Expanding the Pharmacy: How Collaborative Practice Agreements Can Improve Patient Outcomes

Collaborative practice agreements (CPAs) are a great way for pharmacists to more fully use their education and skills while also providing patients with continuity and convenience of care, which can lead to better health outcomes. CPAs create formal relationships between pharmacists and physicians or other providers that allow pharmacists to assume responsibility for specific patient care functions that are otherwise beyond their typical scope of practice.

Jacqueline Eide, PharmD, owner of Goldendale Pharmacy in Goldendale, Washington, practices in a rural area with limited options for health care services. “CPAs allow me to expand access to care to my community for a variety of services,” she said. “This can help improve patient outcomes, especially for conditions like shingles, strep throat, urinary tract infections [UTIs], the flu, and [COVID-19], where timely intervention is critical.”

Eide was one of the first pharmacists in the state of Washington to implement the Clinical Community Pharmacist CPAs in 2016. | image credit: vladico / stock.adobe.com

Eide explained that CPAs place an emphasis on providing preventive care, including vaccines, hormonal contraception, and naloxone, which can help decrease health care costs by preventing unnecessary emergency department visits. “We can also evaluate and treat patients for tobacco cessation, yeast infections, [and] cat bites and provide essential emergency refills of medications, such as insulin and inhalers, which are potentially lifesaving medications,” she said.

In addition, Eide noted that some CPAs can improve outcomes for patients with chronic conditions by allowing pharmacists to initiate or modify therapy for patients with diabetes, asthma, hypertension, or high cholesterol. “This enables a provider to collaborate with the pharmacy to refer patients for regular follow-up [with] a pharmacist [for] more touchpoints to ensure efficacy and optimal patient outcomes,” she said.

Eide pointed out that CPAs expand the role of pharmacists on the health care team, enhance relationships between providers, and often lead to “more job satisfaction for pharmacists in community settings by allowing them to use a wider variety of their skills and knowledge.”

READ MORE: Collaborative Care Approaches Can Improve Provider Shortage, Pharmacist-Physician Relationships

In August 2023, Delaware became the last state to pass legislation allowing pharmacists and prescribers to enter into CPAs. “The prescriber is most often a physician, although a growing number of states are allowing for CPAs between pharmacists and other prescribers such as nurse practitioners,” wrote Lauren Howell, PharmD.¹ Howell went on to write that although “the recognition of CPAs in all states is a huge win for pharmacy, it is imperative that national standardization occurs so that pharmacists, as drug experts, can practice at the top of their license to improve health outcomes for patients.”

“You can look at a CPA from the highest level,” said Anthony Pudlo, PhD, MBA, MSHIA, CEO of the Tennessee Pharmacists Association. “A CPA is an opportunity for a physician or other prescribers to recognize that a pharmacist can truly manage a medication regimen and a patient’s therapy through a formalized structure. This is an amazing thing to witness.”

As states have allowed for such formalized arrangements, “we have all learned from each other,” Pudlo said. “I and my counterparts in other states are helping to expand what the structure of a CPA should look like because some state CPAs are very structured and onerous at times while other states have slightly broader flexibility to those structures.”

Pudlo noted that he is excited that more states continue to look at ways to make it easier for a pharmacist to enter into an agreement with another provider.

“The successes that have come from these CPAs—in some states for many years—have allowed our profession to be on full display and even allowed for more states to see true independent authority granted to pharmacists so they can actively pursue similar medication-management services,” he said.

Moreover, Pudlo encouraged pharmacists to stay up to date on their professional liability insurance through whatever carrier they have. “In addition, it is important to verify with the carrier that such opportunities to act and make adjustments to a CPA are covered under their liability,” he said. “There are potentially more liability concerns for a pharmacist to actively manage a patient’s regimen.”

Some states, however, restrict a pharmacist’s ability to perform certain actions, such as placing limitations on initiating therapy vs adjusting current therapy and on what type of patients can be served, according to Pudlo. “Are you only actively [caring for] a patient who is seen by that provider, or are you able to actively help on a wider community or county level for preventive care?” he asked.

Eide uses a variety of CPAs, including for vaccines, travel medicine, tobacco cessation, emergency and adherence fills, epinephrine autoinjectors, OTC therapy, vitamin B injections, hormonal contraception, and testing and treatment for COVID-19, influenza, and streptococcal pharyngitis as well as for treatment for bee stings, animal bites, burns, conjunctivitis, nail fungus, shingles, UTIs, and vaginal yeast infections.

Besides having extensive experience with CPAs, Eide was one of the fi rst pharmacists in the state of Washington to implement the Clinical Community Pharmacist CPAs in partnership with the Washington State Pharmacy Association and Washington State University in 2016.

“It has been wonderful to be a part of this movement and to see the impact it has on our team, our patients, and our community,” Eide said. “Nothing beats the rewarding feeling of being able to intervene and assess a patient, saving them both time and money.”

