CASE STUDY

Collaborative Practice Agreements: Extending Pharmacy Services, Scope, and Patient Access into the Community

Submitted by: Zachary A. Weber, Pharm.D., BCPS, CDE, Clinical Assistant Professor of Pharmacy Practice, Purdue University College of Pharmacy, Clinical Pharmacy Specialist, Primary Care, Wishard Hospital, 1001 W. 10th St., Myers Building, W7555, Indianapolis, IN 46202, 317-613-2315, ext. 366, [email protected]

E4K. Implementation of collaborative practice agreements.

Situation Analysis Wishard consists of a primary care center, a 339- bed hospital on the Wishard campus, and nine com - munity health centers located throughout Indianapolis that focus on treatment of the vulnera - ble patient population (uninsured or under-insured) of Marian County. The county hospital is govern - Other members of the Wishard team include (back row, from ment-funded and serves as an academic teaching left) Rattan Juneja, M.D.; Kieren Mather, M.D.; Blake Erdel, M.D.; Loice Ongwela, R.N.; Dennis Joseph, M.D.; Eleazer Kaguri, hospital through its affiliations with the Purdue Uni - M.D.; (front row, from left) ZachWeber, Pharm.D.; Amy Carter, versity College of Pharmacy, Butler University R.D.; and Kristen Gilbert, M.D. School of Pharmacy, and Indiana University School Primary Intended Outcomes of Medicine. The environment at Wishard is con - ducive for interdisciplinary practices among phar - 1. Become a more valuable asset to the clinical macists, physicians, and other health care team in providing optimal patient care. providers, which enable the hospital to offer pro - 2. Expand clinical pharmacy services to the outpa - gressive clinical services to its community. There tient setting and provide more opportunities for are about 60 pharmacists at Wishard, a third of enhanced pharmacy involvement in patient care which are clinical specialists, and a number who are faculty members at Purdue University or Butler Relevant PPMI Recommendations School of Pharmacy. B14. Through credentialing and privileging processes, pharmacists should include in their Service Description scope of practice prescribing as part of the collab - Located at various Wishard clinics in the commu - orative practice team. nity, a number of clinical pharmacy specialists established collaborative practice agreements CASE STUDY

that allow them to serve as physician extenders. providers, requiring no additional training for Through these agreements, the pharmacists administrative and clerical staff. As mentioned work with physicians to optimize patients’ med - above, a number of clinical specialists hold faculty ication regimens and attain therapeutic goals, positions at Purdue University, and their clinic managing patients with diabetes, hypertension, hours are supported by their service and engage - dyslipidemia, and anticoagulation services. ment requisite of the school. Each faculty phar - macist may work different days out of the week Prior to the implementation of the service, a and have a collaborative practice agreement at team of pharmacists and physicians developed a multiple clinics. For example, one faculty member collaborative agreement document outlining the may work Monday at one clinic and Wednesday scope of practice. The document was then pre - at another, while a colleague may work Tuesdays sented to the Wishard Pharmacy and Therapeutic and Fridays at an additional Wishard clinic site. Committee for approval. Once the collaborative practice agreement was approved, it served as the foundation for ambulatory care clinical phar - Key Elements for Success macy collaborative drug therapy management 1. Rapport with physicians and willingness to (CDTM) services in both primary and specialty compromise on both sides is important. care clinics. An individual agreement was used 2. Complete support from all levels of hospital for each clinical pharmacist at his or her individual administration (our hospital CEO was kept clinic site(s). The collaborative practice agree - informed and was in full support). ment is tailored for a particular clinic site and con - tains the names of the pharmacist and physicians, 3. Set up your practice to mirror that of the physi - treatment algorithms based on hospital formu - cians as much as possible. The logistics (flow, lary, guidelines for medication adjustments, and schedule, etc.) really make the difference any other quality parameters specific to the prac - between your staff feeling overburdened and tice site (i.e. referrals for diabetes patients to a streamlined process. have an eye exam, etc.). 4. Support and buy-in from all members of staff Once a collaborative practice agreement is estab - at the clinical sites, including clinical, clerical, lished, the pharmacist sets up his or her practice and administrative, is critical. at the respective clinic site. Patients are then 5. Establish a standard process for pharmacy scheduled office visits with the pharmacists services in a clinic. We recommend structuring through a physician referral system. The schedul - a process similar to the process already exist - ing procedure is similar to what is already being ing with the physicians. used to schedule appointments for other CASE STUDY

