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How the pharmacist communicates with other healthcare providers about MTM is of equal importance to how he or she communicates with the patient. This involves keeping physicians (or other providers such as nurse practitioners, physician assistants, social workers, etc.) informed throughout the entire MTM process. To collaborate successfully with other members of the healthcare team (including physicians, nurses, and support staff) pharmacists need to build mutual relationships based on competency and trust.¹ This includes informing prescribers about the initial plans to conduct an MTM interview, in addition to providing adequate follow-up after patient consultation. Follow-up communication should involve discussion of potential medication regimen changes and action plans and obtaining permission to implement changes.

There are, however, some barriers to effective communication. Most healthcare systems do not yet have seamless electronic health records (EHR) between different care settings. Therefore, an update in the pharmacist's computer system does not confer an automatic update to the physician's electronic medical records. If a reliable email "firewall" is not in place to securely send electronic communications, many pharmacists must fax requests and medical record updates to the physician's office. Although this consumes staff time (and invites potential errors if a fax is not received or is overlooked), it is often the only available scenario. Telephone communication can be an effective mode of communication but generally reserved for more urgent questions or follow-up on specific requests.

Introducing Providers to MTM

When planning an MTM session with a patient, it's a good idea to send an introductory letter to the patient's physician/s explaining the overall goals and benefits of MTM. This can be prepared as a form letter and updated for each individual patient. Pharmacists who are initiating a new MTM service might send a generic letter to a large selection of physicians in the area, encouraging collaboration with these providers for the benefit of their patients. Some of the benefits for the physician that can be emphasized are summarized in Table 1. Many physicians who are busy with large patient panels may welcome the opportunity for a comprehensive medication review for a selected group of patients.  Introductory correspondence can be sent to physicians through various methods, including:

• Phone
• Email or regular mail
• Fax
• Letter sent with patient visit
• EHR staff messaging (if within the same group)

Table 1. Benefits of MTM for Prescriber

More efficient patient care (i.e., the pharmacist as the medication expert can identify and resolve medication-related problems effectively) More comprehensive patient follow-up Improved continuity of care Minimization of medication errors, adverse effects, and adverse drug-drug interactions Increased adherence to therapy Enhanced medication reconciliation Reduced duplication of therapy (due to polypharmacy)

Patients as advocates for MTM collaboration

Some pharmacists who are providing MTM have found that patients can serve as advocates in obtaining physician cooperation and buy-in to MTM. For example, at his or her next office visit, the patient might hand-deliver a letter about an upcoming MTM session, introducing the pharmacist and notifying the physician that there will be further correspondence.

When planning which healthcare professionals should receive correspondence, the pharmacist should be aware of:

• Multiple providers
• Any recent care transitions (hospital to home, hospital to rehab facility)
• Other providers (e.g., advanced practice nurses, physical therapists, social workers, physician assistants, nutritionists) who may be involved in care

Approaches to Prescriber Communication

Pharmacists experienced at conducting MTM have noted that some communication methods are more effective than others when corresponding with physicians. Adequate preparation is essential. Pharmacists should make MTM as patient-specific as possible and complete thorough patient work-ups prior to recommending changes to the prescriber.  Offering input without assessing the patient as a whole can negatively impact a physician's reception of MTM services. For example, the pharmacist may make a statement, "Recommend starting the patient on X therapy," without knowing that the patient:

1. 1) has previously tried that medication (and may have discontinued due to intolerable adverse effects, inability to obtain appropriate lab monitoring, or lack of efficacy)
2. 2) does not want to try that particular therapy
3. 3) has a contraindication to the therapy of which the pharmacist may be unaware
4. 4) is receiving another agent that is incompatible with therapy

Physicians must make decisions about patient care in an imperfect world; often, the choice of therapy that looks best "by the book" may be one that the physician has already tried and has found to be unsuitable for that patient. If the MTM pharmacist says, "This therapy is recommended," without knowing what has or has not been tried—or other extenuating circumstances relevant to that individual—this feedback is unhelpful to the physician. If the physician consistently receives irrelevant feedback, he or she may be reluctant to continue cooperating with MTM. Some key Do's and Don'ts of provider communication are summarized in Table 2.

Table 2. Dos and Don'ts for Provider Communication

DO emphasize teamwork and collaboration Stress the benefits to the provider, and any past successes you may have had (without revealing any private patient identifiers).  Make recommendations a discussion and be flexible when appropriate. DO recognize the patient/provider relationship Stress that decisions are made on a collaborative basis and are not intended to leave the physician out of the loop. DO recognize that you may lack key information Instead of stating, "Suggest starting the patient on a long-acting insulin," you might say, "If the patient has not already done so, suggest a trial of …" DON'T use language that may sound accusatory Instead saying, "We will eliminate this patient's problems with drug therapy problems" say, "We will attempt to optimize the patient's drug therapy." Instead of saying, "This therapy is not appropriate," say "You may wish to evaluate the continued need for …" or, "This drug may be contributing to/aggravating [adverse effect]."

