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      Collaborating in Missouri

      Requirements to successfully collaborate in Missouri

      State Regulations for Nurse Practitioners

      Delegation Authority/Process

      • Is an agreement required?
        • Yes, a written collaborative practice arrangement is required.
      • What form of agreement is required?
        • The written collaborative practice arrangement shall contain at least the following provisions:
          • (1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the advanced practice registered nurse;
          • (2) A list of all other offices or locations besides those listed in subdivision (1) of this subsection where the collaborating physician authorized the advanced practice registered nurse to prescribe;
          • (3) A requirement that there shall be posted at every office where the advanced practice registered nurse is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an advanced practice registered nurse and have the right to see the collaborating physician;
          • (4) All specialty or board certifications of the collaborating physician and all certifications of the advanced practice registered nurse;
          • (5) The manner of collaboration between the collaborating physician and the advanced practice registered nurse, including how the collaborating physician and the advanced practice registered nurse will:
            • (a) Engage in collaborative practice consistent with each professional’s skill, training, education, and competence;
            • (b) Maintain geographic proximity, except the collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of twenty-eight days per calendar year for rural health clinics as defined by P.L. 95-210[i], as long as the collaborative practice arrangement includes alternative plans as required in paragraph (c) of this subdivision. This exception to geographic proximity shall apply only to independent rural health clinics, provider-based rural health clinics where the provider is a critical access hospital as provided in 42 U.S.C. Section 1395i-4, and provider-based rural health clinics where the main location of the hospital sponsor is greater than fifty miles from the clinic. The collaborating physician is required to maintain documentation related to this requirement and to present it to the state board of registration for the healing arts when requested; and
            • (c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;
          • (6) A description of the advanced practice registered nurse’s controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the nurse to prescribe and documentation that it is consistent with each professional’s education, knowledge, skill, and competence;
          • (7) A list of all other written practice agreements of the collaborating physician and the advanced practice registered nurse;
          • (8) The duration of the written practice agreement between the collaborating physician and the advanced practice registered nurse;
          • (9) A description of the time and manner of the collaborating physician’s review of the advanced practice registered nurse’s delivery of health care services. The description shall include provisions that the APRN shall submit a minimum of 10% of the charts documenting the APRN’s delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every 14 days; and
          • (10) The collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review every fourteen days a minimum of twenty percent of the charts in which the APRN prescribes controlled substances. The charts reviewed under this subdivision may be counted in the number of charts required to be reviewed under subdivision (9).
          • (11) Guidelines for consultation and referral to the collaborating physician or designated health care facility for services or emergency care that is beyond the education, training, competence, or scope of practice of the APRN shall be established in the collaborative practice arrangement.
          • (12) The methods of treatment, including any authority to administer, dispense, or prescribe drugs, delegated in a collaborative practice arrangement between a collaborating physician and a collaborating APRN shall be delivered only pursuant to a written agreement, jointly agreed-upon protocols, or standing orders that are specific to the clinical conditions treated by the collaborating physician and collaborating APRN.
      • Where must the agreement be stored?
        • There is no requirement as to where to store the agreement. The collaborative practice arrangement and any subsequent notice of termination of the collaborative practice arrangement shall be in writing and shall be maintained by the collaborating professionals for a minimum of 8 years after termination of the collaborative practice arrangement.
      • Does the agreement need to be filed with the state?
        • No explicit requirement for filing.
      • Are there requirements to file the agreement after the initial filing (e.g., for updates or on a specified frequency)
        • No requirement
      • Who must sign the agreement?
        • Nurse Practitioner and Collaborating Physician.
      • How often must the agreement be reviewed/reauthorized?
        • At least annually and revised as necessary.
      • What are the qualifications for the collaborating provider?
        •  The collaborative practice arrangement shall be reviewed at least annually and revised as needed by the collaborating physician and collaborating APRN. Documentation of the annual review shall be maintained as part of the collaborative practice arrangement.
      • What are the qualifications for the NP?
        • Refer here for NP qualifications.
      • Is an alternate collaborating physician required?
        • No explicit requirement.
      • What are the qualifications for the collaborating provider (licensure, same scope, active practice in state, etc.)?
        • No explicit requirements other than physicians licensed in the state. For prescribing purposes, there is an explicit requirement that “the methods of treatment and the authority to administer, dispense, or prescribe drugs delegated in a collaborative practice arrangement between a collaborating physician and collaborating APRN shall be within the scope of practice of each professional and shall be consistent with each professional's skill, training, education, competence, licensure, and/or certification.”

