Insight Matters
Winter, 2002

For the Private Sector, Too:
Advance Practices Nurses May Now Prescribe!

As a result of H.B. 241 signed into law by Governor Taft in February 2000, effective February 1, 2002 advance practice nurses (APNs), who meet specified criteria, may apply for a certificate to prescribe. While Ohio is one of the last states to grant prescriptive authority to advanced practice nurses, the experience will be new to most nurses and physicians in the state. Those of us who have worked in the Veterans Administration, under existing pilot projects or in other states will be familiar with nurse prescribers and may offer guidance to the rest of us.

What follows is an attempt to summarize how APN prescribing will work in Ohio. In reading through this you will have to add a new array of acronyms to your vocabulary including COA (Certificate of Authority), CTP (certificate to prescribe), CNS (clinical nurse specialist), SCA (standard care arrangement) and CPG (Committee on Prescriptive Governance). This is all fairly complicated so I am likely to raise many questions while hopefully answering a few.

Understand first that potential prescribers are generally master's prepared nurses (there are some "grandparent clause" exceptions) who are already functioning in an expanded role as nurse practitioners, nurse-mid-wives or as psychiatric clinical nurse specialists (CNS's). Up until now, and except for psychiatric CNS's, APNs were required to enter into a collaborative relationship with a physician of their specialty to function in their expanded role. This is spelled out in a document called the standard care arrangement (SCA). With the coming of prescriptive authority, psychiatric CNS's will also have to execute an SCA with a psychiatrist if they wish to prescribe. In addition to their RN license, the APN holds a Certificate of Authority (COA) from the Board of Nursing to allow for practice in an expanded role.

In order to prescribe the APN must obtain a Certificate to Prescribe (CTP). Here are the requirements for the CTP:

• The nurse must have a current COA, complete an application and pay a fee.
  - This includes a requirement to have an established SCA with a physician.
• The nurse has completed an acceptable pharmacology course within 3 years of the application.
• The nurse must provide evidence of completion of an externship, including a physician statement that the externship was successfully completed.
  - A first application will actually be an application for an externship certificate.
  
• Nurses can only prescribe medications on the formulary as established by the Committee on Prescriptive Governance (CPG)

The externship:

• The externship is a formal relationship with a collaborating physician.
  
• The nurse holds an externship CTP (xCTP)
  - With an xCTP the APN prescribes under the physician's supervision.
  - During a portion of the externship, the physician must be on the premises while the nurse prescribes.
  
• The supervising physician documents the successful completion of the externship before the APN is eligible for a full CTP.

The Committee on Prescriptive Governance (CPG):

• The composition of the CPG was established by statute and is a committee of the Board of Nursing.
• It is mandated to have 4 RNs, 4 physicians and 2 pharmacists.
• The CPG establishes
  - Standards and procedures for issuing and renewing CTPs
  - Requirements for the pharmacology course
  - Standards and procedures for the conduct of the externship.
  - Recommendations to the Board of Nursing on the Formulary

The Formulary:

• The CPG has been reviewing the formulary over an extended period of time and has completed its initial review.
  - This will be an ongoing process as experience is gained and as new drugs become available.
  - The CPG is very open to input from psychiatrists (but appears wary of being overwhelmed with physician input).
  
• Drugs are placed in one of 5 categories
  - Non-formulary (an APN cannot prescribe)
  - CTP holder may prescribe
  - Physician initiated (a physician must personally evaluate the patient and prescribe the medication; an APN can then continue, modify or stop the medication)
  - Physician consult (the APN can initiate the medication, but only after discussing the case with the collaborating physician)
  - Additional parameters (e.g., with some medications an APN may initiate but is required to review the case with the physician within a specified time frame)

Psychiatric medications and the Formulary:

• Antipsychotic medications are the only class in the entire formulary where a distinction is made between a specialty nurse, in this case a psychiatric CNS, and other nurse prescribers.
  - Psychiatric APNs can initiate an antipsychotic medication.
  
• There must be a physician review within 60 days.
  
• Clozapine, thioridazine, mesoridazine and pimozide are exceptions which must be physician initiated.
  
• Other APNs with a CTP can prescribe antipsychotic medications only after physician initiation.
  
• OPA and two psychiatrists, myself and Dr. Alan Castro from the VA did have input into the formulary in terms of psychiatric medications. This resulted in several significant changes from the draft formulary including:
  - Permitting APN initiation of antipsychotic medications, with the noted exceptions.
  - Requiring that amoxapine and nefazodone be physician initiated.
  - Clarifying that lithium is most appropriately classified as a mood stabilizer or anti-manic agent and having it specified in the formulary (rather than lumped as an antipsychotic agent).
  - Eliminating meprobamate and glutethimide from the formulary.
  - Specifying the list of anticonvulsants being used in psychiatry.

In order to prescribe the APN must enter into a "Standard Care Arrangement" with a physician. Psychiatric nurses must have their SCA with a psychiatrist. Once an externship is complete, the CTP holder prescribes independently under the SCA. Therefore the SCA is critical. In the SCA specific parameters are delineated around the scope of prescriptive authority. Formulary restrictions can be specified; the SCA specifies which drugs, if any, can be prescribed off label and for what "clinically sanctioned" off label use. The SCA also delineates the quality assurance process which includes a process for review of the nurse's prescribing practice.

Given the critical role of the SCA, OPA leadership has discussed the possibility of developing a model SCA for psychiatrists to consider as we enter into collaborative relationships.

A couple of final points: the statute specifies that for the purposes of prescribing a physician cannot collaborate with more than three APNs at the same time. I already pointed out that psychiatric CNS's must collaborate with a psychiatric physician. This offers us real opportunities to collaborate and enhance our ability to meet the tremendous unmet patient needs, especially for people with serious mental illness. However, I believe there may also be a risk we should attend to. Non-psychiatric APNs can prescribe psychiatric drugs in collaboration with non-psychiatric physicians. What if there are collaborations between non-psychiatric physicians, non-psychiatric nurses and non-medical mental health professionals? I fear such collaborations could push physicians and nurses beyond their appropriate scope of practice and could result in patients not getting the specialty care they need. I believe OPA should discuss this issue and perhaps open a dialogue with our primary care colleagues.

I warned you early in this column that I would likely raise more questions than I would answer. As we get experience with APN prescribing, answers and still more questions are sure to arise.

Mark R. Munetz, M.D., Chair, Public Mental Health Committee

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