Collaborative drug therapy management
Collaborative drug therapy management (CDTM) is a form of pharmacy practice in the United States in which a pharmacist initiates, modifies, discontinues or monitors a patient's drug therapy, and orders and interprets related laboratory tests, under the terms of a written agreement with a prescriber, usually a physician.[1] The written instrument that confers the authority is a collaborative practice agreement; CDTM is the practice the agreement authorizes.[2]
CDTM is an expansion of the traditional pharmacist scope of practice rather than a replacement for it. A pharmacist needs no agreement to perform the services already within that scope, among them medication therapy management, immunization, public health screening, patient counseling and recommending a change of therapy to the prescriber. What the agreement adds is the authority to act on a drug-related problem directly instead of referring it back to the prescriber.[2][1]
Because the pharmacist's authority derives from state law, the scope and even the name of CDTM differ from one jurisdiction to the next. Most states authorize it by statute or board rule; a few leave it unregulated, in which case pharmacists act as agents of the prescriber.[3]
Terminology
[edit]The term was coined by the pharmacy editor William A. Zellmer in a 1995 editorial in the American Journal of Health-System Pharmacy.[4] Zellmer argued for it in preference to prescribing, on the grounds that it would be more acceptable to legislators and to physician organizations and that it described more accurately what pharmacists were seeking: a way to resolve drug-related problems as part of a care team. According to the healthcare researcher Karen E. Koch, the modern language of collaborative practice was adopted in part to avoid the contested term dependent prescribing authority.[5]
CDTM is also described as clinical pharmacy services, pharmaceutical care, disease state management or comprehensive medication management, though these terms are broader and cover work that needs no agreement.[6] The agreement itself attracts as many names as the practice: consult agreement, collaborative pharmacy practice agreement, physician-pharmacist agreement, standing order, protocol and physician delegation all appear in state law.[7] A 2026 survey of the 50 states, the District of Columbia and Puerto Rico recorded a distinct statutory or regulatory name for the pharmacist instrument in almost every jurisdiction that authorizes one. Among them are the CDTM agreement of Alabama and Maine, the collaborative drug therapy management framework of New York, the consult agreement of Ohio, the drug therapy modification protocol of Georgia, the collaborative drug therapy management order set of Louisiana, the prescriber-pharmacist agreement of Maryland and the written protocol of Texas, Alaska, Mississippi and New Jersey.[8]
Scope
[edit]Within the traditional scope of practice a pharmacist may detect a drug-related problem and recommend a solution to the prescriber. Under CDTM the pharmacist resolves it directly, within limits the agreement sets. The activities commonly authorized are selecting and initiating a medication for a diagnosed condition, discontinuing a prescription or over-the-counter medication, modifying a regimen by changing its strength, frequency, route or duration, ordering and interpreting laboratory tests to evaluate the patient's response, and continuing therapy by issuing a new prescription.[1] Some agreements also cover administering medications, particularly those given parenterally, such as long-acting injectable antipsychotics.[5]
An agreement is usually written for a defined patient population, a clinical situation or a disease state, and may incorporate an evidence-based protocol for managing the regimen. Its terms are settled between the pharmacist and the prescriber within whatever the state permits.[2][3]
Legal authority
[edit]Authority for CDTM is granted state by state.[1] Washington was the first state to provide for it, amending its pharmacy practice requirements in 1979 to allow "collaborative drug therapy agreements".[9] The federal government recognized the arrangement in 1995.[10] By 2016, 48 states and the District of Columbia had authorized it,[11][12] and Alabama followed in 2022, when the Alabama Pharmacy Collaborative Practice Act took effect alongside a board rule requiring each agreement to be approved by both the pharmacy and the medical board.[13][14]
The year each of the 50 states first authorized the arrangement, and the year of any later revision, is listed below. Unregulated marks a state that has no specific statutory framework, in which pharmacists may nonetheless perform the same activities as agents of the prescriber; not approved marks one where the arrangement has no legal basis.
