Physician's Guide to Medicine - Collaborative Practice Arrangements

Purpose: This rule defines collaborative practice arrangement terms and delimits geographic area; methods of treatment; review of services; and drug/device dispensing or distribution pursuant to prescription.

(1) For the purpose of these rules, the following definitions shall apply:

(A) Advanced practice nurse - a registered professional nurse who is also an advanced practice nurse as defined in section 335.016 (2), RSMo;

(B) Collaborative practice arrangements - refers to written agreements, jointly agreed upon protocols, or standing orders, all of which shall be in writing, for the delivery of health care services; and

(C) Registered professional nurse - a registered professional nurse as defined in section 335.016(9), RSMo, who is not an advanced practice nurse.

(2) Geographic Areas

(A) The collaborating physician in a collaborative practice arrangement shall not be so geographically distanced from the collaborating registered professional nurse or advanced practice nurse as to create an impediment to effective collaboration in the delivery of health care services or the adequate review of those services.

(B) The use of a collaborative practice arrangement by an advanced practice nurse who provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons shall be limited to practice locations where the collaborating physician, or other physician designated in the collaborative practice arrangement, is no further than fifty (50) miles by road, using the most direct route available, from the collaborating advanced practice nurse if the advanced practice nurse is practicing in federally designated health professional shortage areas (HPSAs). Otherwise, in non HPSAs, the collaborating physician and collaborating advanced practice nurse shall practice within thirty (30) miles by road of one another. The provision of the above specified health care services pursuant to a collaborative practice arrangement shall be limited to only an advanced practice nurse.

(C) An advanced practice nurse who desires to enter into a collaborative practice arrangement to provide health care services that include the diagnosis and treatment of acutely or chronically ill or injured persons at a location where the collaborating physician is not continuously present shall practice at the same location with the collaborating physician for a period of at least one (1) calendar month before the collaborating advanced practice nurse practices at a location where the collaborating physician is not present. The provision of the above specified health care services pursuant to a collaborative practice arrangement shall be limited to only an advanced practice nurse.

(3) Methods of Treatment

(A) The methods of treatment and the authority to administer, dispense, or prescribe drugs, delegated in a collaborative practice arrangement between a collaborating physician and collaborating registered professional nurse or advanced practice nurse shall be within the scope of practice of each professional and shall be consistent with each professional´s skill, training, education, and competence.

(B) The collaborating physician shall consider the level of skill, education, training, and competence of the collaborating registered professional nurse or advanced practice nurse and ensure that the delegated responsibilities contained in the collaborative practice arrangement are consistent with that level of skill, education, training, and competence.

(C) The methods of treatment and the authority to administer, dispense, or prescribe drugs delegated to the collaborating registered professional nurse or advanced practice nurse in a collaborative practice arrangement shall also be consistent with the scope of practice of the collaborating physician.

(D) Guidelines for consultation and referral to the collaborating physician or designated health care facility for services or emergency care that is beyond the education, training, competence, or scope of practice of the collaborating registered professional nurse or advanced practice nurse shall be established in the collaborative practice arrangement.

(E) The methods of treatment and authority to administer, dispense, or prescribe drugs delegated to the collaborating registered professional nurse or advanced practice nurse in a collaborative practice arrangement shall not be further delegated to any other person except that the individuals identified in section 338.095 and 338.198, RSMo may communicate prescription drug orders to a pharmacist.

(F) The methods of treatment, including any authority to administer or dispense drugs, delegated in a collaborative practice arrangement between a collaborating physician and a collaborating registered professional nurse shall be delivered only pursuant to a written agreement, jointly agreed-upon protocols, or standing orders that shall describe a specific sequence of orders, steps, or procedures to be followed in providing patient care in specified clinical situations.

(G) The methods of treatment, including any authority to administer, dispense, or prescribe drugs, delegated in a collaborative practice arrangement between a collaborating physician and a collaborating advanced practice nurse shall be delivered only pursuant to a written agreement, jointly agreed upon protocols, or standing orders that are specific to the clinical conditions treated by the collaborating physician and collaborating advanced practice nurse.

(H) The collaborative practice arrangement between a collaborating physician and a collaborating registered professional nurse or advanced practice nurse shall be signed and dated by the collaborating physician and collaborating registered professional nurse or advanced practice nurse before it is implemented, signifying that both are aware of its content and agree to follow the terms of the collaborative practice arrangement. The collaborative practice arrangement and any subsequent notice of termination of the collaborative practice arrangement shall be in writing and shall be maintained by the collaborating professionals for a minimum of eight (8) years after termination of the collaborative practice arrangement. The collaborative practice arrangement shall be reviewed and revised as needed by the collaborating physician and collaborating registered professional nurse or advanced practice nurse.

