For ______And the Physicians of American Health Network of Ohio, P.C

STANDARD CARE ARRANGEMENT

for ______and the physicians of American Health Network of Ohio, P.C.

This Standard Care Arrangement (“SCA”) is a written formal guide for the Certified Nurse Practitioner (“CNP”) employed by American Health Network of Ohio, PC (“AHN”). This SCA is pursuant to Ohio Administrative Code Section 4723.431.

The signatures of all AHN collaborating physicians must be affixed to this CSA. A new or amended SCA shall be executed if the CNP engages in practice with an additional or different collaborating physician(s).

This SCA shall be reviewed and revised on an annual basis. The CNP and at least one collaborating physician shall sign and date the annual review.

Statement of Services:

The CNP may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience.

Certified Nurse Practitioner

The CNP may provide preventative and primary care services and evaluate and promote patient wellness within the nurse’s nursing specialty consistent with the nurse’s education and certification, and in accordance with the rules adopted by the State Nursing Board of Ohio and section 4723.43 of the Ohio revised code. The parameters of this practice include assessment, history taking, physical examination of patients, utilization of differential diagnosis, appropriate interventions, consultation and referral as indicated. Emergency treatment and stabilization are also authorized as are other functions common to the CNP’s area of practice for which the CNP is educationally and experientially prepared. The CNP is responsible for the complete, legible documentation of all patient encounters.

Technology/New Procedure

The CNP will identify new technology/new procedures needed in the clinical practice. Educational inservices and conferences will be utilized as part of the process.

Criteria for Referral/Consultation of a Client

The CNP, consistent with his or her clinical expertise and educational preparation, in conjunction with the collaborating physician, shall determine when a referral or consultation is necessary. Consultation options include, but are not limited to, telephone contact, on-site case review, or discussion and/or physical examination of the client by the collaborating physician. The method of consultation chosen and the resulting plan of care shall be documented in the patient record. All abnormal labs, test results, etc., are to be reviewed by the collaborating physician.

Procedure for Regular Review of Charts and Referrals to Other Health Professionals

A random selection of patient records and patient referrals will be selected annually for review by the CNP and the collaborating physician(s). Care outcomes will be reviewed by the CNP and the collaborating physician(s).

Policy of Care of Adults

The CNP may provide health care for adults from age eighteen and up. Patient care guidelines for adults shall be generally reflective of The American Academy of Family Medicine Standards.

Policy of Care of Children

The CNP may provide services to pediatric patient’s ages one day to eighteen years if such services are within the education, clinical competency, and certification of the CNP. Patient care guidelines for pediatric patients shall be generally reflective of The American Academy of Family Medicine Standards.

Policy for Coverage of Absences

In the event of a planned or unplanned absence by the CNP, scheduled patients will be rescheduled if at all possible. If the patient requires further attention, the patient will be directed to the appropriate health care facility and/or health care provider.

Policy for Resolution of Clinical Disagreements

Should a disagreement arise between the CNP and the collaborating physician(s) regarding diagnosis or treatment, one or more of the following means of resolution shall be followed:

1.  Consult with an uninvolved physicians and/or CNP colleague

2.  Refer to current professional literature (journals, research, text) appropriate to the area in question.

3.  Consult with a specialist in the area in question.

4.  Refer the matter to the AHN Medical Director

Arrangement Regarding Reimbursement

Current state and federal laws governing reimbursement will be adhered to. All reimbursement for medical services shall be made payable to American Health Network of Ohio, PC.

Prescriptive Authority

The CNP who holds a valid Certificate to Prescribe (including an externship CTP), may prescribe in accordance with Sections 4723.48 through 4723.485, Ohio Revised Code, the rules of the Ohio Board of Nursing, and within the formulary made available by the Ohio Board of Nursing.

Prescribing Parameters

1.  The CNP may prescribe within his or her scope of practice, as indicated by the CNP’s educational preparation and training, and the most current Formulary issued by the Ohio Board of Nursing (Formulary).

2.  The signature of the CNP and the collaborating physician(s) on the Standard Care Arrangement (SCA) implies acceptance of the Formulary as written.

3.  Any restrictions to selected drugs within the Formulary, as agreed on by the CNP and the Physician(s) shall be indicated in the Addendum to this SCA.

4.  Specific drugs must be reviewed as indicated in the Formulary.

5.  All drugs /drug categories listed in the Formulary as Physician Initiated (PI) or Physician Consultation (PC) shall be designated as either requiring PI or PC or “CNP may not prescribe” on the attached Addendum. Any drug indicated as “Physician Initiated OR Physician Consult” in the Formulary that is not indicated as PI or PC on the attached Addendum is considered to be “CNP may not prescribe.”

6.  The CNP may prescribe medications for off-label use if the following criteria are met:

·  The off-label indication(s) must be consistent with the CNP Scope of Practice and clinical specialty/subspecialty practice and the Formulary.

·  The drug and off-label indication(s) are included in the attached and dated Addendum to this SCA.

