Standardized practice guide for Collaborative Practice Agreements (CPAs)

Guide statement

In order to meet various state compliance, legislature and nursing regulations, this guide is intended to establish a common recommended standard that may be included in collaborative agreements. A collaborative practice agreement is a crucial document that outlines the relationship between a nurse practitioner (NP) and a collaborating physician. This guide provides a step-by-step approach for nurse practitioners to construct an effective collaborative agreement.

1. Understand Legal Requirements:
   1. Each state has its own set of specific requirements that must be met in a collaborative agreement, we recommend going to your state Board of Registered Nursing.
   2. Research and understand the legal requirements for collaborative agreements in your jurisdiction.
   3. Ensure compliance with state laws and regulations governing nurse practitioner practice.
      
      
2. Identify Collaborating Physician:
   1. Establish a relationship with a qualified and willing collaborating physician.
   2. Confirm that the collaborating physician is licensed and experienced in the relevant specialty (ie, adult psychiatry, childhood/adolescent psychiatry).
      
      
3. Define Scope of Practice:
   1. Clearly outline NP's scope of practice within the collaborative agreement.
   2. Specify the medical services and procedures NPs are authorized to perform within your state.
   3. Consider including the following:
      1. Standardized Protocol for Outpatient Health Care Management
         1. Definition: PMHNPs are authorized to manage mental health and substance use conditions under this protocol. This outpatient protocol includes the process for management of common acute, episodic and chronic mental health and substance use conditions seen in outpatient settings. Conditions include: depression, anxiety, psychotic disorders, mood disorders, trauma-related disorders, personality disorders, substance use disorders, intellectual disabilities, and attention deficit hyperactivity disorder.
         2. Assessment/Diagnosis
            1. Gathering of necessary information consistent with both subjective and objective findings to identify a diagnosis of mental health and substance use conditions and develop differential diagnosis.
               1. Subjective: Obtaining information relevant to chief complaint including history of present illness, risk assessment, substance history, and past psychiatric/medical/family/social history.
               2. Objective: MSE, review of systems, review of available medical and diagnostic data. Obtaining collateral information when necessary.
            2. If diagnosis is not clear, assessment to level of surety plus differential diagnosis
            3. Assessment of condition severity including any functional impairment should be documented
         3. Treatment Plan
            1. Ordering diagnostic laboratory testing when appropriate
            2. Providing patient education and counseling to mental health and/or substance use condition, treatment and prognosis
            3. Follow-up appointment for further evaluation and treatment if indicated
            4. Coordination of Care: Consultation and referral when appropriate (i.e. psychiatrist, psychotherapy, primary care, neurology, sleep clinic, IOP/PHP etc)
         4. Consultation with Supervising Physician: As described above.
         5. Furnishing Medication
            1. Ordering and dispensing medications by the PMHNP will be done in consideration but not limited to the following:
               1. Current medication
               2. Medications deemed appropriate for treatment of presenting illness
               3. History of medication allergies
               4. Contraindications
               5. Medication side effects
               6. Medication dose and therapeutic range guidelines individualized per patient individual needs
               7. Assessment of pregnancy and lactation status
               8. Presence of other patient health conditions
            2. Medication ordered will be within the scope and educational expertise of the PMHNP
            3. PMHNPs responsible for monitoring effectiveness of any medications prescribed, proper documentation, proper follow up schedule and patient education on pertinent side effects
            4. Schedule III: Ordering of Schedule III substances are to be used in acute, maintenance, and chronic mental health and substance use conditions
            5. Schedule II: PMHNPs must follow the Prescription of Schedule II Controlled Substances outlined by state regulations.
         6. Dispensing Medication: PMHNPS may dispense medications under the following conditions:
            1. Drug uses required pharmacy containers and labeling
            2. Documentation of dispensed medications completed
            3. Dispensing encompasses all Federal and State policies
               
               
4. Communication/Responsibilities of Each Party:
   1. Clearly define the roles and responsibilities of both the NP and the collaborating physician.
   2. Detail the specific tasks each party will handle, emphasizing effective collaboration.
   3. Establish clear communication protocols between yourself and your collaborating physician.
   4. Include methods for regular updates, consultations, and addressing emergent situations.
   5. Consider including the following:
      1. Supervision Physician, Consultation, and Communication
         1. PMHNPs are authorized to implement Standardized Procedures in collaboration with a Supervising physician.
         2. Consultation with a Supervising Physician will occur under the following conditions or when deemed necessary, including but not limited to the following:
            1. Situations which are above the bounds outlined in the Standardized procedures
            2. Situations that are outside the scope of practice, experience or competence of the PMHNP
            3. Acute patient decompensation or Crisis situation
            4. Conditions requiring immediate medical intervention
            5. Challenging cases with unanticipated outcomes to various interventions trialed
            6. Inconsistent history, physical or lab findings
            7. At request of the PMHNP, Supervising Physician or patient, the patient’s legal representative or family member
            8. Supervising Physicians are available to PMHNPs by phone, instant messaging, email or video conference.
               
               
5. Protocols for Emergencies:
   1. Develop protocols for handling emergencies and unexpected situations.
   2. Specify procedures for communication and collaboration during urgent medical cases.
   3. Consider including the following:
      1. For crisis emergencies, please call 911 or 988 or go to your nearest emergency room immediately. See below for more mental health resources. You may contact your provider for non-emergent questions or concerns that may be related to your mental health treatment. If you are admitted to the hospital for a mental health concern, please notify your provider as soon as possible.
      2. National Suicide Prevention Line 24/7– 1-800-SUICIDE (784-2433)
      3. Crisis Text Line 24/7– Text the word HOME to 741741
      4. National Alliance on Mental Health (NAMI) 1-800-950-NAMI (6264)
      5. National Domestic Violence Hotline-24/7–1-800-799-7273
      6. SAMHSA- Substance Abuse & Mental Health Service Administration- 24/7 1-800-662-HELP(4357)
         
         
6. Documentation and Chart Review
   1. If your state requires - include any responsibilities to perform chart review functions by the collaborating provider.
   2. Ensure compliance with legal and regulatory standards for record-keeping.
      
      
7. Review and Renewal Process:
   1. Establish a regular review process for the collaborative agreement.
      1. Note - most states require a renewal yearly.
      2. Include provisions for renewing the agreement, ensuring it stays current with any changes in regulations or practice.
         
         
8. Legal Review:
   1. Before finalizing the collaborative agreement, consider seeking legal review.
   2. Ensure that the document complies with all relevant laws and regulations.
      
      
9. Signatures:
   1. Once satisfied with the terms, obtain signatures from both parties.
   2. Consider notarizing the collaborative agreement to add an extra layer of legal authenticity.
      
      
10. Periodic Training and Updates:
    1. Plan for ongoing professional development and staying informed about state licensing requirements.
    2. Stay informed about changes in laws and regulations affecting collaborative practice in your state.

Remember, collaborative agreements are legal documents, and it is essential to consult with legal professionals to ensure compliance with local regulations and the specifics of your practice.

Updated March 01, 2024 16:56