| State | Year authorized |
|---|---|
| Alabama | 2022[13][14] |
| Alaska | 2002[10] |
| Arizona | 2000[10] |
| Arkansas | 1997[10] |
| California | 1981, 2002[10] |
| Colorado | 2007,[15] 2016[16] |
| Connecticut | 2002[10] |
| Delaware | Not approved[12] |
| Florida | 1986, 1997[10] |
| Georgia | 2000[10] |
| Hawaii | 1997, 2002[10] |
| Idaho | 1998[10] |
| Illinois | Unregulated[10] |
| Indiana | 1996,[10] 2011[3] |
| Iowa | 1996[10] |
| Kansas | 1996,[10] 2014[3] |
| Kentucky | 1996[10] |
| Louisiana | 1999[10] |
| Maine | 2013[3] |
| Maryland | 2002[10] |
| Massachusetts | 2009[3] |
| Michigan | 1991[10] |
| Minnesota | 1998[10] |
| Mississippi | 1987[10] |
| Missouri | 2012[3] |
| Montana | 2001[10] |
| Nebraska | 1998[10] |
| Nevada | 1990[10] |
| New Hampshire | 2006[3] |
| New Jersey | 2004[3] |
| New Mexico | 1993, 2002[10] |
| New York | 2011[3] |
| North Carolina | 1999[10] |
| North Dakota | 1995, 2001[10] |
| Ohio | 1999[10] |
| Oklahoma | Unregulated[12] |
| Oregon | 1980[10] |
| Pennsylvania | 2002[10] |
| Rhode Island | 2001[10] |
| South Carolina | 1998[10] |
| South Dakota | 1993[10] |
| Tennessee | 2014[3] |
| Texas | 1995[10] |
| Utah | 2001[10] |
| Vermont | 1992[10] |
| Virginia | 1999,[10] 2013[3] |
| Washington | 1979[10] |
| West Virginia | 2008[3] |
| Wisconsin | 2000[10] |
| Wyoming | 1999[10] |
Variation by state
[edit]States differ in what they call the arrangement, who may be a party to it, what the pharmacist may do under it and how often it must be renewed. Arizona regulates CDTM as a "drug therapy management protocol", Arkansas as "disease state management", Florida as a "prescriber care plan", Idaho as "collaborative pharmacy practice", and Hawaii as a policy, procedure or protocol.[3] Some states confine the prescriber side to a single named physician, while Colorado, Minnesota and Mississippi allow an agreement among several pharmacists and several prescribers; Hawaii and Minnesota count advanced practice nurses among the prescribers who may be a party.[3][12]
Conditions attached to the agreement vary as widely. North Dakota confines CDTM to institutional settings and never permits the modification of Schedule II controlled substances. Georgia requires the agreement to name the patients, disease states, medication classes and dose ranges it covers, and to be renewed every two years. Mississippi requires a pharmacist to complete sixteen hours of continuing education before practicing under an agreement. Idaho requires annual renewal.[3] Illinois and Michigan have no CDTM statute of their own; pharmacists in those states perform the same activities as agents of the prescriber.[3][12] In Michigan that agency is documented in a delegation agreement between the pharmacist and the delegating physician, a signed copy of which is kept at the practice site; Illinois instead works through statewide standing orders issued by statute or by the state regulator, which name no collaborating physician.[8]
The name a state uses is a weak guide to what it permits. Jurisdictions whose instrument is not called a collaborative practice agreement often authorize the same activities as those whose instrument is, and written protocol names the pharmacist instrument in some states and the nurse practitioner instrument in others.[8]
A few states have created a designated credential rather than relying on the agreement alone. New Mexico's Pharmacist Prescriptive Authority Act of 1993 recognizes an advanced practitioner designated a "pharmacist clinician", and North Carolina created the "clinical pharmacist practitioner" in 1999.[3]
The 2026 survey recorded, for each jurisdiction, the name of the pharmacist instrument, whether a written agreement is required at all, whether the instrument may reach controlled substances and how often the parties must meet. Three further conditions proved almost uniform across the 52: no jurisdiction caps the number of pharmacists one prescriber may enter agreements with; physical proximity is unaddressed in 48, Louisiana and New York requiring the prescriber to be on site and Indiana and Texas expressly allowing the parties to be remote; and a chart-review obligation is codified in only two, Massachusetts and New Jersey, both of which leave the proportion of charts to the agreement itself.[8]
