Collaborative Practice
Agreements: How to Get
Started and How to Get Paid
Donald G. Klepser, Ph.D, MBA
Associate Professor
University of Nebraska Medical Center
Department of Pharmacy Practice
Pharmacists
Community Pharmacies
~60,000 in the United States
Most patients visit their pharmacy more often than
any other health care provider
Underutilized health care resource
Regular but incomplete communication with
prescribers and other providers
Overarching Question
How do we develop a patient-centered system that
utilizes the resources and expertise of all members
of the health care team to acheive the best possible
outcomes (Clinical, Humanistic, and Economic) for
patients?
The caveats:
– Without blowing up the system and starting over
– Without fragmenting care
– Without sacrificing profit (must be sustainable)
– Without disrupting workflow
Collaborative Practice
Agreements (CPAs)
Formal practice relationship between pharmacists
and other health care practitioners, whereby the
pharmacist assumes responsibility for specific
patient care functions that are otherwise beyond
their typical “scope of practice” but aligned with their
education and training.
These patient care services can include initiation
and modification of drug therapy.
Collaborative Practice
Agreements (CPAs)
The extent of the services authorized under a
collaborative agreement depends on:
1. The state’s statutory and regulatory provisions
for collaborative practice authority.
2. The terms of the specific agreement between the
pharmacist and other health care practitioners.
50 States, 50 Sets of Rules
States have taken different approaches to
Collaborative Practice Agreements including:
1. The practitioners able to participate in CPAs,
2. The services that may be provided under a CPA,
3. Logistical barriers that limit the utility of such
agreements.
States do not consistently use the same language
when describing CPAs.
– Protocols
– Collaborative Drug Therapy Management
National Governors
Associtiaon (NGA)
In their 2015 paper, The Expanding Role of Pharmacists in a
Transformed Health Care System, the NGA, presented the
following state policy considerations in regards to collaborative
practice provisions:
Enact broad collaborative practice provisions that allow for
specific provider functions to be determined at the provider
level rather than set in state statute or through regulation.
Evaluate practice setting and drug therapy restrictions to
determine whether pharmacists and providers face
disincentives that unnecessarily discourage collaborative
arrangements.
Examine whether CPAs unnecessarily dictate disease or
patient specificity
National Governors Association. The Expanding Role of Pharmacists in a Transformed Health Care System.
http://www.nga.org/files/live/sites/NGA/files/pdf/2015/1501TheExpandingRoleOfPharmacists.pdf
Accessed 6/20/16
National Alliance of State
Pharmacy Associations (NASPA)
NASPA convened a work group to build on the NGA
report to guide policy making.
Used two guiding principles to determine what
needed to be included in Laws and Regulations and
what should be decided by individual practitioners:
1. Framework should be flexible to facilitate
innovation in care delivery
2. Safeguards should be established to ensure
optimal patient care
National Alliance of State
Pharmacy Associations (NASPA)
Made recommendations on
• Participants
• Authorized services
• Requirements and Restrictions
http://naspa.us/wp-content/uploads/2015/08/CPA-Infographic-PDF.pdf
Recommended Elements
of a CPA
Participants
• List which pharmacists and prescribers are
included
• Identify any additional education or training
necessary for the pharmacist
• Identify the patient population
Recommended Elements
of a CPA
Authorized Services
• Specify which disease states are being managed
• Specify the services included
• Specify which protocols or clinical guidelines are
to be followed
Recommended Elements
of a CPA
Requirements and Restrictions
• Specify appropriate level of patient consent
• Specify timeframe for renewal
• Specify the documentation process
• Specify liability insurance requirements
Our Experience with CPAs
Point of Care Testing in
Community Pharmacies
A role for POC testing in community
pharmacies
• >120 CLIA Waived tests
• Complete disease management in the pharmacy
– Influenza and group A streptococcus (GAS)
• Disease screening (HIV and HCV)
• Disease and treatment monitoring
• Precision medicine
• Reduced antimicrobial resistance
• Public health emergencies (lead testing)
Model for Acute Conditions…
Patient
Assessment
Point of
Care Test
Action
Enabled by
Broad CPA
Improved
Health
Outcomes
Model for Acute Conditions…
Patient
Assessment
Point of
Care Test
Action
Enabled by
Broad CPA
Improved
Health
Outcomes
The value is the comprehensive pharmacy service enabled by a
Collaborative Practice Agreement.
Experience from Regional
Chains
Prospective study of Influenza and Group A Strep
(GAS) testing and treatment
56 pharmacies from 5 regional chains in three states
(MI, MN, NE)
Trained all pharmacists (20 hour certificate program)
Developed
Algorithms from clinical guidelines (inclusion and
exclusion criteria, clinical thresholds)
Template state specific collaborative practice
agreements
Workflow (data collection instruments and scripts)
Included in the CPA
Patients eligible to be tested at the pharmacy
– Age
– Symptoms
– Clinical stability
– Comorbidities
Patients with a positive test were offered prescription
Patients with negative test were counseled and provided OTC
options
All patients tested had a follow up call from the pharmacist 2448 hours after their visit
Visit results were shared with the patient, their primary care
provider, if possible, and the collaborating physician
Clinical Studies – Influenza
Results
121 patients screened
46 (38%) excluded from participation
75 (62%) tested, with 8 (11%) positive results
Of positive results, 6 (75%) treated with antiviral, 0 with
antibiotics
59 (79%) of patients were reached for follow-up with 24-48
hours
6 patients sought additional care (4 were referred by
pharmacist)
35% of patients had no primary care provider
39% of patients were seen outside of normal clinic hours
Klepser, et al. Journal of the American Pharmacist Association.
Group A Strep Results
316 patients screened
43 (14%) excluded from participation
273 (86%) tested, with 48 (18%) positive results
Of positive results, 47 (98%) treated
Of negative results, 0 (0%) treated
169 (62%) of patients were reached for follow-up with 24-48 hours
37% of patients had no primary care provider
34% of patients were seen outside of normal clinic hours
Klepser, et al. Journal of the American Pharmacist Association.
Workflow Considerations
Initial patient assessment
Pharmacist collects illness history, runs test, and
obtains vitals
Positive test – Rx processed
Negative test – OTC assistance
Follow-up protocol
Inform PCP
Workflow – Time and
Motion Studies
Overall encounter time of 35.5 minutes
Active pharmacist engagement 9.4 minutes
When technicians played a larger role in data
collection and physical assessment, active
pharmacist engagement fell to 4.95 minutes
Klepser DG, et al. Innovations in Pharmacy. 2014;5:18.
Patient Satisfaction
Strongly
Agree/Agr
ee
Satisfied with how illness was
treated at the pharmacy
86%
Would go back to the pharmacy
for a similar illness in the future
82%
Are comfortable being treated by
my pharmacist for illnesses like
the flu
96%
Klepser DG, et al. National Rural Health Association. 2014
Willingness to Pay
Patients were asked how much they would be
willing to pay for pharmacy based influenza or GAS
service.
60% of patients were willing to pay at least $50 for
these service.
Ongoing Research
Follow up studies
– Expanded to 11 states
– Cultures for GAS negative pediatrics
– Additional funding from NACDSF and Roche
Diagnostics
HIV and HCV screening and linkage to confirmatory
testing
– 3 states (Michigan, Georgia, West Virginia)
– CDC and state public health collaboration
– Mandatory
– Funded by NACDSF
Getting Paid for Care
Provided for under a CPA
Provide a service people value
Provider status
Out of network claim forms
Contract directly with employers
Future payment models
Questions?
Don Klepser
[email protected]