      Collaboration Requirements

      • Are there ratios/limits on the number of NPs that a collaborator may supervise?
        • A collaborating physician shall not enter into a collaborative practice arrangement with more than six full-time equivalent APRNs, full-time equivalent licensed physician assistants, or full-time equivalent assistant physicians, or any combination thereof.
      • Is there an express requirement to review a certain number/percentage of charts?
        • The APRN shall submit a minimum of ten percent of the charts documenting the APRN’s delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every 14 days. The collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review every 14 days a minimum of 20% of the charts in which the APRN prescribes controlled substances. The controlled substance charts may be counted in the number of charts reviewed in the general pool of chart review.
        • The collaborating physician must produce evidence of the chart review upon request of the Missouri State Board of Registration for the Healing Arts.
        • This subsection shall not apply during the time the collaborating physician and collaborating APRN are practicing with the physician continually present.
      • Is there a requirement to meet and, if so, how often and how?
        • No specific requirement for regular meetings.
      • Are there proximity requirements?
        •  The collaborating physician in a collaborative practice arrangement shall not be so geographically distanced from the collaborating RN or APRN as to create an impediment to effective collaboration in the delivery of health care services or the adequate review of those services. AND
        • The following shall apply in the use of a collaborative practice arrangement by an APRN who provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons:
          • 1. No mileage limitation shall apply if the APRN is providing services utilizing telehealth in the care of the patient AND if the services are provided in a rural area of need. A “rural area of need” means any rural area of MO which is located in a health professional shortage area, which is an area designated by the Secretary of Health and Human Services. A list of Health professional shortage areas can be found here
          • 2. If the APRN is not providing services pursuant to the above, the collaborating physician and collaborating APRN shall practice within seventy-five (75) miles by road of one another; and
          • 3. Pursuant to Improved Access to Treatment for Opioid Addictions Act, an APRN collaborating with a physician who is waiver-certified for the use of buprenorphine, may participate in the "Improved Access to Treatment for Opioid Addictions Program" (IATOAP) in any area of the state and provide all services and functions of an APRN. A remote collaborating physician working with an on-site APRN shall be considered on-site for the purposes of IATOAP.

      • Are there location-specific requirements? (e.g., that collaborator must go to practice site at some frequency)

        • An APRN who desires to enter into a collaborative practice arrangement at a location where the collaborating physician is not continuously present shall practice together at the same location with the collaborating physician continuously present for a period of at least one (1) month before the collaborating APRN practices at a location where the collaborating physician is not present. It is the responsibility of the collaborating physician to determine and document the completion of the same location practice described in the previous sentence.

          • This shall not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100.

        • If a collaborative practice arrangement is used in clinical situations where a collaborating APRN provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the collaborating physician shall be present for sufficient periods of time, at least once every two (2) weeks, except in extraordinary circumstances that shall be documented, to participate in such review and to provide necessary medical direction, medical services, consultations, and supervision of the health care staff. If the APRN is providing telehealth services in a rural area of need, the collaborating physician may be present in person or the collaboration may occur via telehealth in order to meet the requirements of this section. Telehealth providers shall obtain the patient's or the patient's guardian's consent before telehealth services are initiated and shall document the patient's or the patient's guardian's consent in the patient's file or chart. All telehealth activities must comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 and all other applicable state and federal laws and regulations.

        • The collaborating physician, or other physician designated in the collaborative practice arrangement, shall be immediately available for consultation to the collaborating APRN at all times, either personally or via telecommunications.Is remote supervision allowed/are there limitations on remote supervision?

       