| State | Name of the instrument | Written agreement | Controlled substances | Meetings |
|---|---|---|---|---|
| Alabama | CDTM agreement | Required | Permitted | Not codified |
| Alaska | Written protocol | Required | Not permitted | Not codified |
| Arizona | Collaborative practice agreement | Required | Not permitted | Not codified |
| Arkansas | Collaborative practice agreement | Required | Not permitted | Not codified |
| California | Collaborative practice agreement | Required | Permitted | Not codified |
| Colorado | Collaborative pharmacy practice agreement | Required | Permitted | Annually |
| Connecticut | Collaborative drug therapy management agreement or care plan | Required | Not permitted | Not codified |
| Delaware | Collaborative pharmacy practice agreement | Required | Permitted | Not codified |
| District of Columbia | Collaborative practice agreement | Required | Not permitted | Not codified |
| Florida | Written collaborative pharmacy practice agreement | Required | Not permitted | As needed |
| Georgia | Drug therapy modification protocol | Required | Permitted | As needed |
| Hawaii | Written collaborative agreement | Required | Not permitted | Not codified |
| Idaho | Written collaborative pharmacy practice agreement | Required | Permitted | Not codified |
| Illinois | - | Not required | Not permitted | Not codified |
| Indiana | Written collaborative practice protocol | Required | Not permitted | Annually |
| Iowa | Written collaborative pharmacy practice agreement | Required | Permitted | Not codified |
| Kansas | Written collaborative practice agreement | Required | Not permitted | Not codified |
| Kentucky | Written collaborative care agreement | Required | Not permitted | Not codified |
| Louisiana | Collaborative drug therapy management order set | Required | Not permitted | Quarterly |
| Maine | CDTM agreement | Required | Not permitted | Not codified |
| Maryland | Prescriber-pharmacist agreement | Required | Not permitted | As needed |
| Massachusetts | Collaborative practice agreement | Required | Not permitted | Not codified |
| Michigan | Delegation agreement | Required | Not permitted | Not codified |
| Minnesota | Written collaborative practice agreement | Required | Not permitted | Not codified |
| Mississippi | Written protocol | Required | Not permitted | Not codified |
| Missouri | Written protocol | Required | Not permitted | Not codified |
| Montana | Written collaborative pharmacy practice agreement | Required | Not permitted | Not codified |
| Nebraska | Written practice agreement | Required | Not permitted | Not codified |
| Nevada | Collaborative practice agreement | Required | Not permitted | Not codified |
| New Hampshire | Collaborative pharmacy practice agreement | Required | Permitted | As needed |
| New Jersey | Written protocol | Required | Not permitted | Annually |
| New Mexico | Written guidelines or protocol | Required | Not permitted | Not codified |
| New York | Collaborative drug therapy management framework | Required | Not permitted | Not codified |
| North Carolina | Written collaborative practice agreement | Required | Permitted | Monthly |
| North Dakota | Collaborative practice agreement | Not required | Not permitted | Not codified |
| Ohio | Consult agreement | Required | Permitted | Not codified |
| Oklahoma | Written collaborative practice agreement | Required | Not permitted | Not codified |
| Oregon | CDTM protocol | Not required | Not permitted | Not codified |
| Pennsylvania | Written collaborative agreement | Required | Permitted | Not codified |
| Puerto Rico | Protocol | Required | Not permitted | Annually |
| Rhode Island | Written collaborative practice agreement | Required | Not permitted | Not codified |
| South Carolina | Collaborative practice agreement | Required | Not permitted | Not codified |
| South Dakota | Protocol | Required | Not permitted | Not codified |
| Tennessee | Collaborative pharmacy practice agreement | Required | Not permitted | Not codified |
| Texas | Written protocol | Required | Not permitted | Annually |
| Utah | Collaborative pharmacy practice agreement | Required | Permitted | Not codified |
