Collaborative Practice Guidelines
Collaborative Practice Agreement – A Guide for Implementation
North Carolina Board of Nursing 21 NCAC 36 .0800 “Approval and Practice Parameters for Nurse Practitioners,” and similar Medical Board Rule 21 NCAC 32M .0100 “Approval of Nurse Practitioners,” were effective August 1, 2004.
What should be in the “Collaborative Practice Agreement?” The CPA is an agreement between the nurse practitioner (NP) and primary supervising physician addressing how they will operationalize the NP administrative code/rules in their practice. The collaborative practice agreement is not an employer contract (CPA). Since practices differ, CPAs will differ according to: types of patients served; most common diagnoses and therapies; complexity of the client population; ready availability of emergency services, diagnostic centers and specialists. No specific format is required.
Required components of the CPA are:
- The drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and performed by the nurse practitioner.
- A pre-determined plan for emergency services.
What drugs, devices, medical treatments, tests and procedures may be prescribed, ordered and performed, or would be appropriate for the diagnosis and treatment of the common medical problems seen in the practice?
The CPA may contain a list by specific drugs or a broad description of categories of drugs and devices for treating the common health problems seen in the practice. For example: categories of drugs, such as antiseizure, anti-diabetic drugs-oral/insulin, hormones, oral contraceptives, cephalosporins, aminoglycosides, antivirals, antiasthmatics, diuretics, antihypertensive etc. . Prescribing exceptions could be by classes of drugs or specific drugs in a class or routes for administration.
Will the NP dispense drugs and devices? If so, apply for dispensing privileges through the Board of Pharmacy. If dispensing, state how this will be done to comply with the Board of Pharmacy, and in accordance with 21 NCAC 36 .1700.
How will the NP address prescribing and dispensing drugs and devices not included in the collaborative practice agreement as stated in rule 21 NCAC 36 .0809 (b)(3)(A)(B) and 21 NCAC 32M .0109 (b)(3)(A)(B).
Will the NP prescribe any controlled drugs? If so, the NP must have a DEA number.
A Nurse Practitioner could do a combination of the above or use a different approach to describe in the CPA the prescribing authority for the Nurse Practitioner. It is required to describe in the CPA, the drugs and devices that may be prescribed by the NP as outlined in Medical Board rule 21 NCAC 32M .0109 “Prescribing Authority” and, in the Board of Nursing rule 21 NCAC 36 .0809 “Prescribing Authority.”
ADDITIONAL ITEMS TO CONSIDER INCLUDING IN THE CPA
In keeping with all regulatory requirements, the CPA is a good place to describe the arrangement for NP – physician continuous availability for the ongoing supervision, consultation, collaboration, referral, and evaluation of care provided by the NP. The CPA may be more structured than required by NP rules, but may not be less. The CPA must be onsite for inspection by members or agents of either Board.
What patients will the NP typically see? Depending on the NP scope of practice (area of academic preparation and national certification), i.e. Family Nurse Practitioner, Women’s Health etc., what diagnoses/problems are most common in the practice? For example, are High Risk Maternity patients seen?
Describe any patients or disease management situations that only the primary or back up supervising physician will see or see in consultation with the NP.
QUALITY IMPROVEMENT PROCESS:
What will be the process for the ongoing review of care provided, including a written plan for evaluating the quality of care provided for one or more frequently encountered clinical problems?
What will be the process for consultation, meetings, and documentation of the quality improvement process meetings?
REQUIREMENTS FOR DOCUMENTATION:
In the Rules, 21 NCAC 36 .0810(b)(1)(2) and 21 NCAC 32M .0110(b)(1)(2) “Quality Assurance Standards for a Collaborative Practice Agreement,” the CPA shall be agreed upon and signed by both the primary supervising physician and the NP, and maintained in each practice site (electronic signature software may be used).
The review of the CPA shall be done at least yearly, and 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 (electronic signature software may be used).
This is not an all-inclusive list of questions or statements to be considered, but is meant to guide the development of the Collaborative Practice Agreement.
No CPA can effectively cover every clinical situation. Therefore, the CPA 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 clinical judgment.
In creating your “Collaborative Practice Agreement” utilize the current Nurse Practitioner rules. If you have further questions, email firstname.lastname@example.org.