For example, Eide said she has treated multiple patients with UTIs when they come to the pharmacy to buy the UTI and yeast infection relief product AZO “to help get them through the weekend” until they can be seen by their primary care physician the next week. “AZO can cover symptoms while the infection worsens and for which early intervention is much better. But with our CPAs, the pharmacist is able to initiate a consult on the spot and get the patient treated then and there.”

Eide also provides testing and therapy for influenza and COVID-19 “so we can initiate treatment for a high-risk patient who otherwise would have to drive over an hour to an [emergency department] or forgo treatment completely,” she said.

In the past, Pudlo has signed CPAs with providers that allow him to write a laboratory order or initiate therapy for various types of injectables. “Overall, I always felt my agreements were a positive experience,” he said. “As a pharmacist, you have that patient right in front of you. But the moment you tell patients that you no longer can help them and that they need to go back to their provider, it...makes it more cumbersome for the patient in the health care system. To me, having a pharmacist be engaged with a CPA helps that overall patient experience as [patients] navigate the health care system.”

Pudlo noted that several studies have found that CPAs improve patient outcomes. “By flexing our clinical knowledge, it is proven we improve clinical outcomes, whether for various primary care disease states like diabetes or hypertension or for more complex and rare diseases, some of which are infectious diseases,” he said.

A literature review of pharmacists engaged in CPAs in the United States found that these pharmacists had a positive impact on achieving desired clinical and financial goals and that providers were satisfi ed with pharmacist involvement. However, lack of reimbursement was a common barrier for pharmacists.²

Another study looked at 2 clinical pharmacists in a rural family medicine clinic who provided comprehensive medication management for 207 patients with diabetes and found significant improvements in the goal attainment rates for hemoglobin A_1C, blood pressure, and appropriate statin therapy. “[These data add] to the evidence supporting the integration of clinical pharmacists into primary care clinics to improve patient outcomes related to diabetes,” wrote the study authors.³

A survey of Canadian community pharmacists and family physicians in Newfoundland and Labrador found that both groups “agree that collaborative practice can positively affect patient outcomes and would like more collaboration opportunities,” wrote the authors. Both groups also agreed that major obstacles to collaboration were lack of time and compensation and the need to interact with multiple pharmacists and physicians.⁴

Pudlo noted that clinical improvements can be achieved in outpatients, inpatients, and even in the specialty pharmacy arena. “There are ample opportunities to [care for] patients when you have the [ability] to adjust drug dosing and monitor and adjust for [adverse] effects,” Pudlo said.

Pudlo added that he expects CPAs to become obsolete eventually and replaced by a pharmacist having independent authority to prescribe without the need for direct oversight from a physician. Going a step further, there has been a movement in Idaho, Alaska, and Iowa toward what has been described as the pharmacy standard-of-care model, “whereby if you have the training, the know-how, the comfort, and the capabilities to provide the true standard of care, you are granted that authority,” Pudlo said. He added that a law passed in Tennessee in 2024 is a miniature version of this concept, allowing pharmacists to independently manage certain disease states and prescribe select drug classes provided the pharmacist abides by the standards of care.

Meanwhile, CPAs are a good starting point for pharmacists to become comfortable with these broadening opportunities, Pudlo said. But challenges remain. “We hear all the time that pharmacists are appreciative of their increased authority, but how do they get compensated for the additional responsibilities?” he asked, adding that conversations are happening at the state level and the national level on ways to compensate pharmacists for these services, perhaps through a state’s Medicaid program or through commercial health plans.

“A collaborative agreement is the easiest way to start understanding how you would bill for such services because it is clearly defined in a CPA,” Pudlo said.

Like Pudlo, Eide is hopeful that more states will give pharmacists a standard-of-practice prescriptive authority to allow independent prescribing. “This would reduce some of the barriers to implementation of these patient-care services and improve access to care,” she said. “While CPAs have helped allow pharmacists to practice at the top of their license, we must recognize that pharmacists are highly educated and have consistently proven their ability to deliver safe, high-quality care.”

Eide added that pharmacists are more than qualified to independently prescribe and meet the health care needs of patients and to address critical gaps in the health care system.

To read these stories and more, download the PDF of the Total Pharmacy April issue here.

References

1. Howell L. Collaborative practice now allowed in all 50 states. American Pharmacists Association blog. December 7, 2023. Accessed February 20, 2025. https://www.pharmacist.com/CEO-Blog/collaborative-practice-now-allowed-in-all-50-states

2. Kerelos T, Gangoo-Dookhan T. The impact of pharmacists engaged in collaborative practice agreements in the United States. J Pharm Pract. 2023;36(6):1480-1484. doi:10.1177/08971900221116684

3. Prudencio J, Kim M. Diabetes-related patient outcomes through comprehensive medication management delivered by clinical pharmacists in a rural family medicine clinic. Pharmacy (Basel). 2020;8(3):115. doi:10.3390/pharmacy8030115.

4. Kelly DV, Bishop L, Young S, Hawboldt J, Phillips L, Keough TM. Pharmacist and physician views on collaborative practice: findings from the community pharmaceutical care project. Can Pharm J (Ott). 2013;146(4):218-226. doi:10.1177/1715163513492642