Collaborating in Massachusetts
Requirements for collaborations for NPs and PAs in Massachusetts
State Regulations for Nurse Practitioners
General
- In which category does the state fall: NP independent practice, transition to independence, or collaboration required?
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- Transition to practice for prescribing. An APRN or psychiatric nurse mental health clinical specialist shall have independent practice authority to issue written prescriptions and medication orders and order tests and therapeutics without the supervision if the nurse practitioner or psychiatric nurse mental health clinical specialist has completed not less than 2 years of supervised practice following certification from a board-recognized certifying body.
- The board may allow an APRN or psychiatric nurse mental health clinical specialist to exercise such independent practice authority upon satisfactory demonstration of not less than 2 years of alternative professional experience; provided, however, that the board determines that the APRN or psychiatric nurse mental health clinical specialist has a demonstrated record of safe prescribing and good conduct consistent with professional licensure obligations required by each jurisdiction in which the nurse practitioner or psychiatric nurse mental health clinical specialist has been licensed.
Delegation Authority/Process
- Is an agreement required?
- Yes, for prescriptive practice.
- What form of agreement is required and what are the requirements for the substance of the agreement?
- The written guidelines shall
- 1. identify the supervising physician and APRN;
- 2. include a defined mechanism for the delegation of supervision to another physician including, but not limited to, the duration and scope of the delegation;
- 3. describe the nature and scope of the APRN's prescribing practice;
- 4. identify the types of medication(s) to be prescribed, specify any limitations on medications to be prescribed; and describe the circumstances in which physician consultation or referral is required;
- 5. describe the use of established procedures for the treatment of common medical conditions which the nurse may encounter;
- 6. include provisions for managing emergencies;
- 7. include a defined mechanism and time frame to monitor prescribing practices;
- 8. include protocols for the initiation of intravenous therapies and Schedule II drugs;
- 9. specify that the initial prescription of Schedule II drugs must be reviewed within 96 hours;
- 10. specify that the guidelines must be kept on file in the workplace and be reviewed and re executed every two years; and
- 11. Include special protocols and specifications regarding intravenous therapies and Schedule II drugs.
- Where must the agreement be stored?
- Agreement must be kept on file “in the workplace.”
- Does the agreement need to be filed with the state?
- Are there requirements to file the agreement after the initial filing?
- Who must sign the agreement?
- Both the supervising physician and APRN. CRNA guidelines do not need to be signed. CNP and PNMHCS guidelines shall be signed.
- How often must the agreement be reviewed/reauthorized?
- Agreement must be reviewed and re-executed every two years.
- What are the qualifications for the collaborating provider?
- Supervising Physician means a licensee holding an unrestricted full license in the Commonwealth of Massachusetts who:
- (a) has completed training in the United States approved by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) or in Canada approved by the Royal College of Physicians and Surgeons in Canada (RCPSC) in a specialty area appropriately related to the APRN's area of practice, is board certified in a specialty area appropriately related to the APRN's area of practice, or has hospital admitting privileges in a specialty area appropriately related to the APRN's area of practice. A physician who collaborates with a Certified Psychiatric Clinical Nurse Specialist shall have completed training in psychiatry approved by the ACGME, AOA or the RCPSC, or be Board certified in psychiatry; and
- (b) holds valid registration(s) to issue written or oral prescriptions or medication orders for controlled substances from the Massachusetts Department of Public Health and the U.S. Drug Enforcement Administration
- A CRNA, CNP or PNMHCS who holds:
- a valid Registered Nurse license in good standing issued by the Board; and
- advanced practice authorization issued by the Board that it is in the same clinical category as the person being supervised or advanced practice authorization in an area appropriately related to the practice of the person being supervised; and
- a controlled substance registration issued by the U.S. Drug Enforcement Administration, or the Department of Public Health, or both, for a minimum of one year; and either:
- a combination of supervised practice for a minimum of two years plus independent practice authority for a minimum of one year; or
- three years of independent practice authority.
- What are the qualifications for the NP?
- Is an alternate collaborating physician required?
- The agreement needs to include a defined mechanism for the delegation of supervision to another physician. A specific individual does not need to be identified.
Collaboration Requirements
- Are there ratios/limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements?
- Is there an express requirement to review a certain number/percentage of charts?
