PSYCHIATRIC MEDICATION THERAPY SERVICES (MTS)

Physician/Clinical Pharmacist Collaborative Agreement

______, Missouri

I.  Purpose: The purpose of this Agreement is to serve as a delegation of specific roles, functions, and authority by and between the physician and the clinical pharmacist as delineated herein. The specific function of this clinical pharmacy service is for delineating and authorizing psychiatric medication therapy services (MTS) provided to patients/clients seen at (Pharmacy or clinical pharmacist practice location) referred by the physician(s) agreeing to the terms of this collaboration and its purposes, and proper execution of this Agreement.

II.  Functions: Upon physician referral, the clinical pharmacist will conduct mental health assessments with an emphasis on pharmacotherapy, physical and psychological routine tests and status reports as agreed upon by the physician and provide services based upon the following situations:

·  Patients with mood disorders and other mental health illnesses will be seen routinely as part of a wellness assessment and quality of life program described in a written mental health and injury protection procedure manual located at the pharmacists permanent practice location and agreed upon by the patient’s physician and pharmacist and reviewed and approved by both health professionals, signed and dated personally at least annually. All psychological and physical evaluations by the pharmacist will occur through the authorization of the physician (psychiatrist) or a physician-designated licensed clinical psychologist. After completion of the initiation evaluation process, the authorizing physician may refer a patient for continuing evaluation and follow-up care with the clinical pharmacist. All physician referrals must be documented and include the patient’s name, address, date of birth, and the date of referral.

·  The pharmacist may provide on-going psychiatric assessments and medication therapy recommendations/changes for a time period not to exceed one-year. The pharmacist will discuss medication changes with the physician during monthly treatment team meetings.

·  Documentation of clinical pharmacy service must occur within 24 hours of the patient encounter and will be provided to the authorizing physician for review.

·  The authorizing physician must have access to all clinical pharmacist progress notes within 24 hours of the patient encounter. The pharmacist and physician may meet in person at any time to discuss medication therapy decisions.

·  Clinical Pharmacy Progress Notes must be completed either on a (Name of Pharmacy or Clinical Pharmacist Practice Location) prescriber note to be placed in the patient chart located at (Name of Pharmacy or Pharmacy Practice and Address) or electronically as a prescriber note and maintained electronically in appropriate and agreed-upon electronic systems.

  1. Prescriber- Clinical Pharmacist Progress Notes must include the following information:

Patient name, date of birth, address, telephone number, pertinent assessments, diagnostic testing performed, the name, strength, dose, dosage schedule or route of administration of any medication modified, referrals to authorizing physician or for emergency care, any consultation with other treatment providers.

·  The authorizing physician must be notified immediately, in person or via telephone, if a patient experiences a life-threatening allergic reaction, overdose or suicide confirmed ideation or reported attempt, or if acute hospitalization is necessary for psychiatric symptom control.

·  The clinical pharmacist may NOT delegate MTS responsibilities. At any time during the course of clinical pharmacy MT services, the authorizing physician may override, rescind, or modify the treatment protocol and procedures being followed by the clinical pharmacist.

III.  Delegation: upon referral to the clinical pharmacist, the referring physician delegates the following authority:

·  Psychiatric assessments with limited physical examination of patients with the following Axis I or II diagnoses receiving treatment at (Name of Pharmacy or Clinical Pharmacist Name and Place of Practice):

  1. Alcohol-use disorders, amphetamine-use disorders, cannabis-use disorders, cocaine-use disorders, hallucinogen-use disorders, nicotine-use disorders, opioid-use disorders, schizophrenia, schizoaffective Disorder, schizophreniform disorder, delusional disorder, psychotic disorder, NOS, major depressive disorder, depressive disorder, NOS, bipolar Disorders, panic disorder, obsessive-compulsive disorder, PTSD, generalized anxiety disorder, anxiety disorder, NOS, gender identity disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder NOS, primary sleep disorders, personality disorders, medication-induced movement disorders, dementia, ADHD or confirmation of suicide ideation or likely high risk of harm to the patient or others reported by the patient, patient’s family or significant other reliable persons.

·  Order of a urine analysis, basic or comprehensive metabolic panel, complete blood count, lipid panel, hemoglobin A1c, pregnancy test, sexually transmitted infection screen (e.g.- RPR), thyroid function tests, electrocardiogram (for medication tolerability evaluation).

