1. State Practice Act Changes Pharmacist Prescriptive Authority Trends
Krystalyn Weaver, PharmD
VP, Policy & Operations
National Alliance of State Pharmacy Associations

2. Definitions of Prescribing Activities
Activity
Definition
Select
When pharmacotherapy is necessary, and after review of an individual patient’s history, medical status, presenting symptoms, and current drug regimen, the clinician chooses the best drug regimen among available therapeutic options.
Initiate
After selecting the best drug therapy for an individual patient, the clinician also determines the most appropriate initial dose and dosage schedule and writes an order or prescription.
Monitor
Once drug therapy is initiated, the clinician evaluates response, adverse effects, therapeutic outcomes, and adherence to determine if the drug, dose, or dosage schedule can be continued or needs to be modified.
Continue
After monitoring the current drug therapy of a patient, the clinician decides to renew or continue the same drug, dose, and dosage schedule.
Modify
After monitoring a patient’s drug therapy, the clinician decides to make an adjustment in dose and/or dosage schedule, or may add, discontinue, or change drug therapy.
Administer
Regardless of who initiates a patient’s drug therapy, the clinician gives the drug directly to the patient, including all routes of administration.
Carmichael JM, et al. Collaborative Drug Therapy Management by Pharmacists.
Pharmacotherapy. 1997;17(5):

3. Continuum of Pharmacist Prescriptive Authority
Collaborative Prescribing
Patient-Specific CPA
Population-Specific CPA
Statewide Protocol
Unrestricted (Category-Specific)
Autonomous Prescribing
Most Restrictive
Least Restrictive
Adams AJ, Weaver KK. The Continuum of Pharmacist Prescriptive Authority. Annals of Pharmacotherapy. June 2016.

4. Collaborative Practice Agreements
Formal Relationship
Delegation
Negotiated Conditions

5. Collaborative agreements are not essential for collaborative care
Collaborative agreements increase efficiency

6. Collaborative Prescribing
Patient-
Specific
CPAs
Population-Specific
CPAs

7. Chronic Care Management Public Health Services
Acute Care
Medication Adherence/ Formulary Management

8. A Note on Standing Orders
Product Specific CPA or Statewide Protocol?

9. Continuum of Pharmacist Prescriptive Authority
Collaborative Prescribing
Patient-Specific CPA
Population-Specific CPA
Statewide Protocol
Unrestricted (Category-Specific)
Autonomous Prescribing
Most Restrictive
Least Restrictive
Adams AJ, Weaver KK. The Continuum of Pharmacist Prescriptive Authority. Annals of Pharmacotherapy. In Press.

10. Autonomous Prescribing
Statewide Protocol
Unrestricted (Category-Specific)
Does not require a partnering prescriber
Issued by an authorized body of the state (e.g. take it or leave it)
Apply to patient populations
Promotes consistency in service provided across state
Used for conditions that do not require a specific diagnosis
Does not require a partnering prescriber
No restriction on authority (except for clinical guidelines)
No explicit restriction on patient populations
Promotes consistency in service provided at pharmacy
Used for conditions that do not require a specific diagnosis

11. Addressing Concerns Training Patient Safety Conflict of Interest
Fragmentation of Care

12. Prevalence
Of pharmacist prescribing authority in the US

13. Most Restrictive Least Restrictive
States with CPA laws
Limited to inpatient settings
Prevent initiation of medications
Allows initiation of medications in outpatient settings
Patient-specific
Limited to one prescriber
Allow multiple prescribers
Population-specific
Most Restrictive
Least Restrictive

14. Prescribing Under a CPA
Based on data collected by NASPA (updated Dec 2015) AK WA ME MT ND NH MN VT OR MA WI ID SD NY RI WY MI CT PA IA NJ NV NE OH IN DE UT IL WV MD CA CO VA
KS* MO DC KY NC TN OK AZ NM AR SC HI AL GA MS TX LA FL
Initiation and modification of therapy allowed
Only modification of therapy allowed
*Kansas is awaiting rule promulgation. Their law is vague regarding services and calls for rules to be issued

15. Prescribing Under a CPA in the Community
Based on data collected by NASPA (updated Dec 2015) AK WA ME MT ND NH MN VT OR MA WI ID SD NY RI WY MI CT PA IA NJ NV NE OH IN DE UT IL WV MD CA CO VA
KS* MO DC KY NC TN OK AZ NM AR SC HI AL GA MS TX LA FL
Initiation of therapy allowed in the community pharmacy setting
*Kansas is awaiting rule promulgation. Their law is vague regarding services and calls for rules to be issued

16. Population-Specific CPA in the Community
Based on data collected by NASPA (updated Dec 2015) AK WA ME MT ND NH MN VT OR MA WI ID SD NY RI WY MI CT PA IA NJ NV NE OH IN DE UT IL WV MD CA CO VA
KS* MO DC KY NC TN OK AZ NM AR SC HI AL GA MS TX LA FL
Initiation of therapy allowed in the community pharmacy setting
*Kansas is awaiting rule promulgation. Their law is vague regarding services and calls for rules to be issued

17. Prescribing Under a Statewide Protocol or Unrestricted (Category-Specific) Authority
Based on data collected by NASPA (updated March 2016) AK WA ME MT ND NH MN VT OR MA WI ID SD NY RI WY MI CT PA IA NJ NV NE OH IN DE UT IL WV MD CA CO VA
KS* MO DC KY NC TN OK AZ NM AR SC HI AL GA MS TX LA
One statewide protocol for pharmacists
Three or more statewide protocols for pharmacists FL
*Kansas is awaiting rule promulgation. Their law is vague regarding services and calls for rules to be issued

18. Best Practices
As identified by key stakeholders

19. Support for Broad Collaborative Authority
Policy Considerations from the National Governors Association
Enact broad collaborative practice provisions that allow for specific provider functions to be determined at the provider level rather than set in state statute or through regulation.
Evaluate practice setting and drug therapy restrictions to determine whether pharmacists and providers face disincentives that unnecessarily discourage collaborative arrangements.
Examine whether CPAs unnecessarily dictate disease or patient specificity.

20. Collaborative Practice Workgroup
Convened by the National Alliance of State Pharmacy Associations

21. Workgroup Recommendations
Included in Laws and Regulations
Framework should be flexible to facilitate innovation in care delivery
Decided by Individual Providers
Safeguards should be established to ensure optimal patient care

22. Building Consensus on Statewide Protocols
Step 1
Stakeholder meeting
Step 2
Develop consensus based document containing:
Recommendations for the model elements of statewide protocol authority
A template for what elements should be included in the clinical protocol used for pharmacist prescribing under a statewide protocol
Step 3
Develop model language based on the consensus based model elements
Step 4
Develop sample/model protocols that could be used as a ready-to-go resource for states enacting statewide protocols

23. Reimagining Scope of Practice Provider responsibility
Patient-Specific CPA
Population-Specific CPA
Statewide Protocol
Unrestricted (Category-Specific)
Legal flexibility
Provider responsibility

24. State Practice Act Changes Pharmacist Prescriptive Authority Trends
Krystalyn Weaver, PharmD
Vice President, Policy & Operations
National Alliance of State Pharmacy Associations