Improving Access, Adherence, and Outcomes Through Pharmacist-Driven CPAs

In this Q&A with Pharmacy Times, Ryan Fuller, PharmD, discusses how collaborative practice agreements (CPAs) in neurology empower pharmacists to play a central role in managing multiple sclerosis (MS) through delegated authority to order labs and medications. He explains how these agreements streamline therapy initiation, improve adherence, and ensure consistent safety monitoring by allowing pharmacists to guide patients through treatment decisions and follow-up. Fuller highlights that pharmacist involvement has reduced delays related to lab completion and insurance authorization, leading to faster, more coordinated care. He also notes that embedded pharmacists help bridge gaps in access when providers are busy, supporting continuity of treatment. Looking ahead, he emphasizes plans to expand CPAs to additional neurologic disease states and underscores their growing value for providers, patients, and interdisciplinary care teams.

Pharmacy Times: Can you walk us through how CPAs are structured at your institution, specifically how authority is delegated between neurologists and pharmacists, and which clinical decisions pharmacists can make independently vs those that require escalation?

Ryan Fuller, PharmD: The CPA at Penn, specifically in neurology, is set up where the pharmacist has authority delegated by the physicians to order certain medications and labs related to MS, specifically for patients [with MS]. It has a very narrow definition of this collaborative practice and is really limited to disease-modifying therapies at this point, and labs associated with starting and maintaining patients on those disease-modifying therapies. At this time, we don't have any collaboration outside of those specific medications, although we've discussed expanding the CPA to include symptom management medications within MS as well.

Pharmacy Times: How do CPA scope and pharmacist authority differ across neurologic disease states (such as MS, spinal muscular atrophy, and myasthenia gravis), and what drives those differences clinically or operationally?

Fuller: So, at the moment, we have a CPA with patients [with MS], and we also have a migraine CPA in place. But outside of those 2 areas, we don't have CPAs established at this point. We do plan on incorporating CPAs in myasthenia gravis, movement disorders, and memory medications for patients. The limitation at this point is where we have pharmacists present, serving in this role of an embedded pharmacist within the clinic. We have most of our pharmacy focus on [patients with] MS, NMO [neuromyelitis optica], and migraine, and we're working to expand that reach to some of the other areas of neurology. So that's the main limitation at this point. In the future, we plan to have CPAs in place for all of those different disease states.

Pharmacy Times: Under your CPAs, what clinical actions can pharmacists independently initiate or modify for patients with MS, including therapy selection, dose adjustments, lab ordering, adverse effect management, or switching disease-modifying therapies (DMTs)?

Fuller: So, our CPA is structured where we can order labs for patients on these DMTs, specific to the DMT, so only labs that are related to patients who are either starting or continuing these DMTs. We can also order the medications themselves. We have the freedom to select which DMT the patient starts, obviously in collaboration with the provider. We always make sure that we know what the provider’s goals are with the patient, and based on how the patient is doing clinically and how the provider feels the MRI activity looks, we can help the patient decide which medication makes the most sense for them and then order those medications.

The CPA allows us to order these medications. We don’t, in Pennsylvania, have prescriptive rights to order them independently, so this is our way of being able to order these medications through this collaborative practice agreement. Hopefully, in the future, we will have those prescriptive rights, but at this point, it’s not something that we have in Pennsylvania.

Pharmacy Times: What breaks down in MS care when CPAs are not in place, and which pharmacist-led interventions would realistically not occur without CPA authority?

Fuller: So, I think the breakdowns that can occur are related to patients who haven’t completed labs or are struggling to get medications ordered and authorized through insurance plans. I think those are the primary breakdowns that we were seeing prior to implementation of the CPA. Starting MS medications often requires more involvement by the team to get patients started, and allowing the pharmacist to be involved in the process has definitely expedited the initiation of therapy and ensured that patients are doing safety monitoring labs and have touch points with the team to make sure that they’re safely continuing on the medications as well.

I think we’ve helped to streamline the start process and made sure that all the safety measures are in place to continue therapy in patients in the practice.

Pharmacy Times: What measurable outcomes have improved with pharmacist-neurologist collaboration under CPAs, whether clinical outcomes, access to care, adherence, or clinic efficiency?

Fuller: So, I think the first thing that we identified when we implemented the CPA was that we were getting patients started on therapy much more quickly than previously. The pharmacist was able to walk the patient through the process, help them make a decision about which medication to start, get the labs ordered, get the medications ordered, and help facilitate getting the patient started at a much quicker rate than we were seeing previously.

Our involvement in patient follow-up has also helped with adherence. We’re ensuring that patients adhere to lab monitoring, and we’re able to see patients if the providers are too busy, which can help maintain patients on therapy. In our practice, we always want to make sure we see patients every 6 months or so, which can be challenging. Having the pharmacist involved can sometimes bridge those challenges and make sure patients have been seen by a pharmacist and continue their therapy.

Pharmacy Times: Looking ahead, how do you see CPAs evolving in neurology care, and what opportunities exist to further expand the role of pharmacists in improving outcomes for patients with neurologic conditions?

Fuller: I think we will continue expanding the CPAs in our clinic and adding different disease states. We plan to add NMO to the disease states that we’re covering, as well as some of the other diseases that I mentioned earlier. We’ve seen with MS that there is better adherence to medication and lab monitoring, and it also offers patients an opportunity to have easier access to someone in the clinic they can talk to about their medication.

I do think that we will continue expanding beyond MS and migraine and add other disease states to the CPA that we’re using currently. At Penn, we’re also seeing CPAs advanced in other areas outside of neurology. I think this is advantageous to providers and patients. As more areas adopt these CPAs, I think the pharmacist’s role will expand, and we’ll see better care for patients. Providers will see the advantage of having the pharmacist involved in helping with follow-up and doing some of the legwork they’re currently handling.