      Physician and NP filing requirements

      • What are the prescription requirements? (identifying collaborators on rxs, restrictions on certain categories of drugs that may or may not be scheduled [one area of concern right now is abortion-inducing medications], etc.)
        • All prescriptions must include the name, address and telephone number of the collaborating physician and APRN
        • Methods of treatment delegated and authority to administer, dispense, or prescribe drugs shall be subject to the following:
          • 1. The physician retains the responsibility for ensuring the appropriate administering, dispensing, prescribing, and control of drugs utilized pursuant to a collaborative practice arrangement in accordance with all state and federal statutes, rules, or regulations;
          • 2. All labeling requirements outlined in section 338.059, RSMo, shall be followed;
          • 3. Consumer product safety laws and Class B container standards shall be followed when packaging drugs for distribution;
          • 4. All drugs shall be stored according to the United States Pharmacopeia (USP), (2010), published by the United States Pharmacopeial Convention, 12601 Twinbrook Parkway, Rockville, Maryland 20852-1790, 800-227-8772; http://www.usp.org/ recommended conditions, which is incorporated by reference. This does not include any later amendments or additions;
          • 5. Outdated drugs shall be separated from the active inventory;
          • 6. Retrievable dispensing logs shall be maintained for all prescription drugs dispensed and shall include all information required by state and federal statutes, rules, or regulations;
          • 7. All prescriptions shall conform to all applicable state and federal statutes, rules, or regulations and shall include the name, address, and telephone number of the collaborating physician and collaborating APRN;
          • 8. The administering or dispensing of a controlled substance by an APRN who has not been delegated authority to prescribe in a collaborative practice arrangement shall be accomplished only under the direction and supervision of the collaborating physician, or other physician designated in the collaborative practice arrangement, and shall only occur on a case-by-case determination of the patient's needs following verbal consultation between the collaborating physician and collaborating APRN. The required consultation and the physician's directions for the administering or dispensing of controlled substances shall be recorded in the patient's chart and in the appropriate dispensing log. These recordings shall be made by the collaborating APRN and shall be cosigned by the collaborating physician following a review of the records;
          • 9. In addition to administering and dispensing controlled substances, an APRN may be delegated the authority to prescribe controlled substances listed in Schedule II hydrocodone and Schedules III, IV, and V of section 195.017, RSMo, in a written collaborative practice arrangement, except that, the collaborative practice arrangement shall not delegate the authority to administer any controlled substances listed in Schedule II hydrocodone and Schedules III, IV, and V of section 195.017, RSMo, for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. When issuing the initial prescription for an opioid controlled substance in treating a patient for acute pain, the APRN shall comply with requirements set forth in section 195.080, RSMo. Schedule II-hydrocodone and Schedule III narcotic controlled substance prescriptions shall be limited to a 120-hour supply without refill. An APRN may prescribe buprenorphine, a Schedule III controlled substance, for up to a 30-day supply without refill for patients receiving medication-assisted treatment for substance abuse disorders under the direction of the collaborating physician as described in sections 334.104 and 630.875, RSMo;
          • 10. An APRN may not prescribe controlled substances for his or her own self or family. Family is defined as spouse, parents, grandparents, great-grandparents, children, grandchildren, great-grandchildren, brothers and sisters, aunts and uncles, nephews and nieces, mother-in-law, father-in-law, brothers-in-law, sisters-in-law, daughters-in-law, and sons-in-law. Adopted and step members are also included in family;
          • 11. An APRN in a collaborative practice arrangement may only dispense starter doses of medication to cover a period of time for 72 hours or less with the exception of Title X family planning providers or publicly funded clinics in community health settings that dispense medications free of charge. The dispensing of drug samples, as defined in 21 U.S.C. section 353(c)(1), is permitted as appropriate to complete drug therapy;
          • 12. The collaborative practice arrangement shall clearly identify the controlled substances the collaborating physician authorizes the collaborating APRN to prescribe and document that it is consistent with each professional's education, knowledge, skill, and competence; and
          • 13. The medications to be administered, dispensed, or prescribed by a collaborating RN or APRN in a collaborative practice arrangement shall be consistent with the education, training, competence, and scopes of practice of the collaborating physician and collaborating APRN.
        • When a collaborative practice arrangement is utilized to provide health care services for conditions other than acute self-limited or well-defined problems, the collaborating physician, or other physician designated in the collaborative practice arrangement, shall examine and evaluate the patient and approve or formulate the plan of treatment for new or significantly changed conditions as soon as is practical, but in no case more than 2 weeks after the patient has been seen by the collaborating APRN. If the APRN is providing telehealth services in a rural area of need, the collaborating physician, or other physician designated in the collaborative practice arrangement, may conduct the examination and evaluation required by this section via live, interactive video or in person. Telehealth providers shall obtain the patient's or the patient's guardian's consent before telehealth services are initiated and shall document the patient's or the patient's guardian's consent in the patient's file or chart. All telehealth activities must comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 and all other applicable state and federal laws and regulations.
      • What are the requirements for controlled substance prescribing?
        • The board of nursing may grant a certificate of controlled substance prescriptive authority to an APRN who:
          • (1) Submits proof of successful completion of an advanced pharmacology course that shall include preceptorial experience in the prescription of drugs, medicines and therapeutic devices; and
          • (2) Provides documentation of a minimum of 300 clock hours preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor; and
          • (3) Provides evidence of a minimum of 1000 hours of practice in an APRN category prior to application for a certificate of prescriptive authority. The 1000 hours shall not include clinical hours obtained in the advanced practice nursing education program. The 1000 hours of practice in an advanced practice nursing category may include transmitting a prescription order orally or telephonically or to an inpatient medical record from protocols developed in collaboration with and signed by a licensed physician; and
          • (4) Has a controlled substance prescribing authority delegated in the collaborative practice arrangement under section 334.104 with a physician who has an unrestricted federal Drug Enforcement Administration registration number and who is actively engaged in a practice comparable in scope, specialty, or expertise to that of the advanced practice registered nurse.

      Sources for Reference

      • § 334.104 R.S.Mo.
      • § 334.108 R.S.Mo.
      • § 335.019 R.S.Mo.
      • § 335.175 R.S.Mo.
      • § 630.875 R.S.Mo.
      • 20 CSR 2200-4.200
      • Board of Nursing Reference