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Introduction to Collaborating

Introduction

This guide is your essential resource for making the most of your collaboration agreement. Whether you're new to this partnership or experienced, we've got you covered.

This document is a resource for practitioners and physicians who are navigating collaborations with Zivian. We provide a step-by-step approach to getting started, from the requirements for your first meeting to your ongoing monthly commitments. You'll also find an overview of the Zivian platform, which is at the heart of our collaboration, offering tools for logging, communication, and data sharing.

Our goal is to help you succeed in your collaboration. We hope this helps you not only understand the basics of a successful collaboration but also have practical insights on how to excel in your collaborative efforts.

Post-Signature Activities and Timeline

Here are your final requirements to start your collaboration! Now that you are signed, please be sure to review and complete each step as your agreement is active.

Step	Responsible Person	Timeline
Login to Zivian Profile and review executed agreement	Physician and Practitioner	Immediately
Submit additional documents to the state Medical Boards	Practitioner Initiated	Immediately
Set up billing in Zivian for direct payment to Physicians	Practitioner Initiated	Immediately
Schedule initial meeting	Practitioner or Physician Initiated	Within 5-days
Get added to new or existing Monthly Meetings facilitated by the Physician	Physician Initiated	Within first 7-days
Grant Electronic Health Record (EHR) access to Physician to review charts	Practitioner Initiated	Within first 14-days
Log notes, meeting information and complete first attestations	Physician Initiated	Within first calendar month
Continually meet monthly commitments required in the agreement	Physician and Practitioner	Ongoing

Initial & Ongoing Monthly Meetings

In this section, we focus on your initial meeting as well as the monthly meeting requirements, designed to enhance our collaboration. The meetings provide a structured framework for open discussions, in-depth clinical case reviews, educational exchanges, and professional development. This section provides guidance, examples and best practices on the process for the initial and ongoing meetings as well as potential discussion topics.

Matching Introductory Meeting

During the introductory meeting, Physicians may ask the following questions to assess a potential match. Practitioners may also ask similar questions to ensure the collaboration is mutually beneficial:

What is your clinical background and experience?

Have you completed any specialized training relevant to our practice or patient population?

Are you comfortable with telemedicine and virtual patient interactions?

Do you have any specific needs or expectations for this collaboration?

Are there any limitations or restrictions to your scope of practice that I should be aware of?

How and when will we communicate with each other?

What is your availability for virtual meetings and consultations?

What is your preferred method of communication (e.g., email, video calls, phone calls)?

How will you handle emergencies or situations that require immediate attention?

Do you have access to the necessary technology and resources for virtual care?

How will patient records and documentation be managed in a virtual collaboration?

What electronic health record (EHR) system or software will you use, and are you familiar with it?

Are you open to participating in quality improvement initiatives and peer reviews?

Are you open to receiving feedback and making improvements as needed?

What are the procedures in place for handling emergencies or unexpected situations during virtual care?

Initial Meeting as Collaborators

The initial meeting after a collaboration agreement is signed must happen in the first 7-days. This can be a telephone call, a video conference or in-person. During this meeting you will want to discuss the following:

Schedule or be added to existing monthly meeting

Establish communication schedule and preferences

Grant and Accept access to EHR for chart reviews

Monthly Meetings

Each collaboration is required to meet at least monthly and attest to the meeting. These meetings may be independent one on one or held in a group setting, which is recommended. The intention of these meetings was to give additional support, guidance, and education to the APCs. The below outlines a proposed agenda and potential topics of discussion:

Proposed Agenda:

Check-in and Welcome: Begin with a quick welcome and check-in to set a positive tone for the meeting.
Review of Patient Cases: Focus on patient care issues, clinical questions, etc. Discussing any urgent or high-priority patient cases that require immediate attention or coordination should not be held until the monthly meeting; rather these cases should be communicated in real time with the Physician.
Operational Questions: This can be questions around logistics such as med-mal providers, recommendations on EHRs, or thoughts around particular workflows or best practices.
Quick Updates: Share brief updates on recent medical developments, important guidelines, or essential information that everyone should be aware of.
Case Studies and Complex Cases: Analyze complex patient cases in detail, exploring diagnostic challenges, treatment options, and the rationale behind decisions made. This can enhance clinical reasoning skills

