1. The Nuts and Bolts of NP/physician Collaborative Agreements in Long Term Care
Deb Bakerjian PhD, RN, FNP
Thomas Caprio MD
Charles Crecelius MD, PhD
Karyn Leible RN, MD, CMD
Mary Pat Rapp PhD, RN, FAANP
Barbara Resnick PhD, RN, FAANP, FAAN

2. Purpose of this Session
This session is designed to help interested nurse practitioners and physicians design a collaborative practice agreement.  The essential components of an agreement will be reviewed followed by small group sessions where the attendees will evaluate the strengths and weaknesses of a variety of agreements.

3. Disclosures
The authors have no disclosures related to this presentation.

4. Learning Objectives
Identify the essential components of a nurse practitioner/physician collaborative practice agreement.
Recognize the strengths and weaknesses of 4-6 different collaborative agreements.
Develop the basic components of a  collaborative practice agreement for a personal practice.

5. Background
A MDA & GAPNA formed Ad Hoc workgroup to explore collaboration
Resulted in white paper published in both JA MDA & Geriatric Nursing
Several areas of agreement in the areas of collaboration
Feedback indicated many NPs & physicians are unsure of how to develop collaborative agreements

6. What is Collaboration?
The regulatory definition of ‘‘collaboration’’ is defined at 42 CFR (c): Collaboration is a process in which a NP works with one or more physicians to deliver health care services within the scope of the practitioner’s expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as provided by the law of the State in which the services are performed.

7. What is Collaboration? contin
In the absence of State law governing collaboration:
Collaboration is a process in which NP has relationship with one or more physicians to deliver health care services.
Such collaboration is evidenced by documenting NPs’ scope of practice and indicating relationships with physicians to deal with issues outside their scope of practice.
NPs must document this collaborative process with physicians.

8. What is Collaboration? contin
Collaboration The regulatory definition of ‘‘collaboration’’ is defined at 42 CFR (c): The collaborating physician does not need to be present with the NP when the services are furnished or to make an independent evaluation of each patient who is seen by the NP.’’

9. Collaboration in Practice
Continuing professional relations that fosters best patient outcomes through optimal use of individual skills
Dynamic process dependent upon skills & competencies of NP & physician
Collaboration is an iterative process involving:
Trust, excellent communication
Mutual goals & common direction in practice
Collaboration requires each party sharing responsibility for care

10. Why Collaborate Expands the overall expertise of the practice
Collaboration between NPs & physicians shown to improve resident outcomes

11. State Regulations
NP scope of practice is regulated at the state level and varies widely
Pearson report is excellent source providing data about state regulations and variations
NPs & physicians must know their state regulations prior to constructing a collaborative agreement
Federal regulation may be more restrictive than states in some cases

12. Collaboration Best Practices
Ideal attributes of NP/physician collaboration include collegiality, respect, & patient-centered care
NPs & physicians skills are unique to their training
Skills often overlap
Complex, high-acuity patient care requires distinct skills of both
Delegated tasks/skills must be mutually understood & agreed upon
Strong collaborative practices shares common goals & key principles
Clinical competency
Consistent care delivery processes
sound problem-solving & decision-making skills

13. Collaborative Agreements
Collaborative agreement is a contract between NP & physician
Based on mutual agreement and understanding of unique skills
Can be either procedurally or process based
Should not be too specific – this is a key area where practices may face problems

14. Processes Should be broad based
Should be realistic and relevant to specific practice
Based on scope of practice allowed in state and within the education, training & experience of NP
Mutually agreed upon

15. Procedures Procedures outline steps to accomplish a specific task
Procedures should be applicable to everyone within a practice (not just the NP)
Procedures are best conceived as a guideline and not specific steps or rigid rules
Preamble to procedures should indicate they are guidelines unless otherwise specified

16. The Road to Collaborative Agreements
Assemble the facts
Members of the team
Credentials of the team
Experience of the team
Practice description
Number & types of patients
Settings/location of patients
Support services available
Payer sources

17. The Road continued
Determine the skills, competencies of the NP & physician based on the practice needs
Determine the responsibilities of the physician & NP
Expectation of patient visits
Expectation of documentation
On call, vacation coverage
Discuss/describe communication process
What about emergencies

18. The Road continued Standardized care processes Resources Documentation
EHR
Paper
Semi-structured forms
Billing processes
Responsibility of clinicians
Communicating work completed to billers

19. The Road continued Confidentiality & non-disclosure Non-compete clause
HIPAA compliance
Non-disclosure of proprietary data
Non-compete clause
Specific non-compete language
Length of time of non-complete

20. The Road continued Provision of resources Payment Office space
Exam rooms (if also seeing office patients)
Telephone, computer, beeper
Payment
Hourly
Annual salary
Fee for services
Benefits, vacations, continuing education

21. The Road continued Audits Know state requirements
Audits should be reciprocal
Ex: 10% of both NP & physician charts will be audited to determine degree that protocols are followed
Ex: Each quarter 20 NP& 20 physician charts will be randomly pulled to review as a team. Each quarter may focus on a different care process or disease process

22. Types of collaborative agreements

23. Typical Collaborative Agreement Sections
General Information (parties)
Names, degrees, licenses
Competencies
Practice description
Settings & conditions of care covered by agreement
Nursing home, office, hospital, patient home
Routine, urgent, emergency
Documentation, medical records
Clinical practice standards, guidelines

24. Collaborative Agreement - Functions
Responsibilities/functions of NP & physician
Evaluation & management
Prescribing (categories & conditions agreed upon)
Procedures (i.e., wound debridement, surgery, IVs, lacerations, EKG, GT replacement, etc.)
Diagnostics
Emergency care
Referrals
Physician back-up, vacation coverage
Consultation requirements

25. Collaborative Agreement
Limitations on authority
Review of care (if required)
Chart review
Signatures needed
Timing of review/signatures
Mutual audits
Duration of agreement

26. Types of Collaboration
NP employed by physician
NP & physician both employed by group or NH (staff model)
NP contracted (self-employed) or employed by NP Practice
NP employed by NH
NP employed by payer (Evercare)
NP in specialty collaborative practice & consulting

27. GROUP WORK- 30 min Break in to 6 small groups
Each group has a vignette and facilitator
Discuss the issues related to the scenario
Be prepared to report out to the rest of the group on your recommendations or questions

28. Wrap UP
Review issues
Answer questions
Other

29. Reference The Pearson Report- Annual state survey of NP Regulations