Louisiana State Board of Nursing and the Louisiana State Board of Medical Examiners

JOINT STATEMENT OF POSITION: Collaboration and Collaborative Practice

Background: Advanced practice registered nurses (APRNs) have been recognized in Louisiana since 1981 and licensed since 1996. Rules regarding prescriptive authority for advanced practice registered nurses were jointly promulgated in 1996 by the Louisiana State Board of Nursing (LSBN) and the Louisiana State Board of Medical Examiners (LSBME). Current statutes allow APRNs to medically diagnose and medically manage patients (including but not limited to prescriptions for legend and certain controlled drugs, assessment studies, therapeutic regimens, medical devices and appliances) within the parameters of a collaborative practice agreement which is a written statement/ document mutually agreed upon by the APRN and one or more licensed physicians or dentists.

Louisiana law allows and authorizes the LSBN and the LSBME to establish and publish standards of practice and to regulate the practice of their licensees including the collaborative practice. The safety and welfare of the citizens of Louisiana is given primary consideration in the issuing of a Joint Position Statement.

Goal: In providing this Statement, it is the intent of the LSBN and the LSBME to: (i) safeguard the life and health of the citizens of Louisiana through promotion of safe and competent practice; (ii) provide guidance to advanced practice registered nurses and physicians licensed in Louisiana in order to meet the expectation and requirements for practice in this state; and (iii) foster compliance with regulations in Louisiana.

Terminology: See the “Definitions and Terms” section for associated provisions agreed upon within this statement per LA R.S.46:XLVII.4505; 4513.B.1, 2 and 3; and 4513.D.1.vi. a-c.

Statement: Collaborative practice in Louisiana currently includes “the joint management of the health care of a patient”. Joint management must encompass a collaborative process in which professionals integrate solutions, merge perspectives, and incorporate expertise into a consensual decision for the management of health care needs of patients. The process of collaboration must allow for appropriate use of clinical judgment, differing approaches to medical diagnoses that meet current standards of care, individual patient needs, and resources.

The advanced practice registered nurse (APRN) must submit the required forms, fees, and collaborative practice agreement to the LSBN and receive formal approval to be authorized to enter into collaborative practice with a physician. Nothing prohibits an APRN from consulting with additional health care providers as needed to provide for the care of the patient. It is the responsibility of the APRN to understand and abide by the requirements of LSBN in all matters related to prescriptive authority.

It is the responsibility of collaborating physicians to ensure they have been properly approved to serve as a collaborating physician. They are also responsible for ensuring that all acts of the prescriptive authority of the APRN are documented and utilized in a manner that is consistent with the collaborative practice agreement. Per LA R.S.46:XLVII: 4513.D.1.vi.c.i, the collaborating physician must “be available by telephone or direct telecommunication for consultation, assistance with medical emergencies, or patient referral at all times that the APRN is exercising prescriptive authority”. In addition, collaborating physicians are expected to be available for hospital admissions and coverage. Any “back up” or secondary physician must also be approved. Back-up physicians are not required but if utilized must meet all provisions, stipulations, and requirements of the primary collaborating physician including receiving approval by LSBN.

In the event the collaborating physician’s primary practice site is different from that of the APRN’s primary practice site and the physician does not have immediate, real time access to the patients electronic medical records, the collaborating physician and the APRN must demonstrate joint management of care. Such joint management may be demonstrated through an individualized plan to ensure services provided to patients meet the parameters of practice agreed upon within the collaborative practice agreement. The plan may include a peer review process, chart review, quality assurance measure, policy and procedure, or other such mechanism. Any plan should provide for review of the controlled substance prescribing practices of the APRN and be implemented at reasonable intervals demonstrating involvement of the physician in the provision of joint management of patient care.

Furthermore, to properly provide joint management, the collaborating physician must be actively engaged in the provision of patient care within the state of Louisiana. The collaborating physician must be providing patient care in the same or a practice comparable in scope, specialty or expertise to that of the advanced practice registered nurse. Physicians who are retired or are otherwise not providing patient care services on a consistent basis cannot serve as a collaborating physician. This does not exclude locum tenens physicians who may serve as a collaborating physician while they are providing care in Louisiana.

