Pushing new boundaries: The scoop on scope of practice
Myriam Shaw Ojeda, PharmD, is an assistant professor at The Ohio State University College of Pharmacy and the director of pharmacy extension and public health initiatives for the Ohio Pharmacists Association in Columbus, OH, and Adriane Irwin, PharmD, MS, is a clinical associate professor and chair of the department of pharmacy practice at Oregon State University College of Pharmacy.
When it comes to a postgraduate opportunity or job search across the country, it is critical to know that pharmacist scope of practice differs from state to state. Why should you factor location and state regulations into your career decision-making process? As Student Pharmacist focuses its gaze westward, two accomplished pharmacists provide answers and highlight their regions.
Could the Heartland be the next step in your adventure? (Myriam)
In the Midwest, the ability to practice pharmacy at the top of one’s license has increased exponentially in the last few years. Pharmacist scope of practice in any state is the care pharmacists can provide independently, in conjunction with other providers, and under regulatory guardrails. Here are some innovative ways pharmacists provide care in the Midwest.
Collaborative practice agreements
Collaborative practice agreements (CPAs) allow pharmacists to have extended care capabilities, including prescribing and deprescribing medications as well as ordering and interpreting tests. Many states in the Midwest have provisions for collaborative practice agreements; however, there are several variations to keep in mind. Ohio and North Dakota passed laws allowing pharmacists to collaborate under a physician’s supervision, but have since broadened this provision to include nurse practitioners and physician assistants as authorized by one or more supervising or collaborating physicians. Additional providers to collaborate with allow pharmacists to positively influence patient care through a broader base of practitioners with different specialties.
Another CPA consideration is the types of CPAs allowed. Illinois allows multiple pharmacists to be under the same CPA with a single physician. In contrast, states like Wisconsin, Missouri, Iowa, and Indiana allow multiple pharmacists in the same CPA with multiple providers. While this should not play a pivotal role in choosing one state over another, broader provisions allow for efficiency in starting new clinical services or joining a practice group.
A statewide protocol is another avenue of extended pharmacist services. Statewide protocols share similarities to CPAs in that they allow pharmacists to care for patients using defined conditions. They are public health-focused parameters that follow the passage of state law. Several states have protocols for ordering and dispensing Naloxone. Indiana allows pharmacists to dispense FDA-approved medications indicated for tobacco cessation. There are specific guardrails written into the statewide protocol that enable pharmacists to care for patients but refer higher-risk patients to their primary care provider, psychiatrist, or another provider. Recently, Ohio passed a law allowing pharmacists to dispense nicotine replacement therapy under a statewide protocol. As of press time, the Ohio Board of Pharmacy has publicly shared a proposed protocol that should go into effect soon. Pharmacists may also be allowed to prescribe category-specific medications under the passage of state laws. In 2020, Minnesota allowed pharmacists to prescribe self-administered hormonal oral contraceptives, and the State Board of Pharmacy has outlined a detailed protocol for pharmacists to follow.
Standing orders vary from statewide protocols, as they require a physician’s order and can be carried out by pharmacists provided the outlined conditions are met. Student pharmacists considering future roles that involve public health issues such as the opioid epidemic, access to contraceptives, and HIV treatment should evaluate states based on whether they have protocols or standing orders already in place to help address these public health issues. Illinois recently passed House Bill 135, allowing pharmacists to provide a hormonal contraceptive consultation following a patient self-screening risk assessment. Pharmacists can then order hormonal contraceptives for patients under a standing order. Pharmacists have to complete training approved by the Accreditation Council for Pharmacy Education in order to have these abilities. Missouri is the third state to allow patients access to HIV post-exposure prophylaxis without a prescription through a pharmacist. The pharmacist can dispense these medications provided they follow a written protocol authorized by a physician.
“A fantastic practice environment”
One final factor to consider is the relationship state associations have with other health care associations, the state legislature, and state regulatory bodies. States that advance the scope of practice quickly have strong ties among these groups mentioned. Students should contact state pharmacy associations when evaluating which locations to pursue a new job position or postgraduate training.
“The Midwest is a fantastic practice environment for pharmacists. Interprofessional collaboration opportunities abound, and pharmacists are seen as respected members of the team.” said Veronica Vernon, PharmD, assistant professor of pharmacy practice at Butler University College of Pharmacy and Health Sciences.
