado Pharmacists Society. Retrieved 7 May 2017.
  14. 1 2 "Collaborative Practice Agreements (CPA) and Pharmacists’ Patient Care Services". aphafoundation.org. The American Pharmacists Association. Retrieved 28 April 2017.
  15. ↑ Yap, Diana. "Wisconsin provider status law backed by state medical society". pharmacist.com. American Pharmacists Association. Retrieved 30 April 2017.
  16. ↑ Sheffer, Joe. "Collaborative practice agreements: Stimulating increased integration". pharmacist.com. American Pharmacists Association. Retrieved 29 April 2017.
  17. 1 2 "Pharmacist Collaborative Practice Agreements: Key Elements for Legislative and Regulatory Authority". The National Alliance of State Pharmacy Associations. Retrieved 29 April 2017.
  18. ↑ Collins, Sonya. "Collaborative practice agreements: NASPA workgroup releases recommendations". pharmacist.com. American Pharmacists Association. Retrieved 29 April 2017.
  19. ↑ McInnis, Terry (October 2011). "The Most Transformative Force in Health Care or the Demise of a Profession?". ACCP Report. Retrieved 9 May 2017.
  20. ↑ Moriarty, Megan. "Reid B. Blackwelder, MD, FAAFP, Assumes Role of President of the American Academy of Family Physicians". aafp.org. American Academy of Family Physicians. Retrieved 13 May 2017.
  21. ↑ Ross, Meghan. "True Community-Based Care Centers on Collaboration". pharmacytimes.com. Pharmacy & Healthcare Communications, LLC. Retrieved 13 May 2017.
  22. ↑ "Pharmacists (Position Paper)". aafp.org. American Academy of Family Physicians. Retrieved 29 April 2017.
  23. ↑ Goldstone, Lisa; DiPaula, Bethany; Caballero, Joshua; Park, Susie; Price, Cristofer; Slater, Magdalena (January 2015). "Improving medication-related outcomes for patients with psychiatric and neurologic disorders: Value of psychiatric pharmacists as part of the health care team". Mental Health Clinician. 5 (1): 1–28. doi:10.9740/mhc.2015.01.001. Retrieved 29 April 2017.
  24. ↑ Carlson, Joe (April 5, 2010). "Primary dispute". Crain Communications, Inc. Modern Healthcare. Retrieved 9 May 2017.
  25. ↑ "Seven Pharmacy Organizations Respond to AMA Scope of Pharmacy Practice Document". nabp.pharmacy. NABP. Retrieved 9 May 2017.
  26. ↑ "AMA to evaluate "expanding scope of pharmacists’ practice"". pharmacist.com. American Pharmacists Association. Retrieved 9 May 2017.
This article is issued from Wikipedia. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.