Changes in APRN Prescriptive Authority SB 406

1. Changes in APRN Prescriptive AuthoritySB 406 Kathy Hutto Governmental Affairs Consultant Jackson Walker L.L.P.

2. WHAT HAS CHANGED? • SITE-BASED APPROACH • MILEAGE LIMITATIONS • DIFFERENT REQUIREMENTS FOR SUPERVISION

3. Other Changes in Rx Authority • Terminology • “Carrying out or signing a prescription drug order “ becomes “Ordering or prescribing drugs & medical devices” • Changes “site” to “practice” • Changes definition of a “site serving a medically underserved population. • Increases delegation ratio from 4 to 7 APRN/PAs (FTE) • Preserves no limit in practices that had no limit previously • Changes “Protocol” to “Prescriptive Authority Agreement” in most practices. (No change for CRNAs)

4. WHAT HAS NOT CHANGED? • Limit on Physician Liability • Facility-Based Practices • Hospitals (care in hospital) and long-term care facilities • No major changes in how delegate, who delegates, etc. • Some clarifications • Which and number of physicians can delegate • Facility-based physicians delegating in private practices • FTE limits in freestanding clinics • CRNA Practice

5. Limit on Physician Liability - MPA • MPA Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT. Unless the physician has reason to believe the physician assistant or advanced practice registered nurse lacked the competency to perform the act, a physician is not liable for an act of a physician assistant or advanced practice registered nurse solely because the physician signed a standing medical order, a standing delegation order, or another order or protocol, or entered into a prescriptive authority agreement, authorizing the physician assistant or advanced practice registered nurse to administer, provide, prescribe, or order a drug or device

6. Limit on Physician Liability – TMB Rules §193.5. Physician Liability for Delegated Acts and Enforcement. (a) [Content of MPA 157.060. Moves qualifier to end.] (b) Notwithstanding subsection (a) of this section, delegating physicians remain responsible to the Board and to their patients for acts performed under the physician's delegated authority. (c) Any physician authorizing standing delegation orders or standing medical orders which authorize the exercise of independent medical judgment or treatment shall be subject to having his or her license to practice medicine in the State of Texas revoked or suspended under §§164.001, 164.052, and 164.053 of the Act.

7. Limitations on APRN Rx Authority in Texas • Delegated & Supervised • Site-based • No Schedule II in most practices

8. MD may delegate ordering & prescribing: • Nonprescription Drugs • Dangerous Drugs - Drugs & medical devices that require a prescription, excluding controlled substances • Controlled Substances (CS) • Schedule II drugs added in limited situations

9. Limits on Schedules III-V (no change) Physicians may also delegate ordering and prescribing Schedules III-V Controlled Substances subject to 4limitations. • The duration of the prescription, including refills of the original prescription, may not exceed 90 days; • Continued treatment with the same controlled substance beyond 90 days requires consultation with the delegating physician prior to writing another prescription or refilling the original prescription; • Treating a child under age 2 requires prior consultation with the delegating physician; and • Consultation with the physician must be noted in the patient’s medical record.

10. Where can a physician delegate prescribing Schedule II, Controlled Substances? 1)  in a hospital facility-based practice, as part of the care provided to a patient who: • (A)  has been admitted to the hospital for an intended length of stay of 24 hours or greater; or • (B)  is receiving services in the emergency department of the hospital; or (2)  as part of the plan of care for the treatment of a person who has executed a written certification of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider.

11. Prescribing Controlled SubstancesDPS Permit and DEA # • Must have delegated prescriptive authority for CSs. • Request permit application from Texas Department of Public Safety (DPS) • Physician must sign application • Physician must register delegation for CSs with TMB • Apply for DEA# online www.deadiversion.usdoj.gov/drugreg/index.html • Report DEA # to DPS

12. Rx Authority Delegation • MD or DO • Prescriptive Authority Agreement (PAA) or Protocol • Physicians delegating through a PAA register delegation at TMB within 30 days • Physician & APRN must keep records until 2 years from the date the PAA is terminated.

13. Special Practice Designations exempt from certain restrictions • Practice serving a medically underserved population • Facility-based (hospital or long-term care)

14. Medically Underserved • Medically Underserved Population (MUP) • Federally designated HPSA, RHC, FQHC • Public health or family planning clinic under contract with HHSC or DSHS • Designated by DSHS (Health Professions Resource Center) www.dshs.state.tx.uschs/hprc/default.shtm • Titles V, X, XVIII, XIX, XXI Federal funding or state-funded • County, state or federal correctional facility • Any practice designated as a site serving a MUP prior to March 1, 2013.

15. Medically Underserved • PAA requirements same as other sites • Advantage - No physician to APRN/PA ratio

16. Facility-Based Sites • Licensed Hospital • Advantage - no delegation ratio • Physician limited to 1 hospital • Long-term Care Facility • Only delegated by medical director • Limited to 2 facilities • 1 physician to 7 APRN/PA ratio • May use current Protocol or PAA

17. Prescriptive AuthorityBON Rule 221.13 (d) Prescriptive authority requires: • Prescriptive Authority Agreement (PAA); or • In facility-based practice, Protocols or other written authorizations (standing medical orders, standing delegation orders, or other order or protocol) • “Medical Aspects of Care” include all functions on the next slide.

