What is a collaborative agreement?

Collaborative agreements are one of the most important topics for Illinois Nurse Practitioners and Illinois health systems. What is a collaborative agreement? A collaborative agreement sets forth the procedures that a Nurse Practitioner will use to work with doctors in the "supervision" of her patients. The collaborative agreement is part of the "supervision requirements" for Nurse Practitioners under Illinois law. As you can imagine, a collaborative agreement is required for every piece of paper containing the words "controlled substance" that an NP fills out either electronically or on paper. At the current time that likely comes to about 50% of all prescription blanks in the Illinois health systems we care about. This is reason number one that NPs need collaborative agreements. It is a time suck. A real time suck, made worse by the fact that NPs have to apply for their own DEA number. What is the purpose of a collaborative agreement? In order to appropriately render services under the Illinois Nurse Practice Act regulations, an advanced practice nurse with an Illinois nursing license must be supervised by a physician with an Illinois physician and surgeon license . This requires a collaborative agreement (this law has even survived a serious constitutional challenge) (See Illinois PRACTICE ACT OF THE ILLINOIS NURSE PRACTICE ACT, 225 ILCS 65/ 65-15). The collaborative agreement is a tool utilized by physicians and Nurse Practitioners in which they can readily and quickly agree to cooperate in providing optimal medical care to Illinois residents. It is a win-win for patients in that they get the benefit of a supervising physician and access to services artfully rendered by NPs. A collaborative agreement is required for every prescription by an NP for a controlled substance according to Illinois administrative regulations. 68 Ill. Adm. Code 1300.240(b)((1)). Why is a collaborative agreement important? The collaborative agreement is important for several reasons, but most importantly it is a regulatory requirement. It is the primary way Board of Pharmacy (IDFPR) (who regulates NPs and APNs) monitors NPs by being notified when an NP violates the collaborative agreement in some way or fails to cooperate with the supervisory relationship. Nurse Practitioners need collaborative agreements in order to render care.

The law in Illinois

Nurse Practitioners (NPs) in Illinois currently have a limited right to practice autonomously. However, certain critical aspects of their practice requires a collaborative agreement ("CA") with a physician licensed in Illinois.
Pursuant to the Nurse Practice Act of 2007 ("the Act"), all Illinois NPs must be "supervised" by a physician licensed to practice medicine in all its branches. However, the Act provides that, contrary to prior versions of the Nurse Practice Act, NPs may now enter into a CA, which "authorizes nurse practitioners with prescriptive authority to prescribe and either directly dispense, except for controlled substances, or delegate the dispensing of legend drugs and controlled substances in accordance with State or federal law". 225 ILCS 65/65-30. This law provides that where a CA is entered into by the NP and the collaborative physician, the NP may write orders and/or prescriptions pursuant to that CA. Essentially, the CA can be thought of as a letter of authority signed by both the NP and the collaborating physician.
The CA can be used to outline the circumstances under which an NP can write prescriptions or orders of individual patients that are not specifically listed in the CA, and can also be written further to include specific orders and drugs within the prescribing authority conferred by the CA.
It is important to note that the Act goes a step further to provide that a CA "shall be recognized" in Illinois, and, importantly, "If an offsite practitioner is responsible for at least some of the care provided to a patient in Illinois, the collaborating practitioner with whom the patient has a CA shall establish a mechanism for providing on-site arrangements with a practitioner licensed in this State who has the competencies necessary to collaborate with the nurse practitioner regarding any care provided to the patient in Illinois." 225 ILCS 65/65-30(d). This grant of authority to establish a mechanism for writing orders for patients in Illinois is in contrast to certain other states, such as New Jersey, where the requirement to establish a contact person for the off-site practitioner may be stricter than in Illinois.
Another significant point to remember is that, while the Nurse Practice Act was amended to expand the authority of the NP in Illinois, if there is a conflict between the Nurse Practice Act and the Illinois Medical Corporation Act, the Act controls. 225 ILCS 65/65-10. The implication is that an NP may be limited in their ability to act autonomously based on, or to the extent allowed by the regulations governing medical corporations in Illinois.

