BLOOD PRESSURE MANAGEMENT

COLLABORATIVE PRACTICE AGREEMENT

The Pharmacy Practice Act allows pharmacists to practice under a Collaborative Practice Agreement with individual physicians. Pharmacists may participate in the practice of managing and modifying drug therapy according to a written protocol between the specific pharmacist and the individual physician(s) who is/are responsible for the patient’s care and authorized to prescribe drugs.

By signing this document, the named physicians agree that the named pharmacist may enter into a Collaborative Practice with them for the management of blood pressure in patients according to the attached protocol for the Blood Pressure Management Program. By signing this document, the physician agrees with the blood pressure management outlined in the attached protocol, the Blood Pressure ManagementProgram.

BLOOD PRESSURE MANAGEMENT PROTOCOL AND COLLABORATIVE AGREEMENT APPROVED BY:

PHARMACIST CLINICIAN:

______

[INSERT PHARMACIST NAME and DEGREE]

PHYSICIANS:

______

[INSERT PHYSICIAN NAME, and DEGREE.][INSERT PHYSICIAN NAME, and DEGREE.]

______

[INSERT PHYSICIAN NAME, and DEGREE.] [INSERT PHYSICIAN NAME, and DEGREE.]

______

[INSERT PHYSICIAN NAME, and DEGREE.][INSERT PHYSICIAN NAME, and DEGREE.]

.

DATE OF IMPLEMENTATION: ______

DATES ANNUAL REVIEW COMPLETED:

Blood Pressure Management Program

Collaborative Practice Agreement

[INSERT CLINIC NAME]

Purpose/Background

Numerous studies have shown the advantages of effective counseling and behavioral therapies for a patient to successfully manage their blood pressure. In a recent NHLBI-funded study, the physician-pharmacist collaborative intervention achieved blood pressure control in 89% of patients with hypertension, including 82% among patients with diabetes. The major reason the intervention has been so effective is because it overcomes clinical inertia, sub-optimal regimens and poor medication adherence. The intent of the current program is to have teams of physicians and community-based pharmacists use a similar approach. This formal protocol will establish a collaborative practice arrangement and standardize the counseling for blood pressure management and allow the Pharmacist to prescribe within the guidelines of this blood pressure management program protocol.

This formal protocol for blood pressure management will provide a detailed description of the type and extent of services the Pharmacist will provide. This will ensure that each patient referred to the Pharmacist for blood pressure control, either by the provider or self-referred by in an established relationship with provider, will receive a pre-established standard of care, and the Provider will have detailed information about the services their patients will receive.

Policy

The pharmacist, any pharmacy residents, and pharmacy students completing rotations under the supervision of the pharmacist, will follow this written protocol.

Organization

The Pharmacist will coordinate the Blood Pressure Control Program. Patients who are interested in managing their blood pressure and desire assistance who are referred or self-refer will be seen as long as they have an established and ongoing care relationship with the Provider.

Following the initial appointment, follow-up phone calls will be made by the pharmacy to assess the patient’s progress. These phone calls will be documented in the patient’s chart and can be made by the Pharmacist, pharmacy resident, and/or pharmacy student. Face-to-face visits at the pharmacy for follow-up should also be documented.

Procedures:

Guidelines for referral

When a physician has a patient who has a blood pressure that is not at goal, the Physician can refer the patient to the Pharmacist for counseling. The physician will document the referral in their progress note in the medical chart. The patient will make an appointment to meet with the Pharmacist at a later time and/or date. Depending on the schedule of the Pharmacist and the patient, the Pharmacist may see the patient immediately on the same day. Patients in established ongoing care relationship with the Provider can be seen by the pharmacist blood pressure management as well. If there are any doubts about an ongoing relationship, this must be confirmed by the Pharmacist. In instances when the primary care physician is not the immediate referring provider, the primary care physician will be notified of the referral to the clinical pharmacist.

