From the Executive Director

Penny Shelton, PharmD, BCGP, FASCP

Our ‘State’ of Collaborative Care

will frst have to register with the Board of Pharma-

cy. The Board of Pharmacy will maintain the registry similar to how the immuni-

zation registry is handled. Practitioners engaged in collaborative agreements would be subject to abiding by the rules and could be audited. Physicians (or institutions such as with a

hospital) establishing the agreement can require

We tried something new at our Convention this past September. We held individual summits for

different sectors of pharmacy to discuss the issues deemed to be

most impactful, either because the issue gave great cause for concern or presented ample opportunity for the profession. One of the top issues to emerge was collaborative practice and provider status designation. The importance of this issue coincided with the unveiling of talking points and proposed draft language for a bill to be run by NCAP during the upcoming 2019 legislative session. The NCAP Board of Directors (BOD), various task force groups, the Policy and Advocacy Committee, staff, and NCAP lobbyist have been working on a bill for the past two years, which if passed, would update our collaborative practice authority. To date, the majority of feedback on the bill has been positive; however, there were some concerns

raised during Convention regarding specifc elements of the bill. At the October BOD meeting, these concerns were reviewed. The

BOD determined there are misperceptions and confusion regarding the bill, as well as a general lack of awareness regarding the state of collaborative practice nationwide; therefore, NCAP plans to provide additional information on the bill

using a variety media between now and the new legislative session. Furthermore, I have decided to

start by dedicating this Executive Director column to the issue.

As healthcare needs, such as

those associated with chronic dis-

ease, mental health and addiction

continue to rise, there is a growing need in all practice settings for pharmacist-provided patient care services. This is particularly true given primary care and nursing shortages, as well as the increasing occurrence of provider burnout. Collaborative care has been shown

to improve patient outcomes, increase access to care, raise

patient satisfaction, and share the care burden with physicians, which helps with physician job satisfaction and burnout.

The NCAP bill entitled “An Act to

Improve Access to Patient Care Services via Collaboration between

Physicians and Pharmacists” seeks to update our current collaborative practice authority statute, and thus the rules for implementation, making it easier for physicians and pharmacists to collaborate. Specifcally, the bill calls for four key changes (elements):

1. Allow any licensed pharmacist and any licensed physician to collaborate versus a set of criteria that

only allow certain pharmacists to be able to enter into

a collaborative agreement. [Currently 29 states allow any licensed pharmacist, in any practice setting, to participate in a collaborative practice agreement.]

2. Move away from an approval process to a registry process. Currently a committee approves the application of the pharmacist as a CPP and approves the agreements (protocol). Under the new process, agreements are negotiated by the physician and the pharmacist and maintained by the practitioners. Any pharmacist participating in a collaborative agreement

additional qualifcations for their agreements if they wish. [Currently 26 states do not require approval of the pharmacist, review or submission of agreements. One state does not require any approval of the pharmacist, review or submis-

sion of agreements, but does maintain a registry of collaborating pharmacists. Eight other states do not have an approval process of the pharmacist or the agreement, but the agreement must be submitted to

the BOP.]

3. Agreements allow for multiple physicians and multiple pharmacists on a single agreement. Institutions and large group practices could have institution-wide agreements. Individual pharmacists such as consultants

or community pharmacists could have multiple physicians sign onto a single agreement. [Currently 29 states allow for multiple

pharmacists and multiple physicians on an agreement.]

4. Supervising physicians may allow their advanced practitioners (NP or PA) to participate in the agreement, but the supervision remains with the physician.

This allows for patients of

NP and PA practitioners to be referred for patient care services with the pharmacist, but keeps the MD / DO as the supervising entity and avoids creating a threetiered hierarchy. [Currently 27 states allow nurse practitioner and physician assistants to participate.]

North Carolina was a pioneer in collaborative practice in the 90’s, but today, pharmacists might be surprised by how limited or restricted our current collaborative practice authority is when compared to other states. As noted above,

the changes we seek for updating our collaborative practice are not unusual or even cutting edge, but rather necessary to help lift up our profession, for all pharmacists, and do away with restrictions that stymy innovation and make it more diffcult for physicians to partner with pharmacists in various practice settings. Furthermore the changes we seek are all in alignment with the collaborative care

model language published by the National Alliance of State Pharma-

cy Associations and endorsed by a number of organizations, including the American Medical Association. There are two other elements to

our bill that are important. One is that we are seeking these changes by updating versus replacing our existing collaborative practice authority, which is through the ‘clinical pharmacist practitioners’ (CPP) designation. The CPP is how NC carries out collaborative

practice. It is also how pharmacists engaged in collaborative practice agreements are delegated prescriptive authority and allowed to legally prescribe. Early on in our process of working with pharmacists from different practices and backgrounds, we agreed that we did not want to ‘hand-cuff’

our own profession by advocating that some pharmacists under a collaborative agreement could prescribe while others could not. We also recognized that even new graduates are graduating with a far greater number of pharmacology and pharmacotherapy hours than a PA or NP, yet we never second guess their authority to prescribe, so why would we put limitations on our own profession? As part of our bill, any pharmacist engaged in a collaborative agreement would have to register with the NC Board of Pharmacy to be placed on the collaborative care (i.e., CPP) registry and receive a CPP number. The ability to prescribe will still be left up to the supervising physician. In addition, the supervising physician can require additional qualifcations in order for the pharmacist to collaborate. For example, the pharmacist may have to get certifed, maintain a specifc number of professional development hours, or be residency trained; however, the statute should be more open and inclusive of the entire profession.

