Pharmacy: Collaborative Practice Agreements to Enable Collaborative Drug Therapy Management


Team-Based Care

Collaborative drug therapy management (CDTM), also known as coordinated drug therapy management, involves developing a collaborative practice agreement (CPA) between one or more health care providers and pharmacists.

A CPA allows qualified pharmacists working within the context of a defined protocol to assume professional responsibility for performing patient assessments, counseling, and referrals; ordering laboratory tests; administering drugs; and selecting, initiating, monitoring, continuing, and adjusting drug regimens.1

The use of CDTM through a CPA is a strategy that can be considered to straddle Domain 3 (health care system interventions) and Domain 4 (community-clinical links).

The evidence of effectiveness chart shows the evidence of effectiveness ratings for the Pharmacy: Collaborative Practice Agreements to Enable Collaborative Drug Therapy Management strategy in the form of a rating symbol corresponding to each of six rating categories. The rating symbol can represent one of three ratings: well supported/supported, promising/emerging, or unsupported/harmful. Effect, Research Design, Internal Validity, Independent Replication, and External and Ecological Validity are rated as well supported/supported. Implementation Guidance is promising/emerging.

Strong evidence exists that CDTM enabled by a CPA is effective. Solid evidence shows that this strategy achieves desired outcomes, with studies demonstrating internal and external validity. This strategy has also been independently replicated, and systematic reviews assessing the use of CDTM have confirmed reliability of impact. Implementation guidance on CPAs to enable CDTM was found to be lacking in comprehensiveness.

The evidence of impact chart shows the evidence of impact ratings for the Pharmacy: Collaborative Practice Agreements to Enable Collaborative Drug Therapy Management strategy in the form of a rating symbol corresponding to each of three rating categories. The rating symbol can represent one of three ratings: supported, moderate, or insufficient. Health Impact and Economic Impact are rated as supported, and Health Disparity Impact is insufficient.

Health Impact

CDTM, enabled by CPAs between pharmacists and other health care providers, has been shown to be effective in improving clinical and behavioral health indicators, including lowering blood pressure, HbA1c, and LDL cholesterol levels; improving treatment quality through pharmacist compliance with clinical guidelines; and increasing patient knowledge and adherence to medication regimens.2

Health Disparity Impact

The goals of reaching populations at risk and reducing health disparities have been taken into account in the development and implementation of CPAs, particularly by pharmacy organizations (e.g., the American Pharmacists Association), state medical and pharmacy boards, and state pharmacy organizations. However, no studies have directly examined the impact of CPAs between pharmacists and providers serving low-income populations. Because pharmacists often work directly with the public in community settings, they are often considered the public’s most accessible health care providers. CPAs can authorize pharmacists to make changes to a patient’s medication or dosage, which can reduce the number of visits a patient has to make and lower costs, while also making it easier for patients to adhere to their medications.

Economic Impact

Research suggests that clinical pharmacy services like CDTM can be cost-saving to the health care system, primarily through avoided hospitalizations and emergency room (ER) visits.3 For example, in 2006, Missouri’s Pharmacy-Assisted CDTM program resulted in a 12% decrease in hospitalizations, a 25% reduction in ER visits, and a decrease in drug-related problems among beneficiaries after 1 year.

This program was also found to have a 2.5 to 1 ROI to the state, with an estimated savings of $518.10 per patient per month.3

  1. Settings
    Enabling CDTM through CPAs has been found to be effective in several clinical and community settings, including Federally Qualified Health Centers (FQHCs), patient-centered medical homes, managed care health systems, community pharmacies, hospital pharmacies, and primary care clinics.
  2. Policy and Law-Related Considerations
    CPAs are typically authorized through state scope-of-practice laws that may or may not allow for their use within pharmacist scope-of-practice laws. Challenges associated with billing for services exist, even at the federal level.12,13 When a CPA is developed, the pharmacist and the prescriber work together to develop the terms of the CPA. They may use recommendations and model language available from various organizations.5,6,14
  3. Implementation Guidance
    CDC has recently developed a CPA toolkit that provides implementation guidance:
  1. Resources
    Several guides and examples are available to educate and guide health care providers, decision makers, insurers, and pharmacists about how pharmacists and other health care providers can better serve patients through CPAs and CDTM. Examples include the following:

Stories from the Field: Collaborative Practice Agreements

CPAs at El Rio Community Center

El Rio Community Health Center serves more than 75,000 people in Pima County, Arizona. In 2011, 20% of El Rio’s adult patients (8,954 of 44,952) had diagnosed hypertension, but only 67% of those diagnosed had the condition under control. Pharmacists at El Rio were encouraged to establish CPAs with the center’s medical providers. These agreements enable pharmacists to work directly with patients to help them manage their hypertension and other chronic conditions, such as diabetes and hyperlipidemia. Within the scope of the CPA, pharmacists have the discretion to change patient medications. After CDTM was implemented, El Rio reported improved clinical outcomes (e.g., lower cholesterol and blood pressure levels), increased use of recommended screenings, and reduced ER visits. The El Rio case study highlights several important considerations for CDTM implementation. These considerations include instilling mission-driven values through training and orientation, accepting pharmacy student interns, and using broad strategies and networks to improve patient care and increase potential partnerships that may extend the use of CPAs.

For more information:
Phone: 520-670-3909
Website: www.elrio.orgExternal

References
  1. Hammond RW, Schwartz AH, Campbell MJ, et al. Collaborative drug therapy management by pharmacists—2003. 2003;23:1210–1225.
  2. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923–933.
  3. S. Department of Health and Human Services. Special Report to the Senate Appropriations Committee on Advancing Clinical Pharmacy Services in Programs Funded by the Health Resources and Services Administration and Its Safety-Net Partners. Washington, DC: U.S. Department of Health and Human Services; 2008.
  4. Centers for Disease Control and Prevention. Advancing Team-Based Care Through Collaborative Practice Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2017.
  5. Weaver K. Pharmacist. Collaborative Agreements: Key Elements for Legislative and Regulatory Authority. Richmond, VA: The National Alliance of State Pharmacy Associations; 2015.
  6. American Pharmacists Association. Collaborative Practice Agreements: NASPA Workgroup Releases Recommendations. https://www.com/collaborative-practice-agreements-naspa-workgroup-releases-recommendationsExternal. Accessed February 14, 2017.
  7. Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2013.
  8. Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Doctors, Nurses, Physician Assistants, and Other Providers. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2013.
  9. Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Government and Private Payers. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2013.
  10. Centers for Disease Control and Prevention. A Program Guide for Public Health: Partnering with Pharmacists in the Prevention and Control of Chronic Diseases. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2012.
  11. Agency for Healthcare Research and Quality. New Models of Primary Care Workforce and Financing Case Example #3: Fairview Health Services. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
  12. McBane S, Dopp A, Abe A, et al. ACCP white paper: Collaborative drug therapy management and comprehensive medication management—2015. Pharmacotherapy. 2015;35(4):e39–e50.
  13. Centers for Disease Control and Prevention. Select Features of State Pharmacist Collaborative Laws. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2013.
  14. National Association of Boards of Pharmacy. Model Pharmacy Act/Rules. https://nabp.pharmacy/publications-reports/resource-documents/model-pharmacy-act-rulesExternal. Accessed May 18, 2017.