North Carolina Board of Nursing

Nursing Practice

Nurse Practitioner

Collaborative Practice Guidelines

Collaborative Practice Agreement – A Guide for Implementation

NC Board of Nursing 21 NCAC36.0800 “Approval and Practice Parameters for Nurse Practitioners,” and similar Medical Board Rule 21 NCAC32M.0100 “Approval of Nurse Practitioners,” were effective August 1, 2004. What are the elements necessary to include in the “Collaborative Practice Agreement?” The Joint Subcommittee of the Board of Nursing and the Medical Board does not require one specific format that the Nurse Practitioner must use. However, each Nurse Practitioner/Primary Supervising Physician’s Collaborative Practice Agreement (CPA) must address how that Nurse Practitioner/Primary Supervising Physician will operationalize Nurse Practitioner Rules in that practice to comply with the administrative code/rules. Since practices differ, Collaborative Practice Agreements will also be different, according to type of patients served; most common diagnoses made; complexity of care for the client population; the ready availability of emergency services, diagnostic centers and specialists; and whether the NP has just graduated versus a “seasoned” NP, or the “seasoned” NP in a new area of practice, or with a new primary supervising physician. NPs could still use written protocols or other specified references described as such in the Collaborative Practice Agreement, although written protocols are not mandatory as in the previous NP rules. You could include in the Collaborative Practice Agreement certain references that will be consulted such as patient care guidelines. The Nurse Practitioner’s Collaborative Practice Agreement must describe the arrangement for nurse practitioner – physician continuous availability to each other for the ongoing supervision, consultation, collaboration, referral, and evaluation of care provided by the nurse practitioner. When the nurse practitioner and primary supervising physician address how they will practice together, the completed document will be the Nurse Practitioner’s Collaborative Practice Agreement.

The COLLABORATIVE PRACTICE AGREEMENT, may be more structured than required by nurse practitioner rules, but may not be less structured or contain less than required by the rules. The following questions and statements are intended to help guide you as you write your collaborative practice agreement.

PATIENT POPULATION:

What patients will you typically see? Depending on your area of education and certification, i.e. FNP, Women’s Health etc., what diagnoses/problems will you commonly see? How will these be managed? For example, do you see High Risk Maternity patients? How are they managed?

What is the arrangement for NP/physician continuous availability to each other for supervision, consultation, collaboration, and evaluation of the medical acts you will perform?

Describe certain patients or disease management situations that the primary or back up supervising physician will only see, or see in consultation with you.

How will you establish the minimum standards for consultation between the nurse practitioner/primary or back-up supervising physician(s), as outlined in the Quality Assurance Standards for a Collaborative Practice Agreement? How and what will your documentation include?

How will consultation and referral of patients be accomplished in your practice?

What is the pre-determined plan for emergency services?

PRESCRIBING AUTHORITY:

What drugs, devices, medical treatments, tests and procedures that may be prescribed, ordered and performed, would be appropriate for the diagnosis and treatment of the common medical problems seen in your NP practice sites?

What drugs and devices will you prescribe in each practice site? You may list by specific drugs or drug categories. A broad description of categories of drugs and devices for treating the common health problems in your particular practice can be developed. For example: categories of drugs, such as antiseizure, hypoglycemic drugs-oral/insulin, hormones and oral contraceptives, cephalosporins, aminoglycosides, antiviral, antiasthmatic, diuretics, antihypertensive etc. can be stated. Prescribing exceptions could be by classes of drugs or specific drugs in a class or routes for administration.

Are you going to dispense drugs and devices? If so, you must apply for dispensing privileges through the Board of Pharmacy. If you will be dispensing, state how this will be done to comply with the Board of Pharmacy, and dispensing in accordance with 21NCAC 36.1700.

How will you address in the new rules prescribing and dispensing drugs and devices that are not included in the collaborative practice agreement as stated in rule 21 NCAC36.0809 (b)(3)(A)(B) and 21 NCAC32M.0109 (b)(3)(A)(B).

Will you prescribe any controlled drugs? If so, you must have a DEA number.

A nurse practitioner could do a combination of the above or use a different approach to describe in the Collaborative Practice Agreement the prescribing authority for the nurse practitioner. It is required to describe in the Collaborative Practice Agreement, the drugs and devices that may be prescribed by the nurse practitioner in each practice site as outlined in Medical Board rule 21 NCAC32M.0109 “Prescribing Authority” and, in the Board of Nursing rule 21 NCAC36.0809 “Prescribing Authority.”

REQUIREMENTS FOR DOCUMENTATION:

In the Rules, 21NCAC36.0810(b)(1)(2) and 21 NCAC32M.0110(b)(1)(2) “Quality Assurance Standards for a Collaborative Practice Agreement,” the Collaborative Practice Agreement shall be agreed upon and signed by both the primary supervising physician and the nurse practitioner, and maintained in each practice site.

The review of the Collaborative Practice Agreement shall be done at least yearly, and shall be acknowledged with a dated signature sheet, signed by both primary supervising physician and the nurse practitioner, appended to the Collaborative Practice Agreement and available for inspection by members or agents of either Board.

Documentation of how the primary or back-up supervising physician(s) and the nurse practitioner shall be continuously available to each other for consultation by direct communication or telecommunication shall be stated.

Documentation for evaluating the plan of the quality of care provided for one or more frequently encountered clinical problems shall occur at the scheduled meetings between the primary supervising physician and the nurse practitioner that occur at least every six months, as outlined in rule NCAC 36.0810(d)(1)-(3)(A)-(C) and rule 21 NCAC 32M.0110(d)(1)-(3)(A)-(C).

QUALITY IMPROVEMENT PROCESS:

What will be your process, developed by the nurse practitioner and the primary supervising physician, for the ongoing review of care provided in each practice site, including a written plan for evaluating the quality of care provided for one or more frequently encountered clinical problems?

What will the plan include?

Every six months there shall be scheduled meetings between the primary supervising physician and the nurse practitioner.

What will be your minimum standards for consultation between you as a nurse practitioner and your primary supervising physician, as outlined in 21 NCAC 36.0810(e)(1)(A)-(B)(2)(3)(A)-(C) and 21 NCAC 32M(e)(1)(A)-(B)(2)(3)(A)-(C)? This nurse practitioner/physician consultation will be different for the new graduate, new nurse practitioner with first time approval to practice in North Carolina vs. a subsequent collaborative practice agreement between a nurse practitioner previously approved to practice in NC and a different primary supervising physician.

What will be the process for consultation, meetings, and documentation of the meetings?

SUMMARY:

This is not an all-inclusive list of questions or statements to be considered for your Collaborative Practice Agreement, but is meant to guide your development of the Collaborative Practice Agreement for your practice.

No collaborative practice agreement can effectively cover every clinical situation. Therefore, the Collaborative Practice Agreement is not intended to be, nor should it be, a substitute for the exercise of professional judgment by the Nurse Practitioner. There are situations involving patient care, both common and unusual that require the individualized exercise of the Nurse Practitioner’s clinical judgment.

In creating your “Collaborative Practice Agreement” utilize the new nurse practitioner rules. If you have further questions, please call Bobby Lowery, RN, PhD, FNP-BC, Practice Consultant, 919-782-3211 Ext. 290.