Components of the agreement

To fully understand how delegation works in Illinois, we must identify the primary components of a written collaborative agreement between a nurse practitioner and a physician that is required by law. The Illinois Nurse Practice Act specifies that the agreement must: (1) identify the licensed professional nurse and the participating physician, and contain a statement of their practice arrangement; (2) describe the quality assurance procedures that will be used; and (3) set forth a plan for professional development of the nurse.
Newly practicing nurse practitioners may only practice with a collaborating physician for the first three years following either the opening of a practice or completion of a 160-hour supervisory clinical preceptorship, whichever occurs first. To practice unsupervised in Illinois, nurse practitioners must fully meet the criteria for such practice and follow the provisions set out in the statute.
The collaboration agreement must include an understanding about the nurse practitioner’s duties, responsibilities, role and physician oversight. Primary care agreement compliance issues will be monitored by the Department of Financial and Professional Regulation’s Division of Professional Regulation. In particular, if an APRN fails to demonstrate competency as required by the collaborative agreement, it is the collaborating physician’s responsibility to supervise and investigate the conduct that created the concern.
An initial collaborative agreement for a nurse practitioner should be with a board-certified family physician, internist, pediatrician or obstetrician, depending on the specialty of the nurse practitioner. In other specialties, the supervision of a physician who also specializes in that area of expertise is preferred. However, certification is not necessary for physician supervisors in a clinical area not covered by a board.

How to draft the agreement

The Illinois Nurse Practice Act outlines the process by which an advanced practice nurse (APN) may enter into and maintain a collaborative agreement with a supervisory physician. According to the Illinois Nursing Practice Act, a "collaborative agreement is an agreement between a physician and an advanced practice nurse that provides for the joint development of a plan to deliver health care within a recognized nursing specialty by the advanced practice nurse." The collaborative agreement must be in writing and signed by the advanced practice nurse and the supervisory physician. The collaborative agreement must include the following provisions:
• The types or categories of patients under the care of the advanced practice nurse
• A description of any limitations or restrictions on the prescriptive authority of the advanced practice nurse
• A description of the procedure the advanced practice nurse must use in prescribing drugs or devices
• Procedures for the transferring of a patient’s care between the advanced practice nurse and the supervisory physician
• Procedures for consultation and referral with respect to patient care that ensure the availability of the supervisory physician to the advanced practice nurse and the patient.
It also must provide that the supervisory physician will review the advanced practice nurse’s patient records at least once every 30 days and that the supervisory physician will see the patient of the advanced practice nurse at least once per 60 days. Under the Illinois nurse practice act, a collaborative agreement must provide that the supervisory physician will designate a substitute physician qualified to provide consultation and referral when the supervisory physician is not available. The collaborative agreement must provide for a 5 years (or less) period not to exceed 1 year if the advanced practice nurse:
• Works less than 4,000 hours a year, or
• Is employed by or practices at a state-operated facility.
After the initial 5-year period, if the supervisory physician has not violated the collaborative agreement, the collaborative agreement must provide for a period of 10 years. If there are any amendments to the agreement after the initial 5-year period, the supervisory physician or the advanced practice nurse shall report the amendment to the Department within 60 days after the amendment is adopted or agreed to, including the name and address of the substitute physician designated as provided in the collaborative agreement. The reason for the amendment must also be included in the notification to the Department.

Practice integration and its advantages and hurdles

Collaborative agreements have long made nurses’ lives easier, creating a legal and practical framework for their scope of practice and adoption. These documents are designed to create the foundation for the nurse practitioner’s ability to treat patients and share the patient’s complete record with the collaborating physician. They also create a patient safety benefit, as physicians cannot act outside their scope without exposing themselves to sanctions for practicing medicine without a license or cause for disciplinary action against their own license.
Seamless integration into daily practice should be expected once an agreement is in place. However, nurse practitioners who attempt to operate independently of their collaborating physician should expect push back. Arguments for NP independence, such as "it’s in writing," may not make much sense from a legal perspective:

• "I’m working in my scope of practice" – if the NP didn’t already discuss a procedure or the like with the physician and get it on the collaborative agreement, then operating independently without any new agreement on that procedure is going to be hard to explain when challenged by the Illinois Department of Professional Regulation or in a failure to diagnose case.
• "I didn’t want to bother my collaborating physician"- I hear this one frequently; the NP works independently because they don’t want to be an annoyance. However , if an NP operates under the collaborative agreement, it’s almost certain that they will need to consult with the collaborating physician to verify that the proposed treatment is appropriate and that the NP has the requisite skills for the procedure.
• "I already do it well" – the issue of NP ineptitude is a separate topic. However, depending on the NP’s training, he or she may not have actually mastered the procedure or treatment they propose to undertake in a different situation. Are they doing it the same way that the physician would have done it? Did the NP actually learn and practice enough to establish the procedure’s nuances? If not, and the NP can’t convince the physician that he or she is qualified to use the procedure, then the NP’s struggle to gain independence is real.

