Collaborative practice gains

Community pharmacists in a retail setting are in a strong position to work collaboratively with physicians to help patients with their drug therapy management.

See also: You want collaborative practice? Win provider status  

Krystalyn WeaverOver the last decade, lawmakers in several states - Kansas, Maine, Massachusetts, Missouri, New Jersey, Tennessee, West Virginia, Wisconsin, and Virginia - have approved legislation that would permit pharmacists in any practice setting to implement collaborative drug therapy management (CDTM) provisions or expand existing CDTM provisions, notes “Collaborative Drug Therapy Management and Comprehensive Medication Management ― 2015,” a white paper produced by the American College of Clinical Pharmacy (ACCP).

At present 48 states and the District of Columbia allow pharmacists and physicians some degree of collaboration in the provision of advanced patient care under collaborative practice agreements (CPAs), said Krystalyn Weaver, PharmD, director of policy and state relations for the National Alliance of State Pharmacy Associations (NASPA).

According to Weaver, NASPA’s research shows that 38 states permit pharmacists to initiate drug therapy through a CPA, and 45 allow pharmacists to modify existing therapy. However, in 29 states, the CPA must specify the medications or specific disease states that can be managed by the pharmacist.

Collaboration in public health  

Community pharmacists are fortunate to have a number of opportunities to collaborate with physicians on public health initiatives. Immunizations, such as those for seasonal influenza, provide an opportunity for retail pharmacists working in some states under a CPA to administer vaccines without the need of a prescription, Weaver noted.

See also: New CDC tool kit helps with collaborative practice agreements

Christy Truong
“Pharmacists have the education and training needed to assess a patient’s immunization status and administer vaccines that are needed. Eliminating the extra barrier of a prescription from another provider can help to increase immunization rates,” she said.

Independent pharmacies are also offering immunizations with the use of CPAs, according to Christy Truong, administrator of the collaborative practice agreement program for immunizations at AmerisourceBergen.

“Each state’s regulatory and licensure requirements for immunization vary. Our program, depending on each state, enables the pharmacist to enter into a partnership with a physician to coordinate immunization administration, pursuant to the applicable state regulations and requirements,” she said. “Our program helps to reduce the administrative fragmentation and the administrative burden for the pharmacist by looking for local physicians that satisfy the state’s requirements, so that they have more time to spend with the patient to do the patient counseling and education.”

CPAs for naloxone therapy

Some states allow pharmacists to provide other public health services, such as testing for tuberculosis, support for smoking cessation, and now the dispensing of naloxone (Narcan), the life-saving medication that reverses opiate overdose.

In 2012, Washington state saw the first collaborative drug therapy agreement that allowed a retail pharmacy to prescribe and dispense under a written guideline for naloxone. According to “Using Law to Support Pharmacy Naloxone Distribution,” an issue brief published by the Network for Public Health Law, other parties to the protocol were the public health agency of Seattle, Washington, and King County, and the University of Washington Alcohol and Drug Abuse Institute.

In 2013, a Rhode Island hospital physician, Josiah Rich, entered into a CPA with Walgreens to conduct a pilot project that allowed pharmacists to identify patients eligible for naloxone and to start the therapy, guided by a written protocol. This process requires the pharmacist to fax a note to the prescriber when naloxone is dispensed; the patient must sign a consent form giving the provider access to the patient’s medical record.

In March 2014, when the state’s Department of Health released regulations pertaining to naloxone, single prescribers were enabled to authorize a non-patient-specific order, allowing police departments access to the opioid antagonist, the issue brief stated.

Since November 2014, another 12 states have worked to pass legislation or regulations authorizing pharmacies to dispense the drug through “standing orders.” These states include California, Delaware, Kentucky, Illinois, Minnesota, New Jersey, North Carolina, Pennsylvania, Tennessee, Vermont, and Wisconsin, the issue brief noted.

Other opportunities

Anna Legreid DoppWith the enactment in April 2014 of legislation known as Wisconsin Act 294, pharmacists in Wisconsin were given “perhaps the most expansive authority” to be found in existing CDTMs, permitting them to “perform any patient care service delegated to a pharmacist by a physician,” Weaver said.

The latitude built into this CPA allows local innovation, enabling each practitioner to determine what functions to delegate to the pharmacist. Some unique CPAs that have been developed by community pharmacists and physicians go beyond immunization authority, said Anna Legreid Dopp, PharmD, vice president of public affairs for the Pharmacy Society of Wisconsin (PSW).

Marvin Moore“One of our members has developed a CPA with refill authorizations, which would extend chronic medications for three months beyond when the prescription would have expired,” Dopp said. “This pharmacy worked with the physician to discuss which medications this might be appropriate for and was allowed to give a three-month extension when the patient runs out of refills, in order to give him time to be seen by the physician.”

