What I Wish I Knew: Developing a Collaborative Practice Agreement: Making It Work for You

Carla Cobb, PharmD, BCPP
Psychiatric Pharmacist
Capita Consulting
Billings, MT

Dr. Carla Cobb is founder and consultant at Capita Consulting. She received her Doctor of Pharmacy degree and completed a residency in psychiatric pharmacy at the University of Texas Health Science Center in San Antonio. She is a founding member and past president of the American Association of Psychiatric Pharmacists (AAPP). She serves on AAPP’s Government Affairs and Professional Affairs committees and on the Montana Pharmacy Association legislative committee. In her current practice she coaches healthcare teams integrating clinical pharmacy and behavioral health services, trains primary care providers on psychiatric pharmacotherapy, and advocates for recognition and payment for patient care services provided by psychiatric pharmacists.

Richard Silvia, PharmD, BCPP
Professor of Pharmacy Practice
MCPHS School of Pharmacy
Boston, MA

Dr. Richard Silvia is a Professor of Pharmacy Practice within the School of Pharmacy-Boston of MCPHS, and is a clinical psychiatric pharmacist at the Codman Square Health Center in Dorchester, MA. He received his Doctor of Pharmacy degree from the University of Rhode Island, and then completed a 2-year residency/fellowship in psychiatric pharmacy through the University of Connecticut and the Institute of Living in Hartford, CT. He is a member of the American Association of Psychiatric Pharmacists (AAPP), chairs the Outpatient Psychiatric Pharmacy Best Practice Model Task Force, and is  the past chair of AAPP’s Professional Affairs committee. He has also chaired a Collaborative Drug Therapy Management (CDTM) Task Force within his school, developing a program to assist other faculty in developing their own CDTM-based practice. His current practice is as an integrated behavioral health provider within the primary care clinics of the health center. He maintains a collaborative practice agreement via CDTM where he provides direct care to patients with mental illness that are referred to him for treatment.

Introduction

A collaborative practice agreement (CPA) is a process by which a licensed practitioner delegates the authority to participate in specified activities to a pharmacist through a written agreement. It most often is used to delegate prescriptive authority to the pharmacist. In some states it may be called collaborative drug therapy management (CDTM). Within the Department of Veterans Affairs the collaborative practice agreement is referred to as a “scope of practice” and is defined by federal policy and is outside the purview of this discussion below.

A CPA may allow a pharmacist to start, change, or discontinue specified medications or classes of medications and/or order laboratory and other tests or procedures (EKG, etc.) at the time of service. This provides for more timely and efficient care compared to a consultative model in which a pharmacist provides recommendations to a practitioner to implement at a later time. CPAs are not required for activities that already fall within a pharmacist’s scope of practice as defined by state laws and regulations. Pharmacist consultations without pharmacist-ordered medication changes do not require a CPA.

CPAs come with an additional of level of responsibility for the pharmacist. They must be familiar with state laws governing CPAs, write and sign a CPA in collaboration with a practitioner, and either submit it to the board of pharmacy (BOP) or keep it on file for review by a pharmacy inspector, depending on state regulations. The pharmacist must also review, update, and/or renew the CPA on a regular basis, depending on state regulations.

Legal Considerations

When developing a CPA the most important first step is to identify and review the laws and regulations governing CPAs in your state. In addition to state regulations, there may be additional elements requested by your collaborating practitioner or practice site.

Common elements in model regulations¹ include:

• the types of decisions that the pharmacist is allowed to make;
• a method and criteria for referring patients to the pharmacist, and for discharge from the service
• a method for the practitioner to monitor compliance with the agreement and clinical outcomes and to intercede where necessary;
• a provision that allows the practitioner to override a collaborative practice decision made by the pharmacist whenever he or she deems it necessary or appropriate;
• a provision that allows either party to cancel the agreement by written notification;
• a procedure for periodic review and renewal within a time frame for the practitioner.

Additional questions that may need to be addressed could include:

• Is a certain length of practice experience, board certification (such as from the Board of Pharmaceutical Specialties), or advanced practice designation required for a CPA?
• Are CPAs permitted with physicians only or are agreements with non-physician practitioners also permitted?
• Is the agreement allowed between one pharmacist and one practitioner or are agreements between groups of pharmacists and/or groups of practitioners permitted?
• Is a CPA limited to specific medications or classes of medications vs a wide range of medications?
• Is the pharmacist allowed to prescribe controlled substances, if they have a DEA registration, under the CPA?
• Is a specific protocol required or is prescribing allowed based on the pharmacist’s clinical judgement?
• Is patient consent required before a medication is prescribed by a pharmacist?
• Is the collaborating practitioner required to review and/or sign each patient visit?

Site Requirements and Practice Development

Before initiating a CPA, some basic questions should be answered. First, determine the purpose and assess the need for a CPA within your clinical setting. How would a CPA improve patient care? This may involve initiating a CPA that is not in your “ideal” area of practice but getting established where there is a defined patient care need and then expanding later as a viable starting point. Start by developing relationships with providers to determine how a CPA may alleviate issues or enhance patient care at your site. Try to cultivate a relationship with a “champion” provider who will help market the practice to other providers. Once the CPA is approved, patient referrals will be needed, so these relationships can be useful.

Another site concern involves credentialing. Many sites require all providers to undergo credentialing before they can see patients. This can involve a review of several areas including licensure, insurance credentialing, and malpractice insurance. This process should be confirmed with the medical director as the CPA is developed.

If you’re unsure how to prepare the CPA, find someone to mentor you in writing the document. Is there someone at the site already practicing under a CPA, even if not in psychiatry? Is there someone at a nearby site? If not, contacting the state BOP or a local school of pharmacy could be helpful. Ask for sample or template CPAs to help you develop your own.

As the CPA practice is initiated, be patient. Referrals may be slow coming in, or there may be a flurry initially and then it may taper off. Use any time to continue developing provider relationships to increase referrals. Speak to other mental health providers, such as therapists, to inquire about patients who might need medication assistance. As the practice develops, be aware of changes within the clinical site. Changes in providers and/or leadership can bring new challenges to the practice. Make sure to develop relationships with new providers, and certainly with new leadership.

Conclusion

Developing a CPA can be a method of increasing pharmacist collaboration with practitioners and improving efficiency in providing patient care services. This information will help you get started in developing a CPA that is appropriate for your practice.