Collaborative practice agreements defined
For more than a decade, written collaborative practice agreements ("CPAs") between Illinois nurses and physicians have allowed advanced practice registered nurses ("APRNs") to engage in the practice of nursing. While nurse practitioners ("NPs") have enjoyed this battle-tested arrangement which allows them to practice in an independent and unregulated manner, some legislators seem to think it is in the best interest of Illinois residents to take away this privilege and not allow APRNs to independently practice otherwise licensed acts. To further this agenda, some legislators are unilaterally terminating the CPAs between physicians and NPs and significantly limiting their authority to practice independently. Senate Bill 3262 is one such proposed measure. State Representative Christine Winger quickly reacted to Senate Bill 3262 and encouraged her constituents to contact their legislators and oppose the bill. As legislative efforts like Senate Bill 3262 move forward, understanding the Illinois direct supervision regulations is increasingly important for nurse practitioners as they prepare for unprecedented changes set to take effect in January.
In Illinois , a CPA is defined by statute as a "written agreement that provides for a collaborative relationship between a license [NP] and one or more partners of a defined specialty who, in accordance with the Medical Practice Act of 1987, are authorized to prescribe." 225 ILCS 65/7.5(B) (emphasis added). The statutory definition of a CPA specifically requires a defined specialty. While the Act does not provide further detail on what constitutes a defined specialty, the Illinois Department of Financial and Professional Regulation ("Division") issued guidance in November 2015 that states "A nurse practitioner, as part of their practice may include a specialty within their competence or area of practice, however, they must have a collaborative agreement in place for the specific specialties they practice." It is important to note that an NP may enter into a CPA with a physician in a specialty for which the NP is not defined. This may be especially useful for NPs who want to enter into CPAs with a specific physician for a limited period of time while the NP is obtaining his or her specialty certification.
Collaborative practice agreement requirements in Illinois
The Nurse Practice Act (225 ILCS 60/65) governs nurse practitioners (NPs) in Illinois. Unlike many other states, Illinois does not have prescriptive authority independent of supervision. Illinois requires NPs to practice under a collaborative agreement with a physician. This agreement must be in writing, with required contents including: written descriptions of NP scope of practice, physician duties, a general plan for managing the clinical practices of the NP, and protocols for referral to secure appropriate supervision from the physician. (225 ILCS 60/65(d)(13) and 225 ILCS 65/65(e)). Physicians need to be comfortable with NP practice guidelines and protocols, and should review and supervise health care and treatment provided by NPs acting on their behalf. These rules are enforced by the Illinois Department of Financial and Professional Regulation. Physicians in Illinois are able to supervise four NP’s in a collaborative relationship. Licensure renewals require evidence of 50 hours of continuing medical education with two hours of education related to the prescribing of controlled substances.
Agreement responsibilities of each collaborator
A key characteristic of collaborative practice agreements is the delegation of certain responsibilities and duties by the collaborating physician to the nurse practitioner based upon the standards established by the Illinois Nurse Practice Act and related administrative rules. According to the Nurse Practice Act, the collaborating relationship formed through the agreement shall include the following: These standards serve as the framework for the collaboration. Both the nurse practitioner and the supervising physician are expected to operate within their professional authority and to abide by the specific terms of the collaborative agreement. Additionally, they must be aware of the differences between their respective boards, particularly in the administrative rules governing each group. Any disputes that arise over the interpretation of the collaborative agreement are to be reviewed by the relevant boards identified in Section 95)b-5) and 65) of the Nurse Practice Act. Further disputes are subject to a determination by the Medical Practice Board. Pursuant to the Nurse Practice Act, the nurse practitioner and the collaborating physician are responsible for the following: The supervision and control of the nurse practitioner are limited by the terms set forth in the collaborative agreement. Such control may not be interpreted to be absolved by the public or private contracting entity. When it comes to contractual obligations, the individual parties must separately pursue action, if necessary.
How practitioners and physicians can establish a collaborative practice agreement
Steps to Understand Illinois Nurse Practitioner Collaborative Practice Agreements
Before an Illinois nurse practitioner can create a collaborative practice agreement, there are several steps to take.
First, the NP needs to decide on a collaborating physician. Often NPs establish a practice where they already know physicians they can collaborate with. However, physicians who have mutual referrals, or are located in the same office, are not considered collaborating physicians. A suitable collaborative partner is typically a supervising physician of the same specialty as the NP’s area of specialization or one who belongs to the same medical group as the NP.
It’s best to draft a collaborative practice agreement that is made up of standard elements and that meets the requirements set forth by the Illinois Department of Financial and Professional Regulation (IDFPR). The IDFPR typically requires that an NP include the name, address, and license number of the collaborating physician. A statement is also required which clearly states the NP and collaborating physician have entered into a collaborative relationship for purposes of prescriptive authority. The collaborative practice agreement should also establish the geographic proximity where the collaboratively relationship takes place.
Nurse practitioners in Illinois must practice under written and signed collaborative agreements. The NP must keep this agreement for seven years. An exception to the seven-year rule is when an NP has changed jobs – in which case the NP can destroy the previous agreement after five years have passed.