Collaborative agreement work has pros and cons. The NP should expect to have to make some sacrifices, such as carefully avoiding independence and extra work to complete new collaborative agreements periodically. But the NP and the physician both benefit from the ability to work together towards a common goal: good patient care.

Downloading and using the pdf form

Collaborative agreements can take a long time to draft, and send back and forth between the physician and the nurse practitioner before mutual agreement. Drafting it out from scratch is usually the most time-consuming step of the entire process, and as such, many nurse practitioners will use a collaborative agreement template that is publicly available online. There is a variety of collaborative agreement templates in PDF form available on the internet. These versions are typically the most reliable, as they are the ones utilized directly in practice by other nurse practitioners in Illinois.
To access an appropriate template, simply by searching for "Illinois collaborative agreement template," generally at least a few page one results are suitable for downloading. In order to download the PDF file, simply find the result that contains these keywords, "Illinois collaborative agreement nurse practitioner PDF template," and click on that result.
At this point, simply select "Download" and select "Save PDF." Then, the document is easily accessible from the Downloads section of your internet browser.
The next step is to use the document and fill it out appropriately. This is very easy, as a PDF file allows you to add text boxes wherever there is a blank space. Simply hover over the lines of text that need to be filled in and select the option to insert a text box into the document. Now, you can either use your keyboard to fill out the spaces or handwrite the information you need to add on a piece of paper, scan it, and transfer it into the template by utilizing the "insert PDF" function on the document editing screen.
Do not forget that both parties must sign the document. Many nurse practitioners will often attempt to solely print out their version of the collaborative agreement even if the physician has not reviewed the document yet. However, both parties to the contract must be in agreement and sign the document for it to be valid. If any changes are necessary after drafting the document, go back into the PDF file and make any necessary edits in order to adapt the document to a variety of situations. This will streamline the editing process and make it easier to resolve issues as they arise.

Looking ahead and possible changes

Assuming that effective and meaningful collaborative agreements are put in place and implemented correctly, the changes to the practice of nurse practitioners should be nothing short of remarkable and, ultimately, will increase access to health care across the board in Illinois. Patient access to both primary care services and specialist physicians are inevitable. But, more importantly, it is expected that the health outcomes for patients will markedly improve with increased access, continuity of care and less expensive options for patients.
Word is that, the type of change in the law to which we have been accustomed for years, such as expanded scopes of practice for physician assistants, will be proposed. Whether these proposed changes will become law remains to be seen. However, we have already begun to see new language added by the legislature to the Physician Practice Act, the Dentistry Practice Act, the Podiatry Act, the Pharmacy Practice Act and other acts, expressly allowing these professionals to practice pursuant to "written collaborative agreements." This is the road-map for nurse practitioners in Illinois and what every single health-care provider should be preparing for to be able to survive in the new world order that is coming .
As we see it, the most significant changes will occur with respect to how health care systems, hospitals and health care providers, across the board, will deal with nurse practitioners going forward. We will see increased competition for starting salaries and employment contracts for nurse practitioners. Further, we may see a future in which independent practices no longer exist and instead, health-care provider networks become the norm for clinics and groups and solo practices. These changes are not necessarily a bad thing and will more likely lead to fairly straightforward licensing and credentialing processes. Already, our experience in representing new clients demonstrates that there is a trend toward a designated department within hospitals and health-care provider networks that are responsible for the credentialing of the advanced practice nursing. This is a change for many hospitals but not all hospitals will handle these changes in the same way. The issues facing hospitals are a fresh opportunity for nurse practitioners and health-care provider networks to negotiate advantageous licensing, appointment and credentialing processes for nurse practitioners, as a condition of the collaborative relationship or employment.