- A supervising physician shall review the NP’s prescriptive practices per written guidelines without prescribed numbers or frequency.
- Is there a requirement to meet and, if so, how often and how?
- Are there proximity/location-specific requirements?
- No requirement, but proximity should be “taken into account.”
- Are there location-specific requirements?
- Is remote supervision allowed/are there limitations on remote supervision?
- Physician and NP filing requirements
- No additional requirements beyond filing the collaboration agreement.
- What are the prescription requirements?
- A prescription issued by a nurse practitioner or psychiatric nurse mental health clinical specialist under shall include the name of the supervising nurse practitioner who has independent practice authority, the supervising psychiatric nurse mental health clinical specialist who has independent practice authority or the supervising physician with whom the nurse practitioner or psychiatric nurse mental health clinical specialist developed and signed mutually agreed upon guidelines.
- What are the requirements for controlled substance prescribing?
- Massachusetts effectively considers all prescription drugs to be controlled substances. Any prescription drugs not identified in Schedule II-V fall within Schedule VI. A MCSR is required to prescribe controlled substances in MA. There are additional requirements for controlled substances prescribing in 105 Mass. Code Regs. 700.003.
- When an APRN registers with the Department of Public Health Drug Control Program (DCP) for prescriptive practice as an APRN with independent prescriptive practice authority, and they are responsible for ordering or storing controlled substances, they need a MA Controlled Substance Registration (MCSR) at each site address. Please refer to the DCP requirements in 105 CMR 700.00 and 105 CMR 721.
- Prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, a licensee must:
- (a) Thoroughly assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and a check of the online Prescription Monitoring Program;
- (b) Discuss the risks and benefits of the medication with the patient;
- (c) Enter into a Pain Management Treatment Agreement with the patient that shall appropriately address drug screening, pill counts, safe storage and disposal and other requirements based on the patient's diagnosis, treatment plan, and risk assessment;
- (d) Supply a Letter of Medical Necessity as required by the Board of Registration in Pharmacy that includes the patient's diagnosis and treatment plan, verifies that other pain management treatments have failed, indicates that a risk assessment was performed and that the licensee and the patient have entered into a Pain Management Treatment Agreement; and
- (e) Document (a) through (d) in the patient's medical record.
- An APRN authorized to prescribe medication is prohibited from prescribing drugs in Schedules II, III, and IV for personal use. Except in an emergency, such APRN is prohibited from prescribing Schedule II drugs to a member of his or her immediate family, including spouse or equivalent, a parent, a child, sibling, parent-in-law, son/daughter-in-law, brother/sister-in-law, step- parent, step-child, step sibling and any other relative residing in the same household.
Sources for Reference
State Regulations for Physician Assistants
General
- Is the supervising physician responsible for PA’s patients?
- Yes. The services of the physician assistant are considered the services of their supervising physician.
Delegation Authority/Process
- Is an agreement required?
- Yes, a written protocol is required.
- Written guidelines are required for prescriptive practice. A supervising physician shall sign prescriptive practice guidelines only with those PAs for whom he is able to provide supervision, taking into account factors including, but not limited to, geographical proximity, practice setting, volume and complexity of the patient population, and the experience, training and availability of the supervising physician and the PA(s).
- What form of agreement is required and what are the requirements for the substance of the agreement?
- Where a PA is involved in the performance of major invasive procedures, such procedures shall be undertaken under specific written protocols, available to the Board upon request, which have been developed between the supervising physician and the PA and which specify, among other things the level of supervision the service requires, e.g., direct (physician in room), personal (physician in building), or general (physician available by telephone).