·  The off-label indication(s) are supported by the current standard clinical practice and literature. The CNP and collaborating physician(s) shall maintain copies of current peer review literature supporting such off-label indication.

·  The signature of the CNP and the collaborating physician(s) indicates agreement to the off-label indication(s) stated in the Addendum to this SCA.

Availability of Timely and Direct Evaluation for the Patient by the Physician

To ensure timely and direct evaluation of the patient by a physician, the collaborating physician or designated physician colleague shall be available to evaluate the patient within 24 hours.

Quality Assurance Provisions Related to Prescriptive Authority

The CNP and the collaborating physician(s) will review a randomized sample of written prescriptions at least semi-annually. This review may be completed as part of the review of referrals described above. Documentation of these reviews will be noted on the signature page of this document.

Additions to the Standard Care Arrangement

Each CNP and collaborating physician may make changes in this document to provide detailed exceptions to the standards described herein, as long as the changes are in writing, incorporated into this SCA, in compliance with Ohio Revised Code, the State of Ohio Board of Nursing Rules and Regulations, and the CNP’s education, training, and clinical experience.

ADDENDUM - FORMULARY

Formulary Restrictions

A copy of the most current edition of the Formulary as published by the State of Ohio Board of Nursing shall be attached hereto and incorporated herein as Exhibit A.

Physician Initiated (PI) and Physician Consultation (PC) Restrictions

Pursuant to the Formulary published by the Ohio Board of Nursing and dated January 14, 2013 (“January 2013 Formulary”), the following drugs are indicated as “CTP holder may prescribe” but require a designation of Physician Initiated (PI) or Physician Consult (PC). The terms PI and PC have the meaning provided in OAC 4723-9-10 and the January 2013 Formulary, i.e.:

“Physician Initiated (PI)” means the collaborating physician is required to have personally examined and evaluated the patient before therapy is initiated in accordance with Rule 4731-11-09 of the Administrative Code. Following discussion with the collaborating physician, the initial order or prescription may be written by an advanced practice registered nurse holding a certificate to prescribe. Once therapy has been initiated, the advanced practice registered nurse may continue, modify, or discontinue the medication without further consultation.

“Physician Consultation (PC)” means a nurse holding a current, valid certificate to prescribe may initiate the medication after direct communication with the collaborating physician regarding a particular patient and documenting the consultation in the patient record. Once the medication is initially authorized by the collaborating physician, a nurse holding a current valid certificate to prescribe may continue, modify, or discontinue the medication without further consultation.

As per the January 2013 Formulary, special requirements regarding acute care certification are applicable to drugs and drug categories marked with an asterisk (*) when administered in their IV form. Other restrictions may also apply (see January 2013 Formulary for specifics).