In no instance is the scope of practice of APRNs delegated to them through the physician’s scope or authority. The provision of effective, comprehensive care hinges upon all professionals functioning to their maximum ability with coordination of care and communication that provides for patient needs and mutual recognition of and respect for each professional’s knowledge, skills, and contributions to the provision of health care.

Definition and Terms:

Collaboration refers to “a cooperative working relationship with licensed physicians, dentists, or other health care providers to jointly contribute to providing patient care and may include but not be limited to discussion of a patient’s diagnosis and cooperation in the management and delivery of health care with each provider performing those activities that he is legally authorized to perform.”

Collaborative practice refers to “the joint management of the health care of a patient by an advanced practice registered nurse performing advanced practice registered nursing and one or more consulting physicians or dentists. Except as otherwise provided in R.S. 37:930, acts of medical diagnosis and prescription by an advanced practice registered nurse shall be in accordance with a collaborative practice agreement.”

Collaborating Physician refers to “a physician actively engaged in clinical practice and the provision of patient care with whom the APRN has developed and signed a collaborative practice agreement for prescriptive and distributing authority and who holds a current, unencumbered, unrestricted and valid medical license issued or recognized by the Louisiana State Board of Medical Examiners and is in good standing with no pending disciplinary proceedings, and practices in accordance with rules of the Louisiana State Board of Medical Examiners”.

Collaborative Practice Agreement―a formal written statement/document addressing the parameters of the collaborative practice which are mutually agreed upon by the advanced practice registered nurse and one or more licensed physicians or dentists which shall include but not be limited to the following provisions:

1. availability of the collaborating physician or dentist for consultation or referral, or both;

2. methods of management of the collaborative practice which shall include clinical practice guidelines;

3. coverage of the health care needs of a patient during any absence of the advanced practice registered nurse, physician, or dentist.

vi.a collaborative practice agreement as defined in 4513.B.1, 2 and 3, with one or more licensed collaborating physicians which shall include, but not be limited to:

(a). a plan of accountability among the parties that:

(i). defines the prescriptive authority of the APRN and the responsibilities of the collaborating physician or physicians;

(ii). delineates a plan for hospital and other healthcare institution admissions and privileges which includes a statement that the collaborating physician must have said privileges at the same institution before an APRN can receive this determination at said institution;

(iii). delineates mechanisms and arrangements for diagnostic and laboratory requests for testing;

(iv). delineates a plan for documentation of medical records;

(b). clinical practice guidelines as required by R.S. 37:913(9)(b) shall contain documentation of the types or categories or schedules of drugs available and generic substitution for prescription and be in accordance with current standards of care and evidence-based practice for the APRN specialty and functional role and be:

(i). mutually agreed upon by the APRN and collaborating physician;

(ii). specific to the practice setting;

3. (iii). maintained on site; and
4. (iv). reviewed and signed at least annually by the APRN and physician to reflect current practice;

(c). documentation of the availability of the collaborating physician when the physician is not physically present in the practice setting. Physicians shall be available to provide consultation as needed:

(i). physician shall be available by telephone or direct telecommunications for consultation, assistance with medical emergencies, or patient referral, as delineated in the collaborative practice agreement;

(ii). the secondary (back-up) physician or physicians shall be in good standing and approved by the Louisiana State Board of Medical Examiners and sign the collaborative practice agreement;

(iii). in the event the collaborating physician and any secondary (back-up) collaborating physician(s) are unavailable, the APRN will not prescribe;

(d). documentation shall be shown that patients are informed about how to access care when both the APRN and/or the collaborating physicians are absent from the practice setting;

(e). an acknowledgement of the mutual obligation and responsibility of the APRN and collaborating physician to insure that all acts of prescriptive authority are properly documented.