Something very exciting occurred recently with the publication by the United States Centers for Disease Control and Prevention (CDC) of a resource and implementation guide for adding pharmacists to the health team. It is available in print and online versions from the CDC as: ‘Advancing Team-Based Care Through Collaborative Practice Agreements’, CDC, Atlanta, Georgia, 2017.
Many of us have lamented the unused capacity of the pharmacist, who in the past spent most of her or his time counting tablets or capsules and placing them in bottles. Gradually, with the growing use of pharmacy automation and technical support personnel, the practicing pharmacist has more time to offer cognitive services such as counselling, patient education, administering immunisations and medication therapy management (MTM). Some progressive pharmacists in conducive environments have developed informal or semi-formal practice arrangements with nearby physicians, but this is not seen as commonplace. Today, with the use of the CDC publication, joint or collaborative practice agreements can become routine.
This document has been a long time in gestation. Back in 1981, the American Public Health Association declared that pharmacists were an underutilised resource in promoting public health. They noted that an estimated 86% of the US population lives within 5 miles of a community pharmacy. Then in 2011, the chief pharmacist officer of the US Public Health Service authored a report titled: ‘Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. The report's findings were endorsed by the then US Surgeon General. It was subsequently decided that the optimal pathway was via collaborative practice models.
So what is a collaborative practice agreements (CPA)? CPAs create a formal practice relationship between a pharmacist and a prescriber. The agreement specifies what function – in addition to the pharmacist's typical scope of practice – is delegated to the pharmacist by the collaborating physician. The CPA authorises pharmacists to initiate, modify or discontinue drug therapy. Functions in this context may include ordering and/or interpreting laboratory tests.
When mutual trust develops between the pharmacist and the prescriber, it is possible for the delegated scope of tasks to expand. This usually expands available services to patients and increases the efficiency and coordination of care. A stated example is the reduction in telephone calls to the physician for refill authorisation or to modify prescriptions, allowing each member of the health team to complement the skills and knowledge of the other members, resulting in improved outcomes.
It was interesting to read that as of May 2016, 48 States in the USA permit some type of pharmacist–prescriber collaborative practice authority. Existing agreements appear to focus on maintenance therapy for chronic conditions, such as diabetes, hypertension, cholesterol, obesity, smoking cessation and compliance enhancement, among others.
The report offers a template for such agreements to be tailored to be within individual state laws and to be as modest or expanded as the involved parties are comfortable with. There is a first section stating the authority and purpose of the CPA. It is followed by a description of the parties to the agreement, and a specific list of patient care functions authorised. Everything should be spelled out and precise to avoid any subsequent misunderstandings. Training and education of the named parties should be included, as well as information describing what liability insurance must be maintained. A section describing the informed consent for patients’ protocols is necessary. Documentation is desirable, as well as guidelines for how communication will take place. Any CPA should have an expiration date and renewal process, as well as an escape clause. Often references are desirable, and there should be place for the signatures of involved parties and witnesses to the CPA.
It is likely that no two CPAs are identical, and there is the probability that they will change as experience dictates. Nevertheless, this document, giving a type of legitimacy or normality, is a positive step for all stakeholders, including the patient. It will be interesting to see how this concept develops in the coming years and whether we might see it outside the USA.