Marvin R. Moore, PharmD, pharmacy manager and co-owner of The Medicine Shoppe/Pharmacy Solutions Inc. in Two Rivers, Wisc., recently established two CPAs with a physician located next door to his pharmacy. Moore can provide patients with a 30-day supply of chronic medication if the physician isn’t available to authorize a refill. The CPA also permits Moore to convert a 30-day supply of medication to a 90-day supply.

With this authority, the community pharmacist can conveniently provide the increased supply of medication if the patient requests it.

“These two CPAs help to protect the patient from going without their medication,” Moore said. “Traditionally, we would provide the patient with a few pills to get them through the weekend, but then there’s the extra trip for the patient with the potential to forget to come back in, and the patient could lose track of his medication. So now [with the CPA] we are able to give the patient a month’s worth of medication, and it helps to avoid the frustration and potentially avoids the interruption of therapy.”

In Wisconsin, one type of CPA grants the pharmacist authority to perform therapeutic interchange. If a drug is not covered by the patient’s insurance, the pharmacist can easily switch between different medications within the same class.

Moore would like to develop a CPA for therapeutic interchanges in order to streamline the process for the patient. “If the physician writes a prescription for one ACE inhibitor and the patient’s insurance doesn’t cover it, we are able to switch to an equivalent ACE inhibitor. We can also do this for an ARB or PPI. Those switches are easy for us to make and wouldn’t require us to access the patient’s medical history,” he said.

Laura TraynorToolkit

Laura Traynor, PharmD, associate professor of pharmacy practice at the School of Pharmacy - Concordia University Wisconsin, was involved in the development of the PSW’s Collaborative Practice Toolkit. The toolkit provides a sample outline of what a CPA should include, as well as examples of potential opportunities available to pharmacists, such as specific disease states to consider for patient care collaboration. It also includes information about how to approach a physician to broach the subject of entering into a CPA and how to build a business case for a CPA.

In regard to specific disease states, anticoagulation management is another appropriate patient care service that can be covered under a CPA, said Traynor, who participated in a CPA for anticoagulation in a primary care clinic.

During the patient visit, she did a point-of-care INR test and based her interpretation of the results on the patient’s range and previous results. With information gathered from the patient about medication adherence and diet, Traynor could provide guidance on dosage adjustment for warfarin and then communicate the information through the patient’s electronic health record to the patient’s primary care doctor. She also was able to refill the warfarin prescription and perform bridging therapy when needed.

“Collaborative practice agreements make life easier for the pharmacist, physician, and the patient,” said Traynor. “It helps to improve the processes of patient care, in order to prevent a lot of unnecessary waiting on the part of the patient or the pharmacist. There are things that can be delegated, and that judgment can be made by the pharmacist.”

Future CPAs

The Wisconsin Pharmacy Quality Collaborative (WPQC) is an initiative undertaken by the PSW to connect community pharmacists certified in specific medication therapy management (MTM) training with doctors and third-party payers throughout Wisconsin. WPQC has identified asthma and diabetes as two specific disease states that could benefit from CPAs between pharmacists and physicians.

PSW’s Dopp explained that a clinical advisory group focused on asthma is working to establish CPAs for asthma management, using Wisconsin Act 294 as an impetus for this goal. Another area that the WPQC may work on is diabetes.

Reimbursement pathways

Several payers reimburse MTM services in Wisconsin, including Medicaid, Dopp said.

“There are several other commercial payers and additional ones that are joining on [through the WPQC program] to reimburse for services of MTM,” Dopp said. “For example, the asthma practice agreement would be used to bolster those services in the WPQC program that are related to asthma, so those would be eligible for reimbursement under that program.”

However, pharmacists in Wisconsin and across the country are hoping that in time the federal provider status bills (H.R. 592 and S. 314), known as the Pharmacy and Medically Underserved Areas Enhancement Act, will be passed. This Act would provide pharmacist-specific billing codes for pharmacists practicing within their scope of practice and their state.

Ned Milenkovich“We are just as anxious as everyone also to have that passed, so that the reimbursement mechanism will be more defined for pharmacists delivering services,” Dopp said. “In Wisconsin, we are one of those states that would have a large percentage of counties that have medically underserved areas [that would be covered by the Act].”

Ned Milenkovich, PharmD, JD, Drug Topics legal compliance columnist and a principal at the Chicago law firm of Much Shelist, explained that pharmacists are providing cognitive healthcare services and getting paid under the MTM model. “However, they are providing all kinds of cognitive services for which they are not being reimbursed,” he said. “So the provider status gives them a mechanism by which they can be reimbursed for those services that they are already providing in some cases for free.”

He added, “If pharmacists can demonstrate through the reimbursement of those dollars that they are having a real impact on outcomes and that the net sum total is a decrease in healthcare costs, then I think you have a winner.”