Visit Protocol

The clinical pharmacist will:

  1. Interview the patient, the medications (including complementary/alternative agents), and the medical record to determine the patient’s Hx of HTN, PMH, pertinent SH, allergies, current medications (Medication list will be updated)
  2. Assess the patient’s:
  3. Individual health goals and level of motivation and ability to implement changes
  4. Any barriers for communicating, retaining, or understanding information, including health literacy level
  5. Adherence to medications

a)Identify causes for nonadherence

b)Address and resolve issues

  1. Review risk stratification for blood pressure and goal for the patient.

Blood Pressure Goals (JAMA 2014, PMID: 24352797)

Patient Characteristics / Blood Pressure Goal
  • < 60 years old
  • Diabetes Mellitus
  • Chronic Kidney Disease
/ <140/<90 mmHg
  • > 60 years old
/ <150/<90 mmHg
  1. Evaluate for the presence of adverse effects from medications
  2. Adverse effects from antihypertensive regimen
  3. Drugs that may elevate blood pressure
  4. Assess blood pressure and pulse
  5. Using proper technique based on AHA recommendations5
  6. Assess orthostatic blood pressures if orthostasis is suspected.
  7. Review any need for laboratory tests and order additional tests or other related assessments as needed
  8. Baseline renal function and serum potassium levels prior to starting ACEIs, ARBs, or diuretics. Then repeated within 1-4 weeks after initiation of these medications and annually once at goal.
  9. 48-hour ambulatory blood pressure monitoring. If this is to be used, instruction on its use should be provided.
  10. Discuss adoption of pertinent social, dietary, and exercise habits
  11. DASH diet
  12. Weight management
  13. Alcohol and smoking
  14. Stress reduction techniques
  15. Immediately notify the referring provider, supervising physician, or transfer to ER as appropriate in the event of any potentially serious or life-threatening hypertension-related complications are present.

Scenarios included but are not limited to the following:

1. SBP >180 and/or DBP >120

2. New onset or increasing chest pain

3. Symptoms of cerebral infarct or thrombosis

4. Mental status changes

5. Acute decrease in renal function

6. New cardiac arrhythmias

7. Pulse 120 bpm

8. Potassium >5.9 mmol/l

  1. Follow algorithm for antihypertensive adjustment every 1-4 weeks:

(Adapted from JAMA 2013, PMID: 23989679 and AHA 2013,

a)

  1. Refill antihypertensive medications as appropriate.
  2. The pharmacist will refer the patient back to provider once blood pressure stabilizes and remains at goal for 6 months. In the event the pharmacist suspects resistant HTN, the patient will be referred back to the physician.
  3. Resistant hypertension is defined as blood pressure that remains elevated above goal despite optimal 3 drug treatment regimen. Potential causes include non-adherence to medications and secondary causes of hypertension (ie renal dysfunction).
  4. Ensure that the patient sees the collaborating provider at least annually,or more frequently as warranted.

(Adapted from AHA 2013,

Documentation

  1. The referring provider will complete a program referral form and transmit it to ______clinic.
  2. The pharmacist will complete a progress note for each patient encounter using ______.
  3. For each visit, the pharmacist will record:
  4. Subjective/objective information
  5. Assessment and Plan
  6. Following each visit, the pharmacist will transmit the visit note to the referring provider.

Communication

The referring physician is the responsible provider for the patient. The pharmacist will work collaboratively with the physician (and their extender where appropriate) and will maintain effective communication regarding patient care by:

  • Initiating communication with the collaborating physician within 48 hours of making a drug therapy change or noting a change in the patient’s health condition.
  • Referring patients for a follow-up visit with the physician as necessary (at least annually)
  • Discussing urgent issues with the collaborating physician in person or via phone. When the patient’s physician is unavailable in urgent situations, the physician on call or another pre-identified physician will be contacted.
  • Calling 911 in emergency situations, then notifying the collaborating physician

Billing

When the pharmacist sees the patient, a non E/M code could be billed according to usual pharmacy practice. Blood pressure management follow-ups by the provider will be billed according to usual medical clinic billing practices.

Quality improvement

The protocol will be reviewed yearly by the pharmacist and staff providers, and revised as needed.