The Nuts and Bolts of NP/MD Collaborative Agreements in Long

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
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
• The authors have no disclosures related to this
Learning Objectives
• Identify the essential components of a nurse
practitioner/physician collaborative practice
• Recognize the strengths and weaknesses of 46 different collaborative agreements.
• Develop the basic components of
a collaborative practice agreement for a
personal practice.
• 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
• Feedback indicated many NPs & physicians are
unsure of how to develop collaborative
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
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
What is Collaboration? contin
The 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
– 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
• Should be broad based
• Should be realistic and relevant to specific
• Based on scope of practice allowed in state
and within the education, training &
experience of NP
• Mutually agreed upon
• 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
– 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
Typical Collaborative Agreement
• General Information (parties)
– Names, degrees, licenses
– Competencies
• Practice description
• Settings & conditions of care covered by
– 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
• The Pearson Report- Annual state survey of NP

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