(I) Methods of treatment delegated and authority to administer, dispense, or prescribe drugs shall be subject to the following:

(1) The physician retains the responsibility for ensuring the appropriate administering, dispensing, prescribing and control of drugs utilized pursuant to a collaborative practice arrangement in accordance with all state and federal statutes, rules, or regulations;

(2) All labeling requirements outlined in Section 338.059, RSMo shall be followed;

(3) Consumer product safety laws and Class B container standards shall be followed when packaging drugs for distribution;

(4) All drugs shall be stored according to the United States Pharmacopeia (USP) recommended conditions;

(5) Outdated drugs shall be separated from the active inventory;

(6) Retrievable dispensing logs shall be maintained for all prescription drugs dispensed and shall include all information required by state and federal statutes, rules, or regulations;

(7) All prescriptions shall conform to all applicable state and federal statutes, rules, or regulations and shall include the name, address, and telephone number of the collaborating physician and collaborating advanced practice nurse;

(8) A registered professional nurse shall not, under any circumstances, prescribe drugs;

(9) An advanced practice nurse shall not, under any circumstances, prescribe controlled substances. The administering or dispensing of a controlled substance by a registered professional nurse or advanced practice nurse in a collaborative practice arrangement shall be accomplished only under the direction and supervision of the collaborating physician, or other physician designated in the collaborative practice arrangement, and shall only occur on a case-by-case determination of the patient´s needs following verbal consultation between the collaborating physician and collaborating registered professional nurse or advanced practice nurse. The required consultation and the physician´s directions for the administering or dispensing of controlled substances shall be recorded in the patient´s chart and in the appropriate dispensing log. These recordings shall be made by the collaborating registered professional nurse or advanced practice nurse and shall be co-signed by the collaborating physician following a review of the records;

(10) An advanced practice nurse or registered professional nurse in a collaborative practice arrangement may only dispense starter doses of medication to cover a period of time for seventy-two (72) hours or less with the exception of Title X family planning providers or publicly funded clinics in community health settings that dispense medications free of charge. The dispensing of drug samples, as defined in 21 U.S.C. Section 353 © (1), is permitted as appropriate to complete drug therapy; and

(11) The medications to be administered, dispensed, or prescribed by a collaborating registered professional nurse or advanced practice nurse in a collaborative practice arrangement shall be consistent with the education, training, competence, and scopes of practice of the collaborating physician and collaborating registered professional nurse or advanced practice nurse.

(J) When a collaborative practice arrangement is utilized to provide health care services for conditions other than acute self-limited or well defined problems, the collaborating physician, or other physician designated in the collaborative practice arrangement, shall see the patient for evaluation and approve or formulate the plan of treatment for new or significantly changed conditions as soon as is practical, but in no case more than two (2) weeks after the patient has been seen by the collaborating advanced practice nurse or registered professional nurse.

(K) Nothing in these rules shall be construed to permit medical diagnosis of any condition by a registered professional nurse pursuant to a collaborative practice arrangement.

(4) Review of Services

(A) In order to assure true collaborative practice and to foster effective communication and review of services, the collaborating physician, or other physician designated in the collaborative practice arrangement, shall be immediately available for consultation to the collaborating registered professional nurse or advanced practice nurse at all times, either personally or via telecommunications;

(B) The collaborating physician shall review the work, records, and practice of the health care delivered pursuant to a collaborative practice arrangement at least once every two (2) weeks. This review shall be documented by the collaborating physician. This subsection shall not apply to the situation described in subsection (4) (E) below or during the time the collaborating physician and collaborating advanced practice nurse are practicing together as required in subsection (2) © above;

© If a collaborative practice arrangement is used in clinical situations where a collaborating advanced practice nurse provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the collaborating physician shall be present for sufficient periods of time, at least once every two (2) weeks, except in extraordinary circumstances that shall be documented, to participate in such review and to provide necessary medical direction, medical services, consultations, and supervision of the health care staff. In such settings the use of a collaborative practice arrangement shall be limited to only an advanced practice nurse and the physician shall not enter into a collaborative practice arrangement with more than three (3) full-time equivalent advanced practice nurses;

(D) The collaborating physician and collaborating registered professional nurse or advanced practice nurse shall determine an appropriate process of review and management of abnormal test results which shall be documented in the collaborative practice arrangement;

(E) In the case of collaborating physicians and collaborating registered professional nurses or advanced practice nurses practicing in settings which provide care to well patients or to those with narrowly circumscribed conditions in public health clinics or community health settings that provide population based health services limited to immunizations, well child care, human immunodeficiency virus (HIV) and sexually transmitted disease care, family planning, tuberculosis control, cancer and other chronic disease and wellness screenings, services related to epidemiologic investigations and prenatal care, review of services shall occur as needed and set forth in the collaborative practice arrangement. If the services provided in such settings include diagnosis and the initiation of treatment of any other disease or injury, then the provisions of subsection (4) © shall apply;

(F) The process and documentation of review shall be on