The Midwest is filled with world-class practice sites with advanced scope of practice provisions. I invite you to take this information with the attitude of seeking to further innovation in pharmacy scope of practice wherever you begin your career. If the Midwest, particularly Ohio, is where you land, I look forward to working with you as a colleague.
Go West, young pharmacist (Adriane)
The western United States is a consistent leader in pharmacy practice. As early as 1993, pharmacists in New Mexico have had a pathway to broad prescriptive authority through the pharmacist clinician credential. Since then, variations of CPAs, or formal collaborations between prescribers and pharmacists that allow pharmacists to actively managing drug therapy regimens, have been implemented in nearly all U.S. states. However, the early and widespread acceptance of CPAs across the west has provided traction for subsequent action on payment for clinical services as well as expansion of pharmacist prescribing to the community clinician.
Provider status momentum
Landmark legislation passed in 2013–2015 in the 3 west coast states (California, Oregon, and Washington) created momentum around pharmacist provider status reform. Washington and Oregon laws, both passed in 2015, specifically address provider status and clarify that pharmacists are reimbursement-eligible providers for clinical services. Washington law even goes as far to require that health insurance provider networks include pharmacists. Similar efforts have followed in New Mexico and Idaho in 2020, and Colorado in 2021. As a result, there are a growing number of pharmacist-run services that include direct billing of third-party payers for revenue rather than relying solely on more “soft dollar” approaches such as improved patient outcomes or reduced hospital readmissions. Zachary Rosko, PharmD, BCPS, director of pharmacy for Neighborhood Health Center in Hillsboro, OR, and one of the leaders in this area, says “[p]harmacists now have real potential to provide a broad scope of services in small primary care and specialty practices and get provider-level reimbursement. Pharmacists will no longer be restricted to only practicing in these advanced roles in large health-systems who can fund these services under other revenue streams.”
In contrast to Washington and Oregon, California’s legislation did not directly address payment. Instead, it aimed to foster new reimbursement and collaborative care opportunities to elevate the role of pharmacists outside of hospitals and health-systems through expanded CPA models. Michel Daher, PharmD, who provides diabetes management services at his community pharmacy, Pax Pharmacy in Duarte, CA, describes the opportunity, “In our area, it can be months before patients can get in to see a specialist. However, we can get patients in right away and then follow them closely. This gets patients to goal more quickly and in a safer way.” Pax Pharmacy was providing diabetes services prior to passage of California’s legislation, but he is hopeful that new approaches will open doors for other pharmacists to help address the access issues that exist in his community and surrounding areas.
The increased focused on community pharmacy as untapped partners in responding to unmet health needs is increasingly appreciated, and this is evident through legislative efforts across the West. California was the first state to pass legislation allowing for pharmacist-provided hormonal contraception. Washington as well as Idaho have paved the way for community pharmacists to prescribe medications for minor ailments and conditions such as allergic rhinitis, cold sores, and uncomplicated urinary tract infections. Oregon has implemented a framework that allows the Oregon Board of Pharmacy to determine which medications and devices a pharmacist may prescribe based on statewide protocols, rather than relying on individual legislative wins.
Advocacy, which has included efforts by student pharmacists, have been instrumental to these legislative successes. Furthermore, in the case of the Oregon formulary framework ongoing involvement from the pharmacy community is essential because the process hinges on Oregon pharmacists submitting ideas to the Board. Kayla Hensley, PharmD, with Kroger Health and chair of the state association committee responsible for concept development, said, “The process is very grassroots. A number of recent concepts have actually been developed by pharmacy residents. To me, this is really exciting because it provides a clear way for new practitioners to develop a sense of ownership for the future of the profession.”
Whether you are practicing in an integrated health-system or a community pharmacy, the practice of pharmacy in the West is constantly evolving and pushing new boundaries. In the words of Sara McElroy, PharmD, “As a new practitioner, I had the opportunity to build pharmacy services from the ground—ranging from using more traditional CPAs for refill authorizations to unique CPAs for gender transition medication management. This success was surely facilitated by a health environment that is receptive to multidisciplinary teams and a willingness to be innovative. This makes practicing in Washington limitless.”
In the next issue: A look at the eastern and southern parts of the country.