Additional Meeting Topics and Discussion Items

If you would like to discuss other things in your monthly meetings, here are some proposed topics to continuing fostering a good and supportive collaboration:

Topic	Options and Examples
Interdisciplinary Collaboration	Discuss strategies for collaborating effectively with other healthcare professionals, such as nurses, pharmacists, social workers, and specialists, to provide holistic patient care.
Evidence-Based Medicine (EBM)	Deepen the understanding of EBM principles and critically appraise the latest research studies and their relevance to clinical practice.
Ethical and Legal Considerations	Address ethical dilemmas, legal issues, and informed consent, especially in cases where decisions might be challenging.
Quality Improvement Projects	Plan and execute quality improvement projects aimed at enhancing patient outcomes, reducing errors, and optimizing workflow processes.
Patient Education and Counseling Techniques	Share techniques for effective patient education and counseling, especially for chronic disease management and lifestyle modifications.
Cultural Competency and Diversity Training	Explore strategies for providing culturally competent care and ensuring sensitivity to the diverse backgrounds and beliefs of patients.
Mental Health and Well-being	Discuss strategies for managing stress, compassion fatigue, and burnout in healthcare professionals. Promote mental health and well-being among team members.
Medical Technology and Innovations	Stay updated on the latest medical technologies, telemedicine trends, and innovations that can improve patient care and practice efficiency.
Continuing Education Plans	Develop continuing education plans based on their professional goals and areas of interest.
Patient Safety	Review patient safety protocols, adverse event reporting, and strategies for preventing medical errors.
Healthcare Policy and Advocacy	Discuss healthcare policy changes, advocacy efforts, and how healthcare providers can engage in shaping healthcare policy at local, state, or national levels.
Research and Publication Opportunities	Encourage team members to engage in research projects and explore opportunities for publication, if applicable.
Long-Term Planning	Develop long-term goals and strategic plans for the healthcare team, including expansion, specialization, or adopting new services.

Zivian Documentation & Compliance Requirements

Monthly you are required to login to your Zivian profile and submit your attestations. When logging in, you are required to review and confirm all requirements for each state you have a collaboration in. Failure to complete these monthly requirements may result in termination of your agreement and contract as its key to stay in compliance.

How to Access Your Collaborations in the Platform

Once your collaborative practice agreement has been signed, it will be added to the Zivian platform. You will be able to search for any collaborations that you have through Zivian by clicking the “Collaborations” button in the top left corner of the page.

The Collaborations view can be filtered by state, monthly attestation status, or collaboration status. If any of your collaborations have monthly requirements that still need to be completed, they will have an “Action Required” status next to them in the list.

To view details about each collaboration, click your collaborator’s name and you can view additional information about them. Here you will find your collaborator’s contact information, and your collaboration documents.

If you see any “action required” flags, that means that there is still an outstanding monthly requirement that has not been completed.

Once you have completed your monthly attestations, the “action required” flag will change to “completed”. You will also be able to download your attestation report and keep it with your other collaboration records in the “Documents” sections within your profile and under each individual collaboration.

All of your documents related to your collaboration and your relationship with Zivian can be found in the Documents section under the Profile tab on the left.

Chart Reviews

Depending on the state and the nature of the collaboration, different regulatory requirements may mandate a certain amount of chart reviews. These reviews play a pivotal role in ensuring patient safety, compliance with regulations, and the overall quality of healthcare services.

