How One MS Pharmacist Used a Collaborative Practice Agreement to Transform Patient Care at Duke

At Duke Neurological Disorders Clinic, clinical pharmacist practitioner Jenelle Hall Montgomery, PharmD, BCACP, CPP, isn’t just advising on medications—she’s prescribing them, switching them, and managing the full arc of a patient’s disease-modifying therapy and symptom treatments, independently and on her own schedule. That autonomy is made possible by a collaborative practice agreement (CPA), a model that Montgomery says has allowed her to practice at the top of her license and forge something rare in MS care: a true, 1-on-1 relationship between pharmacist and patient. Here, she breaks down how the CPA came together, what it actually empowers her to do, and what other pharmacists need to know if they want to build something similar.

Q: Walk us through how your collaborative practice agreement (CPA) came to be and what the impetus was, what stakeholders you needed to have involved, and what it took to get that off the ground.
Jenelle Montgomery, PharmD, BCACP, CPP: There are key components to becoming a Clinical Pharmacist Practitioner (CPP). The overall process involves creating a CPP protocol agreement for your clinic and meeting the qualifications to be approved as a CPP through the North Carolina Board of Pharmacy. Within the MS clinic, I work with both a primary and a backup supervising physician who provide essential guidance and oversight. They help troubleshoot any complex cases if needed and review our protocols to ensure that the medications we prescribe or adjust and the laboratory monitoring we order are appropriate and aligned with best practices. Their support is critical to the success of the role.

I feel that another key component after becoming a CPP is having strong institutional support. The pharmacy department at Duke has been incredibly supportive in helping us achieve our goals and ensuring that we are able to practice at the top of our scope and license. Having both physician oversight and departmental support has allowed me to establish pharmacist services and feel confident in my role as part of the MS care team.

In terms of getting established, Duke provided a strong foundation that allowed me to step into the role and begin contributing right away. One particularly valuable resource has been the inclusion of a pharmacy technician on our team, who assists with prior authorizations and coordination of appeals. This support helps streamline access to medications and allows me to focus more directly on patient care. While I was able to get started quickly, it took about a year or two to fully establish myself, especially in becoming more proficient in managing MS medications, building my patient schedule, and integrating into the workflow of the clinic. Over that time, I was able to grow into the role and begin making a more meaningful impact on patient care.

Q: What does the CPA authorize you to do that you couldn't do before? And can you give an example of what impact that has on patients?

Montgomery: A CPP protocol agreement clearly outlines the scope of what we are able to manage as clinical pharmacists, including the specific medication classes we can oversee. It defines our ability to initiate new therapies, adjust dosing, switch within or between medication classes, and discontinue medications when appropriate. In some settings, it may also include medication administration. The agreement also specifies the laboratory monitoring we are responsible for, ensuring that all aspects of patient care are clearly defined and standardized.

One of the greatest benefits of this agreement is the autonomy it provides within our scope of practice. It allows us to make timely, evidence-based medication decisions without requiring patients to wait for a physician visit for every adjustment. From the patient perspective, this leads to more efficient and responsive care. We are able to initiate, adjust, monitor, or discontinue therapies in a streamlined manner, helping to minimize delays and improve overall access to treatment. Ultimately, this model supports more coordinated, patient-centered care while allowing pharmacists to practice at the top of their training and expertise.

Q: Are you selecting DMTs for patients yourself, or is your role more consultative? Where does that line fall between you and the physician?

Montgomery: Yes, that's a good question. We do play an active role in helping patients select the most appropriate therapy. For example, if a patient is interested in an S1P modulator, there are now several options available. We take the time to review each option in detail, discussing the benefits and potential drawbacks so patients can make an informed choice.

In other cases, a provider may narrow the options to select between anti-CD20 therapies or natalizumab and ask me to guide the patient through those high-efficacy treatments. In those situations, I meet with the patient to provide a more in-depth discussion of each option, focusing on factors such as effectiveness, safety, and how well the therapy fits into their lifestyle.

With the growing number of MS therapies available, choosing the right medication can feel overwhelming for patients.

One of our key roles is to help navigate these options, simplify the decision-making process, and ensure the selected treatment aligns with the patient’s preferences and clinical needs.

Q: What are the factors driving therapy switches beyond cost, and what does a switch look like from your vantage point?
Montgomery: Patients are often referred to me when there has been a change in their disease course, for example, if they’ve experienced a relapse or had intolerable side effects. In these situations, it’s often an appropriate time to consider transitioning to a different disease-modifying therapy. After the patient has been evaluated by a neurologist or advanced practice provider and they provide recommendations, I work with the patient to explore the next treatment option.

During that process, I provide a detailed discussion of the recommended therapies, including their mechanisms of action, how they compare to prior treatments, and which options may be the best fit based on the patient’s clinical profile and preferences. We also review administration considerations, side effect profiles, and any associated safety warnings to support a well-informed decision.

Cost and access are also important considerations. In some cases, insurance coverage may influence the need to switch therapies. I work closely with patients to navigate these challenges by discussing available support programs, financial assistance options, and other resources to help ensure access to treatment and avoid delays or repeated barriers.

Overall, I play an active role in guiding patients through the transition to a new therapy, helping them identify the most appropriate option while ensuring the process is as smooth and supported as possible.

Q: For pharmacists or teams that want to develop something similar, what would you tell them are the biggest barriers and the first steps that they can take?

Montgomery: That’s a great question. One of the primary barriers is in practices that have not historically integrated pharmacists into the care team. In those settings, a key first step is demonstrating the value a clinical pharmacist can bring and helping the team understand how this role enhances patient care. This is especially relevant in the outpatient setting, where not all clinics have an established pharmacist presence. Clearly defining how a pharmacist fits within the team model is essential.

A key first step is demonstrating the value a clinical pharmacist can bring and helping the team understand how this role enhances patient care.

There are also practical considerations, such as clinic space and workflow logistics. For example, determining where patient visits will take place, how to build a schedule, and creating a streamlined referral process from providers are all essential components. These operational pieces can take time to develop and refine.

Engaging key stakeholders early on is critical. Starting with a supervising physician can help define the best approach for integrating into the clinic model. In addition, working with individuals such as the nurse manager or clinic leadership is important for addressing logistical needs, whether that involves securing clinic space or incorporating telehealth options.

Overall, the most common challenges tend to be a combination of awareness and logistics. However, once there is alignment across the care team and an understanding of the pharmacist’s role, integration tends to progress more smoothly, and the model can really gain momentum.

Q: Is there anything you want to add about CPAs or anything?

Montgomery: I’m really proud of the progress clinical pharmacists have made within neurology clinics, including utilization of CPAs. Over time, we’ve become increasingly integrated into the care team and have demonstrated the meaningful impact we can have on patient outcomes. It’s been exciting to see the role continue to expand, and I’m confident that we will keep building on this momentum and growing our presence in the future.