Putting collaborative authority into practice


How the new Connecticut legislation allowing consultant pharmacists to initiate, modify, and discontinue drug therapy will change practice



Putting collaborative authority into practice

New legislation involving collaborative practice between physicians and pharmacists became law in the state of Connecticut on Oct. 1. This legislation enables consultant pharmacists in long-term care facilities to implement doctors' orders without phone calls or faxes to the physician's office, just as is being done by the hospital pharmacists in our state.

This legislation will have a major impact on me as I practice in the long-term care setting. As a consultant pharmacist, I monitor patient safety through safe medication management. I work to achieve therapeutic goals, while avoiding or minimizing adverse drug events, by performing a monthly drug regimen review. I know that adverse drug events and medication misadventures are underreported by most facilities and often preventable. Collaborative practice enables us to follow protocol-based guidelines to prevent drug-related problems as part of our monthly drug regimen review.

In preparation for this legislation becoming law, we have taken the time to research and write the protocol-based guidelines. These guidelines screen for unnecessary drugs for new long-term care residents admitted from the area hospital, who may have had medications, such as proton pump inhibitors and H2 antagonists, added during their hospital stay. These guidelines monitor the effectiveness of residents' current drug regimens. Diseases covered range from hyperlipidemia and hypertension to congestive heart failure and pain management. Anticoagulation therapy is monitored so that the medication dose can be increased or decreased, depending on the most recent PT/INR, until the patient is stabilized. Once written, these guidelines were reviewed by each of the physicians and consultant pharmacists contracted by our long-term care facility, and each practitioner signed the collaborative practice agreement.

The collaborative practice agreement authorizes the pharmacist to initiate, modify, or discontinue a drug therapy that has been prescribed for a patient, order associated laboratory tests, and administer drugs, all in accordance with a patient-specific protocol. Until now, this information has been communicated by the consultant pharmacist on the physician-pharmacist communication sheet as part of the monthly drug regimen review. The newly enacted legislation changes this practice. When a drug therapy is discontinued, we notify the treating physician of such discontinuance within 24 hours via fax. All activities performed by the pharmacist in conjunction with the protocol are documented in the patient's medical record on the physician's order sheet rather than on the physician-pharmacist communication sheet. As part of the monthly report sent to the facility, the pharmacist documents for the physician any changes regarding the patient's drug therapy management.

This effort means the consultant pharmacist is working in consultation with the treating physician to optimize responsiveness to patient needs while avoiding or minimizing adverse drug events. The principal responsibility of the consultant pharmacist is to identify, resolve, and prevent drug therapy problems that impede progress toward the intended therapeutic goal. This legislation allows pharmacists to do this on an expanded basis during their monthly visit to the facility.

Until now, I made recommendations to the physician on the physician-pharmacist communication sheet. The physician may not have seen my recommendation (or the patient) for up to 60 days. With this legislation, the pharmacist writes the order on the physician order sheet, achieving the therapeutic goals faster.

In Connecticut, the hospital collaborative practice agreement legislation was passed a year ago, and it has proved to be beneficial to patient treatment while also being more cost-effective. Physicians embrace medication management by clinical pharmacists in the hospital. Physicians practicing in long-term care have been asking for the same opportunity for collaboration. The new collaborative practice legislation in long-term care should prove to be a positive step for elderly patients in nursing homes.

Our role is shifting from making recommendations to the physician to writing the orders ourselves. With the evolution of the healthcare system, the consultant pharmacist is recognized as an expert in medication management by patients, healthcare providers, and employers. Now we need to get the attention of the third-party payers and policy makers. Recent studies suggest that pharmacist interventions improve patient outcomes, reduce health expenditures, and prevent errors. Isn't it about time we got paid for them as well?

Peggy Manning Memoli, R.Ph., C.G.P., FASCP

The AUTHOR is an adjunct assistant professor at the University of Connecticut School of Pharmacy and Senior Clinical Pharmacist Consultant at The Medicine Centre/LTC in Portland, Conn.


Peggy Memoli. Putting collaborative authority into practice. Drug Topics Oct. 20, 2003;147:13.

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