When reviewing health records, there are specific elements that must be assessed, as well as specific areas of focus as requested by enterprise clients. We have outlined below the key components that collaborating physicians may focus on during EHR reviews:

Medical History	Review the medical history, including previous illnesses, surgeries, and chronic conditions. Assess the accuracy of family and social histories, as they may impact treatment decisions.
Chief Complaint and Presenting Symptoms	Evaluate the chief complaint and present symptoms to understand the reason for the current healthcare encounter. Ensure that the documentation captures the patient's concerns and symptoms comprehensively.
Assessment and Diagnosis	Evaluate the assessment and diagnosis based on the available information. Verify that the diagnosis aligns with the patient's symptoms and/or documentation.
Documentation of Medical Necessity	Review the patient's medical history and the documented medical necessity for the prescription of controlled substances. Verify that the patient's condition meets the criteria for such treatment.
Quantity and Dosage	Ensure that the prescribed quantity and dosage of controlled substances are appropriate based on the patient's condition, medical history, and treatment guidelines.
Treatment and Follow-up Plans	Review the treatment plan, including medications, procedures, and referrals. Ensure that treatment options are evidence-based and aligned with best practices.
Progress Notes	Scrutinize progress notes for each encounter to assess the continuity of care and ensure that notes are comprehensive and provide a clear picture of the medical history.
Care Coordination and Referrals	Confirm that referrals to specialists or other healthcare providers are made when necessary. Ensure that care coordination efforts are well-documented.
Prescription Monitoring Programs (PDMPs)	In states with Prescription Drug Monitoring Programs, confirm that the healthcare professional is using these databases to check a patient's prescription history for controlled substances to prevent overuse or misuse.
Compliance with Regulations	Verify compliance with state and federal regulations governing telemedicine, EHR usage, and patient privacy (e.g., HIPAA)

Additional State Requirements Prior to Launch

Once signed and executed, you will receive a copy of your agreement through email as well as in your Zivian Account.

In some instances, you may be required to complete a few additional steps prior to the agreement being active. Those requirements differ state by state. In most cases, you must submit either a copy of the agreement or attest to having a valid agreement with the State Medical Board. Once completed, all proof of approval, attestation or submissions must be provided to Zivian via our secure Document Portal: Submit Documents Here

States that Require Approval

Alabama
Nevada
North Carolina

States that Require Additional Submissions

Texas
Kentucky
Georgia
Pennsylvania
Indiana
Florida
Tennessee

Be sure to review and ensure you complete all required steps for the states where our agreement is active. Failure to submit additional documents may result in the voiding of an agreement or the Board rejecting your application.

To view the specific state requirements, see the State Submission Process and Guidelines section at the end of this document.

State Submission Process and Guidelines

States with additional Submission Requirements - No formal Approval Required

Texas

APCs must following the process below as its an APC initiated request:

Log into your existing TMB portal account or create a new one.
Create a “New Supervision/Delegation”
Enter your collaborating physician’s information and click “Save” to attest to the relationship. This will create an “Incomplete Relationship” record.
Your collaborating physician will then select this record on their own TMB portal account and attest to your relationship. This will create your final collaborative relationship in the Portal.

If APCs are prescribing Schedule II controlled substances the physician will need to submit the prescription on behalf of the provider.

Kentucky

In order to be granted prescriptive authority in Kentucky, you are required to submit completed CAPA-CS and CAPA-NS Notification forms to the Board of Nursing via the Board of Nursing Nurse Portal.

Georgia

Georgia requires that you file a Collaborative Agreement with the Composite Medical Board to be granted prescriptive authority. The GCMB provides a checklist for filing the agreements found here.

The GCMB requires the submission be mailed to: 2 MLK Jr. Drive SE, East Tower, 11th Floor, Atlanta, GA 30334
You will need to submit a license verification to the GCMB that includes a copy of your current APRN license, copy of national certification (wallet card or letter with expiration date), and a copy of specialty training (if applicable).
The submission will need to include the Registration Form, Collaboration Agreement, Protocol Agreement, License Verification, and a $150 fee (payable to GCMB).

Mississippi

The physician licensee must submit the requested documentation via the online licensure gateway <https://gateway.msbml.ms.gov/>. If a physician wishes to collaborate under the Primary Care Extended Mileage language, the physician must submit a letter via the gateway identifying the name(s), address(es), and license numbers of any collaborative APRNs whose collaboration is the subject of the letter, and which also affirmatively states the physician has read the regulations and meets the extended mileage requirements as stated.

Pennsylvania

Pennsylvania requires that you file a Prescriptive Authority Collaborative Agreement form and provide them with your Collaboration Agreement. Instructions for this process can be found at the following link: Instructions.