18. APRN Practice: Delegated Medical Acts • Prescribing & Ordering Drugs & Medical Devices • Ordering Durable Medical Equipment & Supplies • Establishing a Medical Diagnosis • Verifying medical eligibility for disabled parking placard • Ordering Orthotics and Prosthetics • Ordering respiratory care • Tx Medicaid – Ordering therapy services

19. Protocols • May continue to use in facility-based practices • As permitted by medical staff bylaws & policies • Protocols are not diagnosis or condition specific • Must identify the drugs or categories of drugs the APRN may, or may not, prescribe

20. Recap of Physician Delegating in Hospital • Delegation is through protocols • Delegate to an unlimited number of APRNs/PAs • Does not include freestanding clinics (7 FTE limit) • Limited to delegation in 1 hospital • Physician may also delegate in other practices to a maximum of 7 APRNs/PAs under a Prescriptive Authority Agreement

21. LTC Facility-Based Practice • Same as hospital facility-based except: • Medical Director is only physician who can delegate • Physician may delegate at 2 LTC facilities • Seven FTE limit

22. Prescriptive Authority Agreements • May be used in facility-based practices • Not recommended • Must comply with all PAA requirements • PAA: • All non-facility-based practices • Requirements specified in law

23. Requirements for Parties to the PAA All parties must disclose: • Prior disciplinary action by the licensing board before executing the PAA. • Investigation by the licensing board while a party to the PAA. All parties must cooperate with TMB and BON staff during an inspection or audit relating to the PAA and its implementation.

24. PAA Requirements • In writing, signed and dated by all parties • Name, address & professional license # of parties • Nature of the practice, locations, or settings • Categories of drugs that may or may not be prescribed • Plans for: • Consultation & referral • Addressing patient emergencies • Communicating & sharing information related to treatment • Quality assurance and improvement (QAI) that includes chart review, meetings, & documenting implementation of QAI

25. QAI Plan Requirements • Chart review - Number determined jointly • Purpose/content of QAI monthly meetings • share information about patient care & treatment • changes in treatment plans • issues relating to referrals • discussion of patient care improvement • Document implementation method & compliance

26. QAI MEETING REQUIREMENTS • QAI monthly in-person meetings • Location, day and time determined jointly • Face-to-face 1 year for APRNs who prescribed for 5 of past 7 yrs. • Face-to-face for 3 years for APRNs with less experience • Thereafter, meet quarterly in-person & monthly in between by electronic means. NOTE: TMB Rules [Sec. 193.8(11)(C), TAC] authorizes APRNs who prescribed for 5 of the past 7 yrs with the SAME physician with whom the PAA is being entered to go immediately to quarterly in-person meetings & monthly in between by electronic means. However, BON Rules [Sec. 222.5(d)(2)(B)] requires all APRNs who prescribed for 5 of the past 7 yrs to meet face-to-face for 1 year, even if working with the same physician. Unfortunately, one has to abide by this more restrictive regulation.

27. Cook Books Not Required • The prescriptive authority agreement need not describe the exact steps that an APRN must take with respect to each specific condition, disease, or symptom. • The prescriptive authority agreement should promote the exercise of professional judgment by the APRN commensurate with the APRN’s education and experience and the relationship between the APRN and the physician. • This section shall be liberally construed to allow the use of prescriptive authority agreements to safely and effectively utilize the skills and services of APRNs.

28. Other Key Provisions • The prescriptive authority agreement and any amendments must be reviewed at least annually, dated, and signed by the parties to the agreement. • The prescriptive authority agreement and any amendments must be made available to the board, the Texas Board of Nursing, or the Texas Physician Assistant Board not later than the third business day after the date of receipt of request, if any. • A party to a prescriptive authority agreement must retain a copy of the agreement until the 2nd anniversary of the date the agreement is terminated.

29. Disclosure Requirements • Before executing the prescriptive authority agreement, the physician and the APRN shall disclose to the other prospective party to the agreement any prior disciplinary action by the Texas Medical Board or the Texas Board of Nursing, as applicable. • If a party to a prescriptive authority agreement is notified that the individual is the subject of an investigation by the Texas Medical Board or the Texas Board of Nursing, the individual shall immediately notify the other party to the prescriptive authority agreement.

30. Number of APRNs/PAs to whom a physician may delegate Rx authority? • 7 FTEs in most practices • UNLIMITED in • hospitals (not including free-standing clinics) or • practices serving a medically underserved population (MUP)

31. A Universal Limitation on APRN Prescriptive Authority Scope of Practice In any state, prescriptions are limited to the scope of practice authorized by the state board of nursing.

32. What APRNs Must Know about Rx Authority • Apply for a prescriptive authority number when applying for license to practice as an APRN. • Separate Prescriptive Authority required for each APRN role & population-focus area. • May not write prescriptions until a physician (A) delegates authority, & (B) signs PAA or Protocol • Register delegation on TMB website within 30 days. • May not prescribe controlled substances until have DPS # (CSR) and DEA #. • May not prescribe for yourself, friends or family.

33. Sample Practice Prescriptive Authority Agreement &APRN Guide to Practice, 4th Edition Available at www.cnaptexas.org