Secondly, the NCAP bill is pursuing an open scope of practice by incorporating the following language: “Under a collaborative practice agreement, a supervising physician may delegate to a licensed pharmacist any patient care services the supervising physician deems appropriate.” Furthermore the bill addresses the pharmacistphysician ratio giving more fexibility to the physician. It is also important to note that the pharmacist and supervising physician do not have to be under the same roof.

This will give community pharmacists, for example, the ability to establish agreements to treat positive fu tests, administer long-acting antipsychotic injections, or provide medication assisted treatment for systems much needed fexibility to expand pharmacist-provided outpatient and other clinical services. In addition, this bill should

make it easier for long-term care pharmacists to utilize collaborative care in assisted living and skilled care settings.

In October 2017, Frost and Adams

published a review of advanced practice pharmacist designations in the journal Research in Social and Administrative Pharmacy. There are only four states, including NC, that have an advanced practice designation for pharmacists. Uptake of advanced practice pharmacist designations was found to be low, with less than 10% of the

pharmacists in any of these states taking advantage.

Meanwhile, collaborative practice has advanced in a majority of states as noted above and to the

point that those states with advanced practice designations have fewer practice gains than those without the advanced credential.

In NC, many of the restrictions to the existing CPP credential were put into place in 1998 at a time that precedes the all-PharmD mandate and when NC was one of the frst states with the credential. It has

been two decades now, and the

way we teach and train pharmacists has changed tremendously in that timeframe, but perhaps more importantly, is that less than 2.5% of pharmacists in NC are CPPs. To bring about the change that is needed for patient care in our state, we need more pharmacists and physicians collaborating on all levels in all practice settings. Let us do the right thing and work together to update our collaborative authority statute.

To view the infographic and talking points on the proposed bill see pages 7-8 in this issue of the journal or go to https://www. ncpharmacists.org/content. asp?contentid=149

Collaborative Practice Reform

Updating North Carolina’s Collaborative Practice Authority to Provide Better Care for our Patients

Current State of Collaborative Practice

Strong evidence demonstrates the benefits of pharmacist-physician collaboration on patient care. Since 1998 North Carolina has had a form of physician-pharmacist collaborative practice in which the pharmacists are known as clinical pharmacist practitioners (CPP). Despite being a pioneer in this type of practice, North Carolina has now been surpassed by other states and our collaborative practice is today one of the most restrictive in the nation. It is time to update the collaborative practice authority in North Carolina.

How this Bill Enhances Patient Care

• Reduces regulatory burden on physicians and pharmacists, allowing them to practice patient care as needed • Current law and regulations are very restrictive: o Inhibits effectiveness and efficiency of care due to agreement limitations o Does not allow collaboration with physician designees like nurse practitioners and physician assistants o Restrict the number of pharmacists a physician can supervise • As a result of this bill, CPPs will be able to: o Improve care for opioid addiction by overseeing Medication Assisted Treatment o Extend collaborative care in rural areas for patients regardless of disease states o Administer a rapid flu test and furnish antiviral medications under approved protocols without exposing patients with flu to ER and doctor offices o Enhance transitions of care and population health through flexible collaborative practice agreements which address medication safety concerns before they happen

Key Proposed Changes

• Any licensed physician and pharmacist can enter into a collaborative practice agreement. • Agreement is limited to patient care services allowed and identified by the supervising physician in the written agreement. • Allows for multiple physicians and pharmacists to sign onto a single agreement. • Allows for physicians who have nurse practitioners and physician assistants in their practice or on their care teams to also participate in the collaborative practice agreement with the pharmacist(s). • Gives the physician greater flexibility in the number of collaborative practice agreements in which he/she wishes to participate. • Changes current process from committee approval to a state-wide registry.

This Bill ES T

• Seek autonomy of practice for pharmacists. • Create any new clinical acts or patient care services that is not already allowed under our existing clinical pharmacy practitioner rules. • Interfere or force a change within hospitals or other institutions’ internal requirements for collaborative practice.

1. Source: Bureau of Health Workforce, Health

Resources and Services Administration (HRSA), U.S. Department of Health & Human

Services, Designated Health Professional

Shortage Areas Statistics: Designated HPSA

Quarterly Summary, as of December 31, 2017 2. Source: National Association of Chain Drug

Stores 2018 Pharmacy Opinion Research.

Access: https://accessagenda.nacds.org