Policy 101: Collaborative practice empowers pharmacists to practice as providers

Hub on Provider Status

The federal pharmacist provider status bill introduced in the U.S. House of Representatives (H.R. 4190) on March 11, 2014, defers to states’ scope of practice for what services a pharmacist can provide and be compensated for. This legislation has placed even greater attention on understanding the state-to-state variability in what pharmacists’ scope of practice entails. With this in mind, the National Alliance of State Pharmacy Associations (NASPA) has expanded upon previous research from early 2013 to further examine the variability between state collaborative practice agreement provisions.

Collaborative practice agreements (CPAs) create a formal practice relationship between a pharmacist and another health care provider and specify what patient care services—beyond the pharmacist’s typical scope of practice—can be provided by the pharmacist. These patient care services can include modification of current drug therapy, initiation of new therapy, ordering of labs, and/or physical assessment of the patient. The extent of the services authorized under the collaborative agreement depends on the state’s CPA provisions and the terms of the specific agreement itself.

Recently passed state laws

Since 2013, several states have seen advances in pharmacists’ ability to work collaboratively with physicians and other prescribers to provide advanced care to patients. Currently, 48 states plus the District of Columbia allow for some degree of collaborative practice agreements between pharmacists and other health care providers. Kansas, with the signing of the Senate Substitution for HB 2146 on April 10, 2014, took the total count from 47 to 48.

Other states that recently passed collaborative practice–related legislation include California, Maine, Minnesota, New York, Tennessee, and Wisconsin. In these states, where collaborative practice was already authorized in some capacity, the new legislation expanded upon existing provisions. The simplest language, and perhaps most expansive authority, came out of Wisconsin. Per Wisconsin Act 294, pharmacists in Wisconsin now “may perform any patient care service delegated to the pharmacist by a physician.” This broad-based language allows for pharmacists and physicians to work together collaboratively to determine the best way to optimize patient outcomes.

NASPA analysis: Several new factors

In the most recent analysis, NASPA looked at several new factors related to collaborative agreements as well as those examined in the previous work. These parameters included the services that could be authorized within the agreement, which pharmacists and practitioners could enter into an agreement, patient involvement in the initiation of an agreement, and documentation requirements, among others.

Currently, 38 states allow pharmacists, when authorized under a collaborative agreement, to initiate drug therapy, and 45 allow for the modification of existing therapy (in addition, Florida pharmacists are authorized to initiate a defined list of medications without a collaborative agreement). Some states limit this authority in different ways.  Twenty-nine states require the collaborative agreement to specify the specific medications or specific disease states/conditions that the pharmacist can manage.

Although the majority of states allow all licensed pharmacists to participate in collaborative arrangements, 18 states require specific education or training. These requirements range from the relatively easy to attain, such as in Massachusetts, which requires only a PharmD degree or a BSPharm degree plus 5 years of experience, to the more demanding, such as in Maryland, which requires a PharmD or equivalent training; certification as a specialist or completion of a residency, certificate training program, or board-approved exam; defined clinical experience; and documented training related to the disease states being managed.

The most open CPA provisions allow multiple pharmacists to collaborate with multiple prescribers to care for multiple patients within one agreement. Although these open provisions allow the most efficient care to be provided, they are currently seen in only 10 states. While many states restrict the collaboration to pharmacists and physicians, 21 states allow other prescribers, such as nurse practitioners, physician assistants, dentists, and other prescribers, to enter into a CPA with a pharmacist as well.

Learn state issues, get involved

“It’s important to acknowledge that federal provider status efforts will be a multiyear effort, so we need pharmacists’ involvement for the long haul. We need pharmacists to be involved in the federal campaign, but equally important is their involvement at the state level,” said Stacie Maass, BSPharm, JD, APhA Senior Vice President of Pharmacy Practice and Government Affairs. “The progress that pharmacists and their state associations have made, and will make, for our profession at the state level is what the national pharmacy organizations highlight in our meetings with Members of Congress. [Pharmacists and their state associations] are making the provision and benefit of pharmacists’ patient care services real.”  

Optimizing collaborative practice provisions and other pharmacist scope of practice issues to deliver the high quality patient care that pharmacists are trained to provide is an ongoing, long-term process. Pharmacists should learn about the issues in their state and get involved with their state pharmacy association and APhA and educate policy makers on the role that pharmacists can play in meeting public health needs. State laws and regulations, including those regarding collaborative practice agreements, are constantly evolving. Pharmacists should reach out to their state pharmacy association or board of pharmacy to learn the status of their state’s provisions.

What’s in a name?

There are often a lot of questions about collaborative practice–related terminology, especially by policy makers.

It’s important to note that the term “collaborative practice agreement” is not used in every state. Other terms used include the following: 

  • Collaborative pharmacy practice agreement
  • Consult agreement
  • Physician–pharmacist agreement
  • Standing order or protocol
  • Physician delegation

Terms used for the services provided under a collaborative agreement include the following:

  • Collaborative drug therapy management
  • Drug therapy management
  • Pharmaceutical care
  • Medication therapy services
  • Collaborative pharmacy practice