- A physician who supervises a PA engaged in prescriptive practice shall do so in accordance with written guidelines mutually developed and agreed upon with the PA. In all cases, the written guidelines shall:
- 1. identify the supervising physician;
- 2. include a defined mechanism for the delegation of supervision to another physician including, but not limited to, duration and scope of the delegation;
- 3. specifically describe the nature and scope of the PA’s practice;
- 4. identify the types and classes of medication(s) to be prescribed, specify any limitations on medications to be prescribed, indicate the quantity of any medications, including initial dosage limits and refills, and describe the circumstances in which physician consultation or referral is required;
- 5. include a defined mechanism to monitor prescribing practices, including documentation of review by the supervising physician at least every three months;
- 6. include protocols for the initiation of intravenous therapies and Schedule II drugs;
- 7. specify the frequency of review of initial prescriptions or changes in medication of controlled substances; any prescription or medication order issued by a physician assistant for a Schedule II controlled substance, shall be reviewed by his or her supervising physician, or by a temporary supervising physician designated, within 96 hours after its issuance;
- 8. specify the types and quantities of Schedule VI medications which may be ordered by the PA from a drug wholesaler, manufacturer, laboratory or distributor for use in the practice setting in question;
- 9. identify and specify any limitations on the initiation or renewal of prescriptions which are not within the ordinary scope of practice for the specific work setting in question, but which may be needed to provide appropriate medical care;
- 10. Frequency of medication reviews by the physician assistant and his or her supervising physician;
- 11. The quantity of any medication to be prescribed by a physician assistant, including initial dosage limits and refills
- Additional clarification available here
- Where must the agreement be stored?
- No requirement, but subject to Board review upon request.
- Does the agreement need to be filed with the state?
- Are there requirements to file the agreement after the initial filing?
- Who must sign the agreement?
- Supervising physician and PA.
- How often must the agreement be reviewed/reauthorized?
- The written guidelines for prescriptive authority shall be reviewed annually, and dated and initialed by both the supervising physician and the PA at the time of each review. The guidelines may be altered at any time upon agreement by the supervising physician and PA; any such changes shall be initialed and dated by both parties.
- What are the qualifications for the supervising physician?
- A supervising physician must hold an unrestricted license to practice medicine in MA.
- For supervision of PAs with prescriptive practice, a supervising physician must also:
- 1. have completed ACGME-accredited, AOA accredited or accredited Canadian postgraduate medical training in a specialty area appropriately related to the PA’s area of practice, is board-certified in a specialty area appropriately related to the PA’s area of practice, or has hospital admitting privileges in a specialty area appropriately related to the PA’s area of practice;
- 2. hold valid registration(s) from the Massachusetts Department of Public Health and the DEA to issue written or oral prescriptions or medication orders for controlled substances;
- Is an alternate supervising physician required?
- Not required, but must temporarily delegate to a physician meeting the same qualifications in the event the supervising physician is unavailable. The name and scope of responsibility for the physician providing the temporary supervision must be readily ascertainable from the records kept in the ordinary course of business which are available to patients.
Supervision Requirements
- Are there ratios/limits on the number of PAs that a supervising physician may supervise?
- Is there an express requirement to review a certain number/percentage of charts?
- No but, the supervising physician should review the PA’s prescriptive practice at least every 3 months and provide ongoing direction to the PA regarding prescriptive practice, or, temporarily delegate such review and direction to another licensee holding an unrestricted full license in the Commonwealth who meets the requirements above.
- In circumstances in which the supervising physician has established a therapeutic regimen or other written protocol, the PA checks and records a patient's progress and reports the patient's progress to the supervising physician. Supervision is adequate if it permits a PA who encounters a new problem not covered by a written protocol or which exceeds established parameters to initiate a new patient care plan and consult with the supervising physician.
- Additional requirements apply for supervising PAs operating Fluoroscopic X-ray Systems.
- Is there a requirement to meet and, if so, how often and how?
- Are there proximity requirements?
- No requirement, but proximity should be considered.
- Are there location-specific requirements?
- Is remote supervision allowed?
- Yes, continuous but does not require the physical presence of the supervising physician.
- Are there patient notice requirements?
- PAs must inform each patient that he or she is a PA. A PA renders medical services only under the supervision of a full licensee, except in life-threatening emergencies when no licensee is available.
- The PA must wear a name tag which identifies him or her as a PA.
- Physician and PA filing requirements
- No additional forms are required.
- What are the prescription requirements?
- PAs must comply with general prescribing requirements. Additional requirements apply for PAs holding a temporary license.
- What are the requirements for controlled substance prescribing?
- Any prescription or medication order issued by a PA for a Schedule II controlled substance, shall be reviewed by his or her supervising physician, or by a temporary supervising physician within 96 hours after its issuance.
- A PA may order only Schedule VI controlled substances from a drug wholesaler, manufacturer, distributor or laboratory, and only in accordance with the written guidelines developed with his or her supervising physician. A PA may sign only for sample Schedule VI controlled substances received by or sent to the practice setting by a pharmaceutical representative.
Sources for Reference
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