| Vermont | Written collaborative practice agreement | Required | Not permitted | Not codified |
| Virginia | Written collaborative agreement | Required | Permitted | Not codified |
| Washington | Collaborative drug therapy agreement | Required | Permitted | Not codified |
| West Virginia | Collaborative pharmacy practice notification | Required | Not permitted | Not codified |
| Wisconsin | Delegation agreement | Required | Not permitted | Not codified |
| Wyoming | Collaborative practice agreement | Required | Not permitted | Not codified |
Effect on outcomes
[edit]CDTM has been applied to the management of chronic conditions including diabetes mellitus, asthma and hypertension, and evidence suggests it improves the measures used to track them: attainment of target hemoglobin A1c in diabetes, lung function in asthma, and blood pressure control in hypertension. Pharmacists working under agreements have also been reported to raise the quality of care in the oncology setting, including the management of antiemetic therapy.[17]
CDTM has also been described as a way to integrate pharmacists into accountable care organization practices, to relieve the time pressure on primary care visits and to reduce delays in managing chronic conditions.[18]
Payment
[edit]Pharmacists are not recognized as providers under Medicare Part B, so CDTM furnished to a Medicare beneficiary is not directly reimbursable under that benefit.[19] Bills to change this have been introduced repeatedly without being enacted. The Pharmacy and Medically Underserved Areas Enhancement Act, introduced in both chambers in January 2017, would have allowed payment for services a pharmacist is licensed to perform in their own state, and for which a physician would have been paid, when furnished in a federally designated medically underserved area.[20]
Professional positions
[edit]CDTM is a standing object of advocacy for pharmacy organizations. The American College of Clinical Pharmacy has published periodic white papers on it, in 1997, 2003 and 2015, covering the legislative record and models of payment.[3][10] In January 2012 the American Pharmacists Association convened a consortium of pharmacy, medical and nursing stakeholders from twelve states, which published recommendations on integrating collaborative practice into everyday care.[2] In July 2015 the National Alliance of State Pharmacy Associations convened an eighteen-member working group that recommended what state legislatures should put in CDTM laws.[21]
Physician organizations have responded unevenly. The American Academy of Family Physicians supported collaborative agreements in a 2012 position paper while warning that fully autonomous pharmacist prescribing would fragment care.[22] In 2010 the American Medical Association published a Scope of Practice Data Series whose report on pharmacy characterized collaborative agreements as an encroachment on the practice of medicine; seven national pharmacy organizations wrote jointly to the AMA asking it to correct and reissue the report.[23] In 2011 the AMA House of Delegates adopted a narrower resolution, directing the association to develop model state legislation against independent pharmacist practice arrangements conducted without physician involvement rather than against collaborative ones.[24]
See also
[edit]References
[edit]- 1 2 3 4 Carmichael, Jannet (2003). Encyclopedia of Clinical Pharmacy. New York: Marcel Dekker. pp. 199–206. ISBN 0-8247-0752-4.
- 1 2 3 4 "Collaborative Practice Agreements and Pharmacists' Patient Care Services". aphafoundation.org. American Pharmacists Association Foundation. Retrieved September 5, 2026.
- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 McBane, SE; Dopp, AL; Abe, A; et al. (2015). "Collaborative Drug Therapy Management and Comprehensive Medication Management-2015" (PDF). Pharmacotherapy. 35 (4): e39–e50. doi:10.1002/phar.1563. PMID 25884536.
- ↑ Zellmer, William A. (August 1, 1995). "Collaborative drug therapy management". American Journal of Health-System Pharmacy. 52 (15): 1732. doi:10.1093/ajhp/52.15.1732. PMID 7583839.
- 1 2 Koch, Karen. "Trends in collaborative drug therapy management". Medscape. WebMD. Retrieved September 5, 2026.