Resource Utilization aged clinics. The following emerging themes Personnel: No significant personnel allocated were identified: disease state management other than the pharmacist and physician writing up expertise, patient alliance, practice novelty, the terms to the collaborative practice agreement. accessibility, increased sense of patient well- being, compassion, comparable care, collabo - IT and other infrastructure: All documentation rative Pharm.D./M.D. relationship, coordination and the referral procedure were the same as of care, and intensified care. existing. Only addition is the pharmacist schedule to the electronic scheduling program. Lessons Learned Return on Investment: Neutral; at Wishard in par - 1. Regardless of the position, in addition to estab - ticular, the clinical specialists who practice in the lishing a collaborative agreement, set up a clinics under the collaborative practice agreement billing structure from the beginning. Until are employed by Purdue, so there were no addi - recently in Indiana, pharmacists were not rec - tional costs to the hospital. No official study has ognized as providers in state legislation. Simi - yet been done on the rate of readmissions after larly, there is no standard format or structure the implementation of the collaborative practice. to follow for pharmacist billing. This lack of provider recognition status and standard billing Recognized Intangible Benefits structure has made many practices hesitant to 1. Wider recognition of clinical pharmacy serv - allow for pharmacists to bill. In order to bill, ices, outside of inpatient area. each institution must have an approved billing format. The best billing format would be for 2. Clinic sites serving as study sites for various pharmacists to bill incident-to-physician (using research studies. The pharmacists involved are CPT codes 99211 through 99215). When enter - consistently contacted to review other CDTM ing a new practice, it is always easiest to estab - practice models for the expansion of ambulatory lish a billing structure from the beginning to care pharmacy services at other institutions. allow for financial justification of the pharma - cist’s role in the new clinic site. 3. With a progressive nature, this program would be very appealing from a recruitment standpoint. Other Considerations Outcome Measures Since the Collaborative Practice Agreement involves other parties, such as physicians, bear in 1. Clinical outcomes: Reductions in A1C levels of 10.5 mind that during the drafting process of agree - percent to 8.5 percent over course of six months; ment terms, the physician may need additional LDL decreased from 105 to 85 after six months. time to review the document and make revisions. 2. A qualitative analysis was done based on tran - This piece can become the rate-limiting step, so script analysis of 30 patient interviews to patience in the collaborative agreement develop - assess patient perceptions of pharmacist-man - ment is important. CASE STUDY

Suggestions for Other Helpful References Hospitals/Health Systems 1. Gonzalvo J, Papineau EC, Ramsey DC, et al. The affiliations with Purdue and Butler make Patient Perceptions of Pharmacist-Managed Wishard an academic teaching center, allowing Clinics: A Qualitative Analysis. J Pharm Technol for progressive models and a willingness to 2012; 28:10-15 expand practice. As mentioned above, support 2. Harris IM, Baker E, Berry T, et al. Developing a from all levels of hospital administration is essen - Business-Practice Model for Pharmacy Services tial in implementing a collaborative practice at in Ambulatory Setting, ACCP White Paper. your institute. Additionally, for smaller commu - Pharmacotherapy 2008;28(2):7e–34e) nity hospitals with a small pharmacy staff, you may want to consider first drafting a proposal to 3. Stubbings J, Nutescu E, et al. Payment for Clini - your hospital outlining the benefits of having a cal Pharmacy Services Revisited. Pharmacother - collaborative practice with goals of hiring an addi - apy 2011; 31(1):1-8 tional pharmacist to facilitate the model.

Also, make sure to assess the need for the collab - orative practice service in your community. Wishard is an institute set up to serve the unin - sured and under-insured.