·  Standardized assessments related to psychiatric symptom evaluation or medication tolerability and effectiveness, status/progress, including the Abnormal Involuntary Movement Scale (AIMS), Barnes Akathisia Scale, Simpson-Angus Scale (SAS), Patient Health Questionnaire (PHQ-9), Mini-Mental State Exam (MMSE), Young Mania Rating Scale (YMRS), Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF), the Sheehan Disability Rating Scale or the Pierce Suicide Intent Scale or the Beck’s Suicide Intent Scale and/or other agreed-upon depression and suicide risk assessments. The clinical pharmacist may, especially when the authorizing physician hereto is unavailable or difficult to contact, take any legal action to prevent self-harm or harm to others by the patients under the care of this protocol/Agreement.

·  The clinical pharmacist may NOT initiate or modify any controlled substance treatments.

·  The clinical pharmacist agrees to complete and confirm the successful completion and passing score on accompanying test(s) of at least 1 hour of C.E. Credit (as approved by any national or state approved organization to grant such credits to any health or mental health profession) annually.

·  Provide medication therapy services (MTS) which includes the initiation, titration, taper, or discontinuation of the following psychiatric medications (all dosing shall adhere to currently accepted FDA-labeling and guidelines):

1.  Antipsychotics: haloperidol (Haldol®), chlorpromazine (Thorazine®), thioridazine (Mellaril®), loxapine (Loxitane®), perphenazine (Trilafon®), trifluoperazine (Stelazine®), thiothixene (Navane®), fluphenazine (Prolixin®), clozapine (Clozaril®), risperidone (Risperdal®), olanzapine (Zyprexa®), quetiapine (Seroquel®), ziprasidone (Geodon®), aripiprazole (Abilify®), paliperidone (Invega®), asenapine (Saphris®), iloperidone (Fanapt®), lurasidone (Latuda™)

2.  Anticholinergic Agents: benztropine (Cogentin®), trihexyphenidyl (Artane®), diphenhydramine (Benadryl®), hydroxyzine (Vistaril®)

3.  Mood Stabilizers: lamotrigine (Lamictal®), valproate (Depakote®), oxcarbazepine (Trileptal®), carbamazepine (Tegretol®), lithium (Lithobid®), topiramate (Topamax®)

4.  Antidepressants: fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), fluvoxamine (Luvox®), citalopram (Celexa®), escitalopram (Lexapro®), bupropion (Wellbutrin®), trazodone (Desyrel®), nefazodone (Serzone®), venlafaxine (Effexor®, Effexor XR®), desvenlafaxine (Pristiq®), duloxetine (Cymbalta®), mirtazapine (Remeron®), vilazodone (Viibryd™), Selegiline (Emsam®), desipramine (Norpramin®), nortriptyline (Pamelor®), protriptyline (Vivactyl®), amitriptyline (Elavil®), imipramine (Tofranil®), clomipramine (Anafranil®), doxepin (Sinequan®), atomoxetine (Strattera®)

5.  Anxiolytic Agents: buspirone (Buspar®)

6.  Antihypertensives (for psychiatric purposes): propranolol, clonidine, prazosin

7.  Nicotine Dependence Treatments: varenicline (Chantix®), nicotine replacement therapy (patches, gum, lozenge, inhaler)

8.  Glucometers, test strips, and lancets for diabetes management

9.  Vitamins, Other O-T-C Products Such As: folic acid, thiamine, multivitamin, cyanocobalamin (B12). L-tryptophan, Sam-e, St. John’s Wort, 5-hydroxytryptophan (5-HT)

IV.  Quality Assurance: a sample of current (within the past 90 days) progress notes will be discussed with the referring physician. The delegating physician will provide in-depth written or recorded verbal review on 10% of progress notes submitted by the clinical pharmacist monthly, including the names of the patients reviewed, the physician’s name and the date of the review.

Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)

(Print)______

MTS Pharmacist, R.Ph.

Psychiatric Clinical Pharmacist

(Print)______

Physician’s Name, M.D. or D.O.

Authorizing Physician/Psychiatrist

Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)

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Signature Signature

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Date Date

Pharmacy or Practice Name/ Location Office or Practice Name

Street, City, Zip, Missouri Street, City, Zip, Missouri

E-Mail Address______E-mail Address______

Office Phone: ______Office Phone ______

Mobile Phn: ______Mobile Phn: ______

Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)