The Nuts and Bolts of NP/physician Collaborative

Agreements in Long Term CareDeb Bakerjian PhD, RN, FNP

Thomas Caprio MDCharles Crecelius MD, PhDKaryn Leible RN, MD, CMD

Mary Pat Rapp PhD, RN, FAANPBarbara Resnick PhD, RN, FAANP, FAAN

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.

Disclosures

• The authors have no disclosures related to this presentation.

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.

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

What is Collaboration?

The regulatory definition of ‘‘collaboration’’ is defined at 42 CFR 410.75 (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.

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.

What is Collaboration? contin

CollaborationThe regulatory definition of ‘‘collaboration’’ is defined at 42 CFR 410.75 (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.’’

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

Why Collaborate

• Expands the overall expertise of the practice• Collaboration between NPs & physicians

shown to improve resident outcomes

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

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

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

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

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

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

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

The Road continued

• Standardized care processes• Resources• Documentation– EHR– Paper– Semi-structured forms

• Billing processes– Responsibility of clinicians– Communicating work completed to billers

The Road continued

• Confidentiality & non-disclosure– HIPAA compliance– Non-disclosure of proprietary data

• Non-compete clause– Specific non-compete language– Length of time of non-complete

The Road continued

• Provision of resources– Office space– Exam rooms (if also seeing office patients)– Telephone, computer, beeper

• Payment– Hourly– Annual salary– Fee for services– Benefits, vacations, continuing education

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

TYPES OF COLLABORATIVE AGREEMENTS

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

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

Collaborative Agreement

• Limitations on authority• Review of care (if required)– Chart review– Signatures needed– Timing of review/signatures

• Mutual audits• Duration of agreement

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

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

Wrap UP

• Review issues• Answer questions• Other

Reference

• The Pearson Report- Annual state survey of NP Regulationshttp://www.pearsonreport.com/