How collaborative practice agreements affect patient care
Illinois nurse practitioner collaborative practice agreements (CPAs) have a significant effect on the quality of patient care and access to healthcare services across the state. CPAs outline the working relationship between nurse practitioners (NPs) and physicians, facilitating a level of practice autonomy that is reflective of their skills and experience, while ensuring physician oversight.
By removing practice hurdles, such as mandatory physician oversight in certain circumstances, CPAs can promote greater efficiency in service delivery. For instance, low-acuity patients who may have otherwise visited an onerous emergency room are able to receive the care they need at a nurse-managed clinic. The result is a higher quality of care for patients, as well as a reduction in the burden placed on the healthcare system . This is particularly important in underserved and high-need areas of the state that are particularly sensitive to healthcare access challenges.
CPAs are also a boon for collaborating physicians, as they can help them expand their reach – increasing the number of patients they are able to serve and decreasing wait times and other barriers to care. Additionally, NPs are steadily assuming more complex clinical duties, increasing the demand for physicians’ supervision. CPAs allow physicians to maintain advanced oversight of multiple NPs across various locations, enhancing patient care.
The impact of these agreements on patient care will continue to increase in the years to come, as demand for healthcare services rises. By allowing NPs to operate with a higher degree of clinical independence, CPAs will support improved healthcare access by freeing up physicians to treat additional patients on a fixed schedule.
Concerns of collaborative practice agreements
Many non-doctor owned practices in Illinois are finding it difficult to obtain Illinois NP collaborative practice agreements. When a nurse practitioner or advanced practice nurse approaches a physician with whom they have worked to obtain a collaborative agreement, the doctor may believe that a collaborative agreement is not necessary or even know that one is required. Additionally, a physician may decline to be a supervisory physician for an advanced practice nurse and may not be comfortable with an advanced practice nurse being independent in the clinic. Most physicians who do complete Illinois NP collaborative practice agreements must be found through word of mouth.
Practicing on their own, though, is simply too much risk for many nurse practitioners, leading them to understand that finding a collaborative practice agreement with a physician is critical. Even nurse practitioners with their own practices require collaboration agreements due to licensure laws.
The first thing an NP should do is search for collaborative practice agreement physicians in their area. Many NP clinics find physicians through personnel connections, so NPs should ask around. Doctors will also learn about NPs who may be looking for collaborative practice agreements from other physicians. NPs may also be able to locate physicians in professional associations. Directories may also be available to NPs through associations, hospital staff services, the state medical board, or even from word of mouth.
While physician salaries are falling, being a collaborative agreement physician carries risks that many physicians aren’t comfortable assuming. To practice at the same level as an NP, most physicians find they must get business insurance on top of their medical malpractice insurance. This can be cost-prohibitive, particularly in certain specialties. For example, an obstetrician may not want to do collaborative practice agreements with NPs who would then be able to provide obstetrical services while billing for physician levels of service-urging a patient to sue. While this is unlikely to actually happen, some doctors fear the outcome.
The NP should also make sure that their practice qualifies for collaborative practice agreements. Not all NPs qualify because they do not provide evidenced based care in their practices. For example, if an NP owns a medical spa, they may not qualify for a collaborative practice agreement because the care is not a medically necessary service. Similarly, if an NP owns a natural supplement store, they would not be providing evidenced-based care.
To become eligible for a collaborative practice agreement, a nurse practitioner must provide evidence-based care. He must also perform ten patient charts which reflect their proficiency and ability to provide evidenced-based care. In the first year of practice, an NP is limited to 150 NPs. In the second and third years of practice, he must have between 51 and 149 patients. It is only after the third year that an NP may go up to a full 400 patients. The NP must also complete two CE hours during the first three years of practice and each year after that in order to remain qualified.
NPs at non-physician owned businesses that have physician collaborators must also be employed by an organization, and not an independent NP practitioner.
Collaborative practice’s future in Illinois
The future of collaborative practice in Illinois is uncertain. Although the state legislature formally enacted permission for the use of nurse practitioner collaborative practice agreements in 2004, the use of these agreements has not dramatically increased in Illinois due to legislative budget constraints and the high cost of liability insurance for collaborative arrangements. As patient needs and practice trends continue to evolve, however, collaborative agreements may become more widely used. As pressure continues to mount for Illinois lawmakers to increase reimbursement rates for nurse practitioners, collaborative practice will likely be similarly scrutinized. If more insurance plans and government programs grant personalized plans of care greater consideration, collaborative practice agreements may become more widely accepted .
Perhaps the most critical aspect of collaborative practice agreements is the defined scope of practice. Illinois does not currently have any regulations defining this scope. Further, while the Illinois Nursing Practice Act does provide a general definition of collaboration, these definitions are subject to interpretation. The Illinois Department of Professional and Financial Regulation, Division of Professional Regulation appears to be developing over the coming years a more clear and uniform definition of collaboration. Many states lead the way in identifying such a definition, and Illinois should consider following their example. Until then, collaborative practice agreements are a solution that Illinois advanced nursing practice has to increase patient access to care.