Collaborative Practice Agreement
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Practitioners Responsible for the Delegation of Drug Therapy Management
John Malloy, M.D., physician and James Guyer, M.D., Medical Director, RiverStone Health
Pharmacist Authorized to Dispense Drugs and Engage in Drug Therapy Management
Carla D. Cobb, Pharm.D., Board Certified Psychiatric Pharmacist, Clinical Pharmacist
Specialist, RiverStone Health
Pharmacist’s Privileges for Drug Therapy Management
a.
Types of Diseases and Drugs Involved
The pharmacist is authorized to:
i.
Perform drug therapy management with patients who have psychiatric illnesses.
These disease states may include, but are not limited to, depression, bipolar
disorder, schizophrenia, anxiety disorders, personality disorders, attention deficit
hyperactivity disorder, and substance abuse.
ii.
Perform drug therapy management with the medications commonly used to treat
the above listed disorders. These medications may include, but are not limited to,
antidepressants,
mood
stabilizers,
anticonvulsants,
antipsychotics,
anxiolytics/hypnotics, and medications used to treat the adverse effects of such
medications.
b.
Types of Drug Therapy Management Allowed
The pharmacist is authorized to:
i.
Obtain pertinent information about the patient’s medical condition including signs
and symptoms of illness, past and present medications, adverse effects, and
medication adherence.
ii.
Monitor vital signs and administer rating scales when appropriate.
iii.
Initiate a medication in the authorized therapeutics categories.
iv.
Continue a medication or renew an expired prescription of a medication for stable
medical conditions that were previously prescribed by a RiverStone Health
provider.
v.
Modify a medication including alteration of a dose or dosing interval or
conversion to a more suitable drug to improve efficacy, ensure availability,
decrease toxicity, or decrease cost of a medication.
vi.
Discontinue medications causing drug interactions or adverse reactions.
vii.
Order laboratory tests relevant to authorized medication management.
viii. Educate patients concerning disease states, medication benefits and potential
adverse effects and toxicity, and medication adherence.
c.
Procedures and Methods, Decision Criteria, and Plan the Pharmacist is to Follow
a.
The patient will schedule an appointment with the pharmacist. During the
appointment the pharmacist will interview the patient and obtain vital signs or
administer rating scales, as appropriate. Medication adjustments will be made, if
necessary. The patient will be educated about the disease state and medications.
The visit will be documented in the patient’s medical record. The medical record
and any interventions will be reviewed and co-signed by the practitioner.
b.
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The pharmacist may write prescriptions to be filled at the Community Health
Center (CHC) pharmacy at RiverStone Health. CHC pharmacy will be provided
with a copy of this agreement. Prescriptions written or refilled will be
documented in the patient’s medical record.
Method for Documenting Decisions
Decisions and the rational of such decisions made by the pharmacist will be documented in the
patient’s medical record within 24 hours following each intervention. This will be a part of the
patient’s permanent medical record and will be considered confidential information. The
practitioner will review and co-sign all documentation by the pharmacist.
Method for Reporting Adverse Events to the Practitioner
All adverse effects or toxicities identified by the pharmacist will be documented in the patient’s
medical record. The practitioner will review and co-sign all such documentation. In case of a
severe adverse event, the patient will be immediately referred to a practitioner or other
appropriate medical provider
Method for Practitioner to Monitor Clinical Outcomes
The pharmacist will document clinical outcomes in the patient’s medical record. The
documentation will include the evaluation of the response of signs and symptoms, vital signs,
results of rating scales, and other objective data when available. The practitioner will review and
co-sign all such documentation.
Provisions for Practitioner to Override the Protocol Agreement
The practitioner has the authority to override the protocol agreement whenever the practitioner
deems such action is necessary or appropriate for a specific patient. The practitioner will
document such actions in the patient’s medical record.
Provision to Cancel the Agreement by Written Notification
Either party may terminate this agreement upon thirty (30) days written notice to the other party.
Effective Date
This agreement will be effective from July 1, 2010 for a period of one year.
Annual Review
The annual review, renewal, and revision, if necessary, of this agreement, will be completed by
June 30, 2011.
Records Address
Collaborative practice records will be maintained in the patient’s medical record at RiverStone
Health, 123 S. 27th St., Billings, Montana 59101.
Obtaining the Patient’s Written Consent
Written informed consent will be obtained from the patient prior to participating in drug therapy
management. The original signed copy of the consent will be maintained in the patient’s medical
record.
Medical Records
The medical records of collaborative practice will be maintained for a period of at least seven
years.
Carla Cobb, Pharm.D.
Date
John Malloy, M.D.
Date
James Guyer, M.D.
Date
Submit to:
Montana Board of Pharmacy
301 South Park Ave., 4th Floor
P.O. Box 200513
Helena, MT 59620-0513