Collaborative Practice Agreements and MTM

Collaborative agreements between physicians and pharmacists can help avoid some of the communication pitfalls described above, because they are less one-sided. These arrangements are intended to provide greater access to and sharing of patient records and ongoing cooperation between healthcare professionals about what therapies are best for the patient.^2,3

What is a Collaborative Practice Agreement?

The concept of a collaborative work agreement between physicians and pharmacists is known by a number of different terms, including collaborative practice agreement (CPA), collaborative working relationship, and collaborative drug therapy management (CDTM).^2,4-6 These formal agreements are arranged in advance between a pharmacist and licensed prescriber. They offer the advantage of allowing the pharmacist to operate under protocol to make immediate changes in drug therapy and to provide immediate, on-site delivery of care to patients (such as ordering of pertinent laboratory tests).

Terms of collaborative practice agreements by state

CPA regulations are constantly evolving at the state level. Currently, 48 states plus the District of Columbia have authorized collaborative agreements between pharmacists and physicians. What is permitted under the terms of these agreements is also determined on a state-by-state basis.⁷ The extent of services that can be performed by pharmacists within the CPA varies from state to state. Some states have stringent restrictions, and others leave more of the decision-making up to the discretion of the provider. For example:

• 38 states currently allow pharmacists to initiate drug therapy under a CPA
• 45 states allow pharmacists to modify existing drug therapy
• In Florida, pharmacists are permitted to initiate a defined list of medications without a CPA
• In 29 states, the CPA specifies the medications and/or disease states in which pharmacists can initiate or change therapies.

Some of the most broadly written CPA terms are in the State of Wisconsin, which states that pharmacists "may perform any patient care service delegated to the pharmacist by a physician." Services performed by pharmacists under CPAs are not limited to modification of drug therapy and monitoring of laboratory tests. For example, a CPA might include activities such as administering medications to patients who are unable to do so by themselves. In such cases, the physician could order through the CPA that a patient goes to the pharmacy to receive regular medication on schedule.

Some states require minimum credentialing for pharmacists to participate in CPAs. In California, for example, pharmacists participating in CPAs must be residency trained.⁸ Other states require specific continuing education or completion of a certificate training program.

In January 2015, the National Governors Association released a paper supporting full integration of pharmacists into the healthcare system. The paper recommends amendment of existing laws and regulations so pharmacists can practice to the full scope of their training. This was followed by the release of a National Alliance of State Pharmacy Associations (NASPA) Collaborative Practice Workgroup Report in July 2015, which recommended a movement toward national standardization of CPA regulations (Table 3).⁹

Table 3. Recommendations on CPAs from the Report of National Alliance of State Pharmacy Associations, July 20159

Recommendations for State Laws/Regulations: Any practitioner with prescriptive authority may collaborate with pharmacists using a CPA. CPAs may be between a single or multiple pharmacists and a single or multiple prescribers. CPAs may apply to a single patient, multiple patients, or patient populations as specified in the agreement. Elements to be Determined at the Practitioner Level CPAs should specify which patient(s) and/or patient population(s) can receive services under the agreement. Depending on the complexity of the services being provided under a CPA, it may be appropriate for the pharmacist to have additional credentials or training, beyond what is required for licensure. CPAs should specify which pharmacist(s) may provide services under the CPA. A pharmacist's practice setting should not be a barrier to their ability to enter into a CPA.

What are the benefits of CPAs?

The benefits of CPAs have been studied extensively and described in the literature.^10-13 It is important to note, however, that the concept of a CPA is not necessarily synonymous with MTM. A formal agreement of this nature is not required in order for pharmacists to successfully conduct MTM services, but there are clearly benefits to multiple parties in formal collaborative agreements.

Using the term collaborative drug therapy management (CDTM) agreement, the Academy of Managed Care Pharmacy (AMCP) recently issued a practice advisory which outlined the benefits of such an agreement for the various groups involved (Table 4).⁵

Table 4. Benefits of Collaborative Drug Therapy Management (CDTM) Arrangements Between Pharmacists and Physicians5

Benefits to Patients Increased access to health care Enhanced patient care through optimized drug therapy management Decreased drug-related problems (adverse drug reactions, drug interactions, poor adherence) Reduced costs through optimal use of medications and minimization of drug related problems Pharmacist identification of underlying conditions that require the care of a physician Benefits to Physicians Reduced visits for chronic disease patients, freeing more time for physician patient interaction and for management of complex cases Delegation of medication management to the drug therapy specialist (pharmacist) who has unique skills and knowledge that can be used to support the physician's therapy strategies Referral of patients by pharmacists to physicians Enhanced ability to achieve pay-for-performance goals Benefits to Pharmacists Allows pharmacists to move from a product-oriented service to a patient-focused practice using their unique knowledge to improve clinical outcomes Allows pharmacists to demonstrate their value as an integral part of the health care team Benefits to Health Plans/Managed Care Organizations Utilizing the pharmacotherapy skills of the pharmacist to decrease chronic disease physician visits for medication therapy related issues Enhanced drug therapy outcomes through optimization of drug therapy regimens Improved patient satisfaction Reduced costs of care More targeted physician referrals

Adapted with permission from Academy of Managed Care Pharmacy. Practice Advisory on Collaborative Drug Therapy Management. February 2012. Copyright (c) AMCP. All rights reserved.

