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July 2015, Vol 3, No 7 - Inside Pharmacy
Andrea Brookhart, PharmD, BCACP

During my first national professional meeting, I attended a session about the future of the pharmacy profession. I learned about collaborative practice agreements (CPAs) for the first time, and left the session feeling intrigued.

CPAs are formal agreements where licensed providers diagnose patients, supervise their care, and refer them to pharmacists following a protocol that lets the pharmacist perform specific types of patient care as defined in the agreement.1 After learning more about CPAs through research, study, and residency training, it struck me that the future of pharmacy is already here. Laws regarding CPAs vary widely from state to state,1,2 as do the terms used to describe them (Figure).2 Some form of CPA is available in 47 states, with 38 of those allowing pharmacists to initiate medications.2 Thus, in many states, CPAs allow pharmacists to practice as providers and have a larger impact on patient care today.

Figure

Identifying Gaps in Care

I have since become a community pharmacist, and practice 1 half-day per week at a local, free clinic pharmacy. When starting this clinic’s first clinical pharmacy program in the middle of 2013, I hoped to develop pharmacy services that closed specific gaps in care the clinic’s patients were experiencing. One of the first main gaps in care we identified was the time it took for patients to receive medication refills. Patients are asked to call the pharmacy 7 days before they need a medication refill, affording this volunteer-run pharmacy enough time to fill the prescription. However, the coordinator of the pharmacy—a certified pharmacy technician—reported that we were missing this 7-day window about 15% of the time. Furthermore, he identified that the delay was mainly attributed to a backlog of refill requests sitting on the desk of the clinic’s sole prescriber. Thus, our need for a CPA was born.

Our first CPA was with that prescriber, a nurse practitioner who was swamped by her significant responsibilities, and needed collaborative care assistance to help patients. The CPA only authorized pharmacists to refill medications for several major disease states, including diabetes, hypertension, dyslipidemia, asthma, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. Since the implementation of the CPA, the free clinic pharmacy misses the 7-day refill window <1% of the time. We were thrilled to close our first gap in care with the CPA, by no longer contributing to medication nonadherence with delayed refills.

Development of a CPA

The story of enacting our clinic’s first CPA is a case study on how to enter into CPAs with prescribers. First, we identified the need for the service; then, key stakeholders who would be involved in the collaborative care of patients were identified. After our team was assembled, we began gathering resources and analyzing laws around CPAs in our state, referring to our state pharmacy association for examples of written agreements and guidance on our scope of practice. We presented our idea to the clinic’s medical advisory committee for their approval of the program and, finally, signed the agreement.

Learning from the CPA

I have learned many lessons while practicing under a CPA, and because I am a full-time pharmacist at a large supermarket chain, I acknowledge considerations for other practice sites. Because CPA regulations and the scope of pharmacy practice vary widely from state to state, the CPA I describe may be simplistic compared with the options available in other states, or even impossible depending on the state. State pharmacy associations are continually working to improve state practice acts, and are great resources for pharmacists seeking to clarify their own scope of practice.

In addition, our practice site does not require payment for the pharmacy services provided. However, although our visits with patients run solely on time donated by pharmacists, payment mechanisms (eg, billing incidents to a physician, billing facility fees, and using transitional care billing codes) are available for pharmacists performing these types of patient care. Moreover, certain payers reimburse for medication therapy management (MTM) through billing of MTM Current Procedural Terminology (CPT) codes, or individual contracts. Pharmacist provider status may provide the additional mechanisms for compensation that pharmacists need to collaborate with other healthcare providers on a full-time basis and address critical gaps in the care of underserved patients.

Finally, I have learned that pharmacy services should be tailored to meet the needs of the providers and patients at a given practice site. Coming to a practice site with predetermined goals may not be well-received by providers, and may not meet the needs of the site’s existing patients. We have had amazing opportunities to expand our CPA and begin closing additional gaps in patient care. We have used our CPA to perform medication interchange to help keep the pharmacy’s drug budget on track, allowing us to continue purchasing generic medications to give to patients.

As part of our CPA, we also began providing diabetes education to patients who would have otherwise been on a waiting list, as well as titrating their insulin. Most recently, we expanded our CPA to include modification of lipid-lowering therapy, to aid volunteer prescribers’ efforts to get patients on appropriately intense statin therapy, in line with current guidelines. By continually collaborating to identify gaps in care and to meet patient care needs, our clinical pharmacy program is able to contribute positively to the overall health and wellness of our patients.

Acknowledgment

Chris Hicks, CPhT, Pharmacy Coordinator at the Charlottesville Free Clinic (CFC), Charlottesville, VA, helped assemble relevant data for this piece. I would also like to acknowledge Mr Hicks and the rest of the CFC clinical pharmacy team for their hard work and continued support as we try to improve the lives of patients.


References

  1. Centers for Disease Control and Prevention. Collaborative practice agreements and pharmacists’ patient care services: a resource for pharmacists. www.cdc.gov/dhdsp/pubs/docs/Translational_Tools_Pharmacists.pdf. Published October 2013. Accessed June 4, 2015.
  2. Weaver KK. Policy 101: collaborative practice empowers pharmacists to practice as providers. www.pharmacist.com/policy-101-collaborative-practice-empowers-pharmacists-practice-providers. Published October 1, 2014. Accessed June 4, 2015.
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Last modified: July 28, 2015
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