(1) Nutrients & Nutritional Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Electrolytes (parenteral)*
Amino acids (parenteral)*
IV nutritional therapy: protein substrates, caloric intake, lipids, vitamins (parenteral), minerals, electrolytes, trace metals)*
Chelating agents: succimer, trientene HCl
Dialysis Solutions:
Peritoneal dialysis solution
Hemodialysis solution
(2) Hematological Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Hematopoietic Agents:
Colony-stimulating factors
(NOTE: SCA must be with physician specializing in Hematology/Oncology)
Filgrastim; Pegfilgrastim; Sargramostim (NOTE: SCA must be with physician specializing in Hematology/Oncology)
Stem Cell Mobilizers: Plerixafor Injection
Interleukins: Oprelvekin (neumega (NOTE: SCA must be with physician specializing in Hematology/Oncology)
Thrombopoietin Receptor Agonist: Eltrombopag
(NOTE: SCA must be with physician specializing in Hematology/Oncology)
Thrombopoietin Mimetic Agents: Romiplostim Injection (NOTE:
SCA must be with physician specializing in Hematology/Oncology
Antiplatelet agents:
Glycoprotein inhibitors
Anticoagulants:
Antithrombin agents
Thrombin inhibitors
Dabigatran Etexilate Mesylate Oral (Pradaxa)
Selective factor Xa Inhibitor
Coumarin Anticoagulants
Warfarin Sodium
Coagulants: Heparin Antagonist (Protamine Sulfate)
Antisickling Agents: Hydroxyurea
Protein C1 Inhibitor
C1 Injector, Human
Antihemophilic agents
Antihemophilic factor combinations
Hemostatics
Tranexamic Acid
Plasma expanders
Kallikrein Inhibitors: Ecallantide
Bradykinin Inhibitors: Icatibant
(3) Endocrine & Metabolic Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Sex hormones:
Ovulation stimulants
Gonadotropin-releasing hormones
Androgens
Danazol
Uterine-active agents
Agent for cervical ripening:
Dinoprostone
Uterine relaxants
Bisphosphonates
Pamidronate Disodium Injection
Zometa
Reclast (for other than osteoporosis)
Antidiabetic agents:
IV Insulin
Amylin analog (Symlin)
Incretin mimetic agents
Glucagon-like Peptide 1 Receptor Agonists:
Liraglutide
Adrenocorticol Steroids
Mineral corticoids
Thyroid Drugs:
Growth Hormone Releasing Factor: Tesamorelin Acetate Injection
Insulin-like growth factor
Growth hormone
Velaglucerase Alfa Injection
Taliglucerase Alfa
Somatostatin Analogs:
Lanreotide Acetate
Galsulfase
Idursulfase
Calcitonin-salmon: injectable
Calcium receptor agonist (Sensipar)
Ivacaftor
Agents for Gout: Pegloticase Injection
(4) Cardiovascular Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Inotropic Agents IV*
Antiarrhythmic agents (po) (IV*)
Calcium Channel Blocking Agents IV*
Nimodipine
Vasodilators
Nitrates IV*
Endothelin Receptor Antagonist
Peripheral vasodilators IV*
Antiadrenergics/Sympatholytics
Beta-blockers IV*
Alpha/beta Adrenergics IV*
Renin Angiotensin System Antagonists IV*
Vasodilator Combinations
Agents for Hypertensive Emergencies: Nitroprusside Sodium; Diazoxide; Fenoldopam Mesylate; Trimethaphan Camsylate
Antihyperlipidemic agents (simvastin, ezetimibe) HMG-CoA Reductase Inhibitors for pediatric dosing
Vasopressors Used in Shock IV*
Agents for Patent Ductus Arteriosus: Indomethacin; Ibuprofen lysine (other than Neonatal NP CTP holder)
Sclerosing Agents: Polidocanol
Miscellaneous antianginal agents (Ranexa) (other than Adult Acute Care CTP holder)
(6) Respiratory Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Monoclonal antibodies: Omalizumab (Xolair)
Respiratory enzymes (other than Neonatal NPs)
(7) CNS Agents
**Note restrictions in the law for ALL Schedule II Controlled Drugs / CNP may not prescribe / CMP may prescribe if PI / CNP may prescribe if PC /
CNS Stimulants
Analeptics: Caffeine IV
Amphetamines; Methylphenidate HCl (without formal established diagnosis)
Analgesics: generally
Schedule II analgesics (CTP holders initiating therapy with a schedule II medication for > 7-day supply)
Non-narcotic Analgesic Combinations
Antidepressants
Nefaxodone
MAO inhibitors
Antipsychotic agents
Clozapine; thioridizine; pimozide
Phenothiazine derivatives; Thioxanthine derivatives; Phenlbutylpiperidine derivatives; Dihydroindolone derivatives; Dibenzapine derivatives; Benzisoxazole derivatives; Quinolinone derivative
Lithium (CTP holder other than psych)
NMDA receptor antagonists: (Namenda)
Misc. psychotherapy agents
Atomoxetine (CTP holder other than psych)
Sedatives & Hypnotics, Nonbarbiturates
Chloral Hydrate
Anticonvulsants
Ezogaine
Antiparkinson Agents
EMSAM (selegiline transdermal system)
Adenosine phosphate
Cholinergic muscle stimulants:
Riluzole
Physical adjuncts; hyaluronic acid derivatives
Potassium Channel Blocker: Dalfampridine
Botulinum toxins – ONLY for spasticity, cervical dystonia & chronic migraine in related specialty clinic with specific uses addressed
(8) GI Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Dextranomer/Sodium Hyaluronate
Gallstone solubilizing agents
(9) Anti-Infectives; Systemic / CNP may not prescribe / CNP may prescribe with PI / CNP may prescribe with PC /
Antibiotics:
Glycyclines: Tigecycline
Streptogramines: Synercid
Lipopeptides: Daptomycin
Vancomycin
Lipoglycopeptides: Telvancin HCl injection
Oxazolidinones: Linezolin
Aminoglycosides: parenteral; nebulized
Antifungal Agents
IV route of administration
Micafungin sodium inject
Triazole antifungals
Antituberculosis agents (other than INH: TB prophylaxis)
Antiviral Agents:
Foscarnet sodium; Ganciclovir; Valganciclovir (IV)
Telaprevir oral; Boceprevir oral
Anti-herpes Virus Agents
Ribavirin
Adefovir dipivoxil
Entecavir
Antiretroviral agents
Protease Inhibitors
Nucleotide Analog Reverse Transcriptase Inhibitors
Nucleoside Reverse Transcriptase Inhibitors
Non-Nucleoside Reverse Transcriptase Inhibitors
Cellular Chemokine Receptor Antagonist (Maraviroc)
Integrase Inhibitors (Raltegravir)
Fusion Inhibitors
Leprostatics
Antiprotazoals
(10) Biologic/Immunologic Agents / CNP may not prescribe / CNP may prescribe if PI / CNP may prescribe if PC /
Immune Globulins
Agents for primary immune deficiency (Vivaglobulin)
Monoclonal antibody:
Eculizuman Injection (Soliris)
Denosumab
Belimumab (Benlysta)
Allergenic extracts
Immunologic agents
Immunostimulants
Immunosuppressives
Immunomodulators
Fingolimod
Thalidomide
Revlimid (allowed for Hem/Onc only)
Cimzia
Antirheumatic agents
Keratinocyte Growth Factors: Palifermin

** For Humira, see FDA warning