According to guidelines from the Centers for Medicare and Medicaid Services (CMS), a "collaborative practice protocol," consists of a written document that identifies drug therapy management actions that a pharmacist is authorized to perform for a patient.¹⁴ The CMS further states that this document should be developed jointly by the pharmacist and the physician and should include a description of the terms of agreement, including:

• Identify each physician and pharmacist permitted to participate in a patient's collaborative drug therapy management, including all covering physicians and/or pharmacists.
• Establish the means by which the physician and/or pharmacist will be notified about covering practitioners for collaborative practice purposes;
• Specify functions and responsibilities, including the scope of practice and authority, to be exercised by the pharmacist;
• Indicate any restrictions placed on the use of certain types or classes of drugs or drug therapies;
• Indicate any diagnosis or types of diseases that are specifically included or excluded;
• Include copies of all protocols to be used in the collaborative practice;
• Indicate effective date for the agreement;
• Be signed and dated by physician(s) and pharmacist(s).

Summary and Conclusions

Pharmacist-physician communication is anticipated to become more formalized as MTM services continue to expand.⁴ Pharmacists involved in MTM need to be aware of the types of agreements that can be made with physicians in the specific geographic location and what privileges can be granted through such agreements.

In addition, it behooves pharmacists who are practicing MTM to determine how best to communicate with specific providers without "stepping on toes" or making it appear that they are trying to subvert the physician's authority in patient care. This might mean simply asking the physician, "How would you prefer to communicate," and "What types of suggestions would be valuable to you in the care of this patient?" When the pharmacist lacks full background information about a patient, it may be best to state it up front, by saying, "I don't have access to the patient's full medical record, so I don't know if this approach has been tried before. Do you think this recommendation would be appropriate?" This is usually better received than a statement such as "I recommend the patient be placed on drug X."

Collaborative Practice Agreements (CPAs) allow pharmacists to provide value-added benefits to the healthcare system and to practice to the full extent of their training. CPAs are currently regulated on a state-by-state basis. However, pharmacists should be aware that there is a national movement toward standardizing CPA regulations. The final CPA standardization has yet to be determined, but will likely consist of two parts: state laws regulating CPAs and elements determined at the practitioner level. Pharmacists should strive to keep up with the rapidly evolving regulatory requirements regarding CPAs.

References

1. Liu Y, Doucette WR, Farris KB. Examining the development of pharmacist-physician collaboration over 3 months. Res Social Adm Pharm. 2010;6(4):324-333.
2. Snyder ME, Zillich AJ, Primack BA, et al. Exploring successful community pharmacist-physician collaborative working relationships using mixed methods. Res Social Adm Pharm. 2010;6(4):307-323.
3. Shah B, Chewning B. Conceptualizing and measuring pharmacist-patient communication: a review of published studies. Res Social Adm Pharm. 2006;2(2):153-185.
4. Roberts S, Gainsbrugh R. Medication therapy management and collaborative drug therapy management. J Manag Care Pharm. 2010;16(1):67-68.
5. Academy of Managed Care Pharmacy. Practice Advisory on Collaborative Drug Therapy Management. .
6. McDonough RP, Doucette WR. Dynamics of pharmaceutical care: developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41(5).
7. Centers for Disease Control and Prevention (CDC). Collaborative Practice Agreements and Pharmacists' Patient Care Services. A guide for pharmacists. National Center for Chronic Disease Prevention and Health Promotion. 2012.
8. California State Pharmacy Law (Business and Professions Code 4000 et seq) 4210 & 4052. Department of Consumer Affairs, Board of Pharmacy, CA.gov. Available at: http://www.pharmacy.ca.gov/laws_regs/.
9. National Alliance of State Pharmacy Associations. Pharmacist collaborative practice agreements: Key elements for legislative and regulatory authority. July 2015. Available at: http://naspa.us/wp-content/uploads/2015/07/CPA-Workgroup-Report-FINAL.pdf.
10. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43(2):173-184.
11. Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc (2003). 2008;48(1):23-31.
12. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3):383-391.
13. LeBuhn R, Swankin DA. Reforming Scopres of Practice: A White Paper. Washington, DC: Citizen AdvocacyCenter; 2010. Available at: http://www.ncsbn.org/Reformingscopesofpractice-whitepaper.pdf.
14. Centers for Medicare and Medicaid Services. CMS Physician/Non-physician Collaborative Practice Plan Guidelines. Available at: http://www.cms.org/uploads/CollabPracticePlan.pdf.

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