Collaborative Practice Agreement

Medication Management Pharmacist

South Carolina

Collaborative Practice Agreements (CPAs) are used to create formal relationships between pharmacists and physicians that allow for expanded patient care services the pharmacist can provide to patients and the healthcare team.

The authority to obtain patient history, collaborate on physical assessments, order and assess diagnostic tests, make medication related medical decisions, and modify therapy management options is derived from the delegation of that authority by the South Carolina licensed physicians signed below who shall supervise the delivery of those delegated medical acts, in accordance with South Carolina Code 40-47-20 (13) and 40-47-195 and the South Carolina pharmacist scope of practice.

The South Carolina licensed physician(s) signed below are working in collaboration with ______, Medication Management Pharmacist, licensed in South Carolina, and agree to delegate and supervise delegated medical acts as defined in the attached Scope of Pharmacy Practice Guidelines and Treatment Protocols.

______

(Name, MD, SC License #)

______

(Name, MD, SC License#)

______

(Name, MD,SC License#)

______

(Accepted by Name, PharmD,SC License#)

Scope of Practice Guidelines

Purpose/Background

The goal of this agreement is to improve care, achieve optimal outcomes, and provide continuity of care to patients through the provision of pharmacy patient care services which include therapy care plan development, medication management, education, monitoring, and follow-up.

To enhance collaborative patient care, pharmacists will be delegated the authority to obtain a patient medical history, order and evaluate laboratory results, conduct limited examinations, and make medical decisions including initiating, modifying, or discontinuing treatment when appropriate with their scope of practice.

This document identifies the specific responsibilities of collaborative partners to provide safe, effective and timely care to patients.

Organization

Location(s):

(Insert various collaborative practice sites for supervising physicians)

Guidelines for referral: Only the supervisingphysician(s)can refer patients they feel would benefit from pharmacy patient care services and the referral will be documented in the patient’s chart.

Conditions:(For example purposes only-modify for practice)

Diabetes

Hypertension

Congestive Heart Failure

COPD

Asthma

Lipid Disorders

Anticoagulation Management

Polypharmacy Management

Others as identified in attached Treatment Guidelines

Patient Care Services provided by the pharmacist under the supervisor of the physician:

Obtain patient medical history,

Order and evaluate laboratory results

Conduct limited examinations

Make medical decisions including initiating, modifying, or discontinuing treatment

Refill authorization

Documentation: All patient encounters will be documented in the patient record and will be available to the supervising physician for review.

Quality Improvement

Data will be continuously monitored to ensure that patients are receiving optimal care. Clinical activities will be reviewed from time to time by the clinical pharmacist and physician providers, and revised as needed.

Modifications

Any modifications to this agreement must be dated and signed by all collaborative partners.

South Carolina Pharmacist Scope of Practice for Patient Care Services

Following is the opinion issued on March 18, 2015 by the South Carolina Board of Pharmacy regarding the scope of practice for pharmacist providing patient care services.

The South Carolina Board of Pharmacy confirms that the scope of pharmacy practice as defined in the South Carolina Pharmacy Practice Act permits a South Carolina licensed pharmacist, in collaboration with a South Carolina licensed physician, to obtain a patient medical history, evaluate laboratory results, conduct limited examinations, and make medical decisions pursuant to a medical order.

Treatment Guidelines

(For example purposes only-modify for practice)

  1. Anticoagulation

The ACCP Conference on Antithrombotic and Thrombolytic Therapy, CHEST Supplement

  1. Asthma

National Asthma Education and Prevention Program Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma

  1. Chronic Heart Failure

ACC/AHA Guideline for the Diagnosis and Management of Chronic Heart Failure in the Adult

  1. Cholesterol

NCEP: Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

  1. Diabetes

American Diabetes Association Clinical Practice Guidelines, Diabetes Care

  1. Hypertension

The Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

  1. Smoking Cessation:

Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

V-06.01.2015