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The Future of Patient Medication Management

Looking to improve patient medication management? Few initiatives have the potential deliver the impact of entering into collaborative practice agreements (CPAs).

CPAs are legal agreements between pharmacists and collaborating prescribers, often physicians. They specify what patient care functions can be delegated to the pharmacist and the rules that guide when the pharmacist can provide those services.

As Anne Burns of the American Pharmacists Association (APhA) told Elements magazine, "Collaborative partnerships between pharmacists and physicians empower team-based care, which has been proven to result in better quality care and health outcomes for patients.”

Achieving Comprehensive Medication Management with CPAs

Vital to patient medication management success is a commitment to delivering comprehensive medication management (CMM), whenever possible. As we have previously discussed, CMM requires involvement from more than just a clinical pharmacist. It should be a team-driven activity, with insight and recommendations provided by the likes of primary care providers, specialists, nurses, care coordinators, patient navigators, social workers, and others, where and when appropriate.” CPAs represent a means to formalize such team-driven collaboration.

Here are six more things to know about CPAs.

1. Term can vary by state

Not all states use the term CPA, notes a Pharmacy Today report. Variations include collaborative pharmacy practice agreement, consult agreement, physician–pharmacist agreement, standing order or protocol, and physician delegation.

Furthermore, the report notes that terms used for the services provided under a CPA can vary as well and include collaborative drug therapy management, drug therapy management, pharmaceutical care, medication therapy services, and collaborative pharmacy practice.

2. CPAs have a long history

CPAs originated in Washington in 1979, notes a National Alliance of State Pharmacy Associations (NASPA) report, with the passing of the Pharmacy Practice Act. The report further indicates that, as of August 2018, 48 states and the District of Columbia permitted pharmacist-prescriber collaborative practice authority, with prescribers unable to delegate authority to pharmacists via a CPA in Alabama and Delaware.

In a March 2018 Pharmacy Today report, Jeff Rochon, chief executive officer of the Washington State Pharmacy Association, stated that about 9,000 pharmacists were working under more than 34,000 active CPAs. 

3. CPAs can deliver numerous benefits

CPAs can help enhance collaborative care delivery efficiency and effectiveness, notes a NASPA report. When used to their full potential, CPAs have the ability to increase access to care, expand available services to patients, increase the efficiency and coordination of care, and leverage pharmacists' medication expertise to complement the skills and knowledge of the other health care team members.”

Examples of pharmacy-provided services that may be performed under a CPA include the following:

  • Authorizing prescription refills
  • Substitution of like medications (i.e., therapeutic interchange)
  • Dose optimization
  • Anticoagulation clinics
  • Hypertension clinics
  • Ordering of and interpreting laboratory tests

The NASPA report notes that these and other services delegated under a CPA agreement can … decrease the number of phone calls required to authorize refills or modify prescriptions, thus allowing each member of the healthcare team to complement the skills and knowledge of the other member(s), more effectively facilitate patient care, and improve patient outcomes.”

4. Requirements vary by state

CPA-related laws vary from state to state, according to an APhA report. State laws can differ on whether CPAs apply to single or multiple patients, are limited to certain practice settings, which parties are allowed to enter them (e.g., all prescribers, physicians only, physicians and nurse practitioners), pharmacist qualifications (e.g., approved by or registered with state boards, PharmD, continuing education), and more. Some states require parties to have liability insurance or declare CPAs invalid after a certain period of time.”

To learn your state's current pharmacy laws and regulations, visit the National Association of Boards of Pharmacy's website, then navigate to your state's board of pharmacy website. It is advisable to consult legal counsel when developing and entering into a CPA.

5. Pharmacists can perform numerous patient care services without CPAs

CPAs are not required for pharmacists to legally provide some patient care services, notes a report from the Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention (DHDSP). It states, For example, assessing medication therapy for drug-related problems, performing hypertension and cholesterol screenings, and educating patients are already within pharmacists' regular scope of practice. A CPA is not required for pharmacists or practitioners to collaborate in providing care.”

6. There are potential barriers for implementing CPAs

If you elect to pursue CPAs, understand that there are barriers that may stand in the way of success. In an interview at The Academy of Managed Care Pharmacy 2018, Tina Joseph, assistant professor at Nova Southeastern University, said she believed the most significant barrier is having a strong relationship with the provider you want to have a collaborative practice agreement with. The problem with that is it can take a lot of time to develop trust and make sure that the provider feels very comfortable, but it's a very important step.”

Other barriers she noted include:

  • lack of provider status for pharmacists, which can create billing challenges;
  • lack of patient understanding concerning expanded scope of pharmacists; and
  • different state laws governing CPAs.

If you can overcome these barriers, CPAs have the potential to deliver significant improvements in patient medication management, CMM, and, overall, outcomes. As Jeff Durthaler, pharmacist consultant for DHDSP, notes in the Elements report, In coordination with other healthcare professionals, pharmacists are playing a greater role in the delivery of healthcare services. The pharmacist's role on a patient's care team continues to expand and the use of CPAs can accelerate this expansion.”

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