Medication Therapy Management Clinical Pharmacist Collaborative Practice Agreement

DuPage Medical Group

Medication Therapy Management Clinical Pharmacist Collaborative Practice Agreement

Revised: 11/11/2010

Purpose

The Illinois Pharmacy Practice Act allows licensed pharmacists to offer Medication Therapy Management (MTM) services which may include patient care functions authorized by a physician licensed to practice medicine in all its branches under specified conditions in a standing order from the physician (225 ILCS 85/3(aa)).

The purpose of this document is to outline the patient care activities in which pharmacists practicing in the MTM Clinics at DuPage Medical Group (DMG) may participate. These privileges must be re-requested and this document must be signed annually.

Our Mission

The clinical pharmacists at DMG seek to enhance patient care through the provision of clinical pharmacy services that in collaboration with other health care providers improves patient overall health, wellbeing, and health outcomes. The clinical pharmacists also aim to provide a quality teaching and research environment for pharmacy students and residents to advance the profession of pharmacy.

Clinical Pharmacist Qualifications

The clinical pharmacists at DMG have received a doctorate of pharmacy degree and have also completed a pharmacy residency program or have equivalent experience. They are licensed as registered pharmacists by the State of Illinois and some have completed additional certifications. The clinical pharmacists are also faculty at Midwestern University Chicago College of Pharmacy. Fourth year pharmacy students and pharmacy residents will participate in patient care activities under the supervision of the clinical pharmacists.

MTM Clinic Services

The clinical pharmacists, pharmacy residents, and students will follow this collaborative practice agreement and the MTM clinic policies and procedures while practicing at DMG. Clinical pharmacy services are only available to patients who are under the care of a DMG physician and have been referredby their DMG physicianusing the MTM Clinic Referral Form in the EMR.

MTM clinic visits will include a comprehensive medication review to identify any medication related problems. The clinical pharmacist will assist in resolving medication access andadherence issues, address patients’ medication related questions, and monitor foradverse effects and drug interactions. The clinical pharmacist will then collaborate with the supervising physician to facilitate any suggested medication changes. The supervising physician is the referring physician if he/she is onsite at the time the patient is seen by the MTM pharmacist. If the referring physician is not onsite at that time, then the supervising physician is the covering MD for the referring physician.

Scope of Practice

For all MTM Clinic referrals, the clinical pharmacist shall have the authority to:

Access and update patient medical records and important health information that may influence clinical decisions.
Evaluate patients’ therapeutic regimens based on efficacy, safety, tolerability, drug interactions, cost, patient preference, and professionally recognized clinical guidelines.
Interview patients and perform targeted physical assessments as deemed necessary to assess response to therapy.
Provide patient education regarding disease states, self monitoring, and medication therapy.
Order laboratory tests to aid in monitoring drug therapy.
Provide verbal and/or written recommendations to the supervising physician pertaining to drug-related problems, cost effective therapy, and/or professionally recognized treatment guidelines.
Evaluate patient response to pharmacological interventions and provide verbal and/or written recommendations for modification of drug therapy as clinically indicated.
Schedule and complete MTM clinic follow-up as deemed necessary by the clinical pharmacist.
Refill maintenance medications for chronic conditions such as diabetes, hyperlipidemia, hypertension, hypothyroidism, GERD, etc. in accordance with the DMG MTM Clinic Policies and Procedures. Refills of controlled substances in schedules II-V will require physician authentication.
Document patient encounters in the electronic medical record. Documentation must be completed within 48 hours of the encounter and should be in accordance with the DMG MTM Clinic Policies and Procedures.
Discharge patients from MTM clinic in accordance with the DMG MTM Clinic Policies and Procedures.

Additional Responsibilities of the Clinical Pharmacist

Precept and provide direct patient care opportunities for pharmacy residents and students.
Maintain responsibilities as faculty members of Midwestern University Chicago College of Pharmacy.
Perform administrative functions to maintain DMG clinical pharmacy services.
Conduct quality assurance assessments for clinical pharmacy services.
Coordinate clinical research and perform outcomes assessments for clinical pharmacy services.
Respond to drug information requests from other healthcare providers.
Provide staff education and development as requested.

Clinical Pharmacist Information

Name:______

IL License Number & Exp Date: ______

Certifications: ______

Certifying Organization: ______

Certification Expiration Date: ______

Primary Practice Site: ______

Contact Number: ______

Under this agreement, ______will work with the collaborating physicians in an active practice to deliver clinical pharmacy services to the patients of DuPage Medical Group as described in this collaborative practice agreement.

I, THE UNDERSIGNED, AGREE TO THE TERMS AND CONDITIONS OF THIS WRITTEN COLLABORATIVE AGREEMENT.

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Clinical Pharmacist SignatureDatePhysician’s SignatureDate

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