- ↑ Kim Jun, Jeany (2017). "The role of pharmacy through collaborative practice in an ambulatory care clinic". American Journal of Lifestyle Medicine. 13 (3): 275–281. doi:10.1177/1559827617691721. PMC 6506972. PMID 31105491.
- ↑ Weaver, Krystalyn. "Policy 101: Collaborative practice empowers pharmacists to practice as providers". pharmacist.com. American Pharmacists Association. Retrieved September 5, 2026.
- 1 2 3 4 5 "Pharmacist drug therapy management, state by state". Collaborative Drug Therapy Management. Retrieved September 6, 2026.
- ↑ "Laws of 1979, ch. 90: Practice of pharmacy-Requirements" (PDF). Washington State Legislature. Retrieved September 5, 2026.
- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Hammond, RW; Schwartz, AH; Campbell, MJ; et al. (2003). "Collaborative drug therapy management by pharmacists-2003" (PDF). Pharmacotherapy. 23 (9): 1210–1225. doi:10.1592/phco.23.10.1210.32752. PMID 14524655.
- ↑ Gilchrist, Allison. "Collaborative practice agreements open opportunities, liabilities for pharmacists". pharmacytimes.com. Retrieved September 5, 2026.
- 1 2 3 4 5 Advancing Team-Based Care Through Collaborative Practice Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team. Atlanta: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 2017.
- 1 2 "Code of Alabama § 34-23-77: Collaborative practice agreement". Justia. Retrieved September 5, 2026.
- 1 2 "Alabama Administrative Code r. 680-X-2-.44: Collaborative Practice". Alabama State Board of Pharmacy. Retrieved September 5, 2026.
- ↑ "Code of Colorado Regulations: 3 CCR 719-1". Secretary of State of Colorado. Retrieved October 27, 2017.
- ↑ "Statewide Protocol Continuing Education On-Demand Webinar". copharm.org. Colorado Pharmacists Society. Archived from the original on October 28, 2017. Retrieved May 7, 2017.
- ↑ Merten, Julianna A.; Shapiro, Jamie F.; Gulbis, Alison M.; et al. (April 2013). "Utilization of collaborative practice agreements between physicians and pharmacists as a mechanism to increase capacity to care for hematopoietic stem cell transplant recipients". Biology of Blood and Marrow Transplantation. 19 (4): 509–518. doi:10.1016/j.bbmt.2012.12.022. PMC 3694445. PMID 23419976.
- ↑ Joseph, T.; Hale, G.; Gernant, S.; et al. (2016). "Pharmacists in ACOs part 3: Chronic care management, chronic disease state management, and transition of care". Pharmacy Times. Retrieved September 5, 2026.
- ↑ Medicare Benefit Policy Manual, chapter 15. Centers for Medicare and Medicaid Services. 2010.
- ↑ "H.R.592 - Pharmacy and Medically Underserved Areas Enhancement Act, 115th Congress". congress.gov. Retrieved September 5, 2026.
- ↑ "Pharmacist Collaborative Practice Agreements: Key Elements for Legislative and Regulatory Authority". National Alliance of State Pharmacy Associations. July 2015. Retrieved September 5, 2026.
- ↑ "Pharmacists (position paper)". American Academy of Family Physicians. Retrieved September 5, 2026.
- ↑ "Seven pharmacy organizations respond to AMA scope of pharmacy practice document". National Association of Boards of Pharmacy. May 5, 2010. Retrieved September 5, 2026.
- ↑ Posey, L. Michael (June 24, 2011). "AMA to evaluate "expanding scope of pharmacists' practice"". pharmacist.com. American Pharmacists Association. Retrieved September 5, 2026.
External links
[edit]- Collaborative Practice Agreements and Pharmacists' Patient Care Services - Centers for Disease Control and Prevention
- Pharmacist Collaborative Practice Agreements: Key Elements for Legislative and Regulatory Authority - National Alliance of State Pharmacy Associations
- Collaborative Drug Therapy Management and Comprehensive Medication Management-2015 - American College of Clinical Pharmacy