The Prescriptive Authority Collaborative Agreement Form is available when you log in to your Pennsylvania Licensing System account.

Indiana

In order to prescribe independently, APRNs must submit an Advanced Practice Registered Nurse application. A detailed list of the requirements can be found at this link: APRN Application Requirements

- this application will need to be submitted to the Professional Licensing Agency. The Indiana Professional Licensing Agency site can be found at this link: Professional Licensing Agency.

Florida

Physicians must facilitate and submit a copy of the signed agreement along with the Protocol form found APRN Protocol Form.

This must be filed within 30 days of entering into the relationship, protocol, or orders. Forms must be mailed to:

Department of Health

Division of Medical Quality Assurance

Board of Medicine

4052 Bald Cypress Way, Bin C03

Tallahassee, FL 32399-3253

Tennessee

Only required when prescriptive authority is delegated. Complete the Notice and Formulary Form. Once completed, it must be mailed to:

Tennessee Board of Nursing

665 Mainstream Drive

Nashville, TN 37243

Update the Controlled Substance Monitoring Database (CSMD):

Nurse practitioners should enter your driver’s license number to identify you as their supervisor.
You'll receive a notification when you log in to CSMD, indicating pending relationships.
On the "My Account" screen, approve pending relationships.
If the supervisory relationship ends, revoke it from the "My Account" page in CSMD.

The following states require approval before practicing:

Alabama

Alabama requires that the Physician and Provider file the agreement and additional documentation to the Board of Medicine and Board of Nursing. Zivian will share the template Quality Assurance Plan that can be adjusted and updated between the physician and practitioner if deemed necessary.

The Physician will need to complete the Commencement Form at this link. This will include listing all collaborations they are in including those outside of Alabama. The hours must be less than 360 hours per a week for all collaborations. This includes a $200 fee to submit this form.
The Provider will need to file a Standard Protocol based on their specialty as well as a Quality Assurance plan with the collaborating Physician. These documents can be submitted at this link. Both of these steps will need to be done to have the agreement approved.

Zivian does not help with the writing of these two documents.

North Carolina

Nurse Practitioners in North Carolina must submit an "Approval to Practice" application, under a collaborative practice agreement with a supervising physician. This applies to those seeking approval to practice for the first time or with existing Nurse Practitioner registration.

Application Fees:

$100.00 (Per Physician for Nurse Practitioner in a Paid Position)
$20.00 (Per Physician for Nurse Practitioner in a Volunteer Position)

Nurse Practitioners cannot practice until receiving approval from the Board of Nursing. Approval documents will be emailed upon final approval.

If Nurse Practitioners haven't submitted their Nurse Practitioner Registration, they can file both forms together:

$25.00 (Registration)
Plus the respective physician fees mentioned above.

The North Carolina Board of Nursing and the North Carolina Medical Board jointly review and approve initial Approval to Practice applications.

Practice should only commence after receiving approval, with notification sent via email.

For more details, visit: Nurse Practitioner | North Carolina Board of Nursing

Nevada

In Nevada, APRNs and their collaborating physicians are required to mail a notification of their collaboration to the Board and wait for approval. After your collaboration is executed Zivian will share the document you must notarize and submit to the state board.

A copy of this form can be found here: Notification to Nevada State Board on Collaboration Agreement

South Carolina

In South Carolina, please review form and instructions here: https://llr.sc.gov/nurse/pdf/Prescriptive_Authority_App_Elec_Inst.pdf

You will need the following documents to upload to your electronic application:

Evidence of required educational contact hours as indicated in Requirements.
Completed New Employment/ Change of Practice/ Prescriptive Authority Form (Form is in Instructions and Forms package), if applicable
Copy of current state-issued license verification or a current DEA registration that reflects current prescriptive authority licensure, if applicable.

We recommend following the below application sequence for prescriptive authority:

Obtain a SC APRN license.
Once employed and if desired, apply for prescriptive authority. You will need the pharmacology hours and the collaborating Physician.
Once prescriptive authority is granted and if you desire a DEA license, apply for the Controlled Substance Registry through SC DHEC.
Apply for DEA license.