CPAP Module 19, Section 2: Partnering with Nurses and Care Managers
MODULE 19: INTERPROFESSIONAL COLLABORATION

Section 2: Partnering with Nurses and Care Managers

Building Alliances on the Front Lines of Patient Care.

SECTION 19.2

Partnering with Nurses and Care Managers

Building Alliances on the Front Lines of Patient Care.

19.2.1 The “Why”: The Care Team as a Force Multiplier

If the prescriber is the strategic decision-maker, then nurses and care managers are the logistical and operational commanders on the front lines of patient care. In your community practice, your interactions with the broader care team might have been limited or indirect. As a CPAP, however, these professionals become your most vital allies. They are the individuals who have the most direct and frequent contact with the patient, who understand the nuances of their home life, and who manage the day-to-day execution of the care plan. To ignore them is to work with one hand tied behind your back; to partner with them effectively is to amplify your own impact tenfold.

Nurses, both in the inpatient and outpatient settings, are the primary point of contact for patients with questions and concerns. When a patient is told a medication needs a “PA,” their first call is rarely to the insurance company—it is to the nurse at their doctor’s office. An uninformed nurse can only say, “I’m sorry, we’re waiting on the insurance,” which creates patient anxiety and frustration. An empowered nurse, armed with a clear, concise update from you, can say, “Yes, we’re working on that. The specialty pharmacist has already submitted the request and is just waiting for the doctor to send one more lab result. They expect to have an answer for us by tomorrow afternoon.” This transforms the patient experience from one of uncertainty to one of confidence in their care team.

Care managers, also known as case managers, take a broader, more holistic view. They are concerned not just with a single prescription, but with the patient’s entire journey through the healthcare system. They are masters of resource navigation, helping patients overcome barriers like transportation, financial hardship, and health literacy. For a CPAP, the care manager is a treasure trove of contextual information that can be the key to unlocking an approval. They may know that a patient has already failed a preferred medication while under the care of a previous physician, or that a patient’s home situation makes a once-monthly injection far more feasible than a daily oral pill. They are your partners in building the non-clinical side of the medical necessity argument, which is often just as important as the clinical data.

This section is dedicated to forging these critical partnerships. You will learn to see the healthcare system through their eyes—to understand their workflows, respect their expertise, and provide them with the specific, actionable information they need to do their jobs effectively. By investing in these relationships, you will build a powerful network of allies, all working in concert to ensure patients get the medications they need as quickly and smoothly as possible. You move from being a solo practitioner to being the central communications hub for the entire medication access process.

Retail Pharmacist Analogy: The Pharmacist and Lead Technician Partnership

Think about the busiest day you ever had in your retail pharmacy. You have a line of patients, phones ringing, a stack of prescriptions to verify, and an immunization clinic in full swing. You cannot do it all alone. Your success depends entirely on your partnership with your lead technician.

A dysfunctional partnership looks like this: The technician constantly interrupts your workflow with questions you’ve already answered. “Where is the metformin? What’s the NDC for this? This script is rejecting, what do I do?” They put angry customers on the phone with you without any context. You feel like you’re doing two jobs at once: your own and theirs.

A high-functioning partnership looks like this: You have empowered your lead technician. They know the workflow. They can solve 90% of the insurance rejections on their own. When they do need you, they come prepared. “Dr. Smith, I have Mrs. Jones on line 2. Her Cialis rejected for a PA. I’ve already checked her profile and she’s never tried generic sildenafil. I told her that’s likely the first step. Do you want to speak with her or shall I have the intern call Dr. Smith’s office to request the switch?”

This technician is not just a helper; they are a force multiplier. You have invested time in training them, you trust their judgment, and you provide them with the information they need to operate independently. This frees you up to focus on the high-level clinical tasks that only a pharmacist can do: counseling, verifying, and immunizing. Your relationship with nurses and care managers is identical. By providing them with clear, actionable information and trusting their expertise, you empower them to manage patient communication and gather essential data, freeing you to focus on the complex clinical arguments and strategic navigation of the PA process.

19.2.2 Speaking Their Language: Understanding Nursing and Care Management Workflows

To effectively partner with nurses and care managers, you must first understand the world they operate in. Their priorities, documentation methods, and daily tasks are different from yours and from the prescribers’. By aligning your communication with their existing workflows, you make it easier for them to help you. Pushing information in a way that disrupts their flow will be met with resistance, while integrating into it will be welcomed.

Masterclass Table: Nursing & Care Management Workflows and Your Integration Points

Task / Workflow Primary Objective The PA “Pain Point” The CPAP Solution & Integration Point
Patient Triage (Phone/Portal) Quickly assess a patient’s reported symptom/issue, determine urgency, and route them to the appropriate level of care or provide a pre-approved provider response. A patient calls asking, “Why isn’t my prescription ready?” The nurse has no information and must interrupt the provider to ask for a status, creating a work cascade. Provide proactive, templated updates in the patient’s chart. “PA for Ozempic submitted 10/15. Pending A1c results. ETA for determination: 48-72 hours.” The nurse can now confidently answer the patient’s question without escalation.
Rooming a Patient / Pre-Visit Prep Gather vital signs, update medication lists (medication reconciliation), and understand the reason for the visit to prepare the provider. A PA was denied for a patient’s biologic, and the provider wants to discuss alternatives at today’s visit, but the nurse doesn’t know what the formulary options are. When a PA is denied, send an EHR message to the provider’s nursing pool: “FYI for Mr. Smith’s appt today: PA for Taltz was denied. Formulary alternatives are Humira and Skyrizi. I have attached the payer’s clinical policy for reference.” The nurse can print this and have it ready for the provider.
Patient Education & Counseling Explain new medications, disease states, or treatment plans to patients in an understandable way, ensuring they know how and when to take their medicine. A PA is finally approved, but the medication has a complex administration (e.g., a self-injection device) and the nurse is unfamiliar with it. When you confirm an approval, include a link to the drug’s administration video or a printable patient-friendly injection guide in your closing note. “Farxiga PA approved. For patient education, here is a link to the manufacturer’s ‘how to’ video: [link].”
Care Coordination / Discharge Planning (Primarily Care Managers) Ensure a smooth transition from one care setting to another (e.g., hospital to home), making sure all necessary prescriptions, equipment, and follow-up appointments are arranged. A patient is ready for hospital discharge, but the critical new anticoagulant requires a PA, and the process hasn’t even been started, potentially delaying discharge by a day or more. Work with inpatient care managers proactively. Introduce yourself as their outpatient PA resource. Encourage them to send you potential discharge PA issues 24-48 hours *before* the planned discharge so you can begin the work concurrently.
Benefit Investigation (Primarily Care Managers) Help patients understand their insurance benefits and connect them with financial assistance programs, manufacturer copay cards, or charitable foundations. A PA is approved, but the copay is $500, and the patient cannot afford it. The care manager now has to start a new, lengthy search for assistance programs. Integrate financial assistance into your workflow. When you secure an approval for a high-cost drug, investigate copay card eligibility simultaneously. “Dupixent PA approved. Patient is eligible for the MyWay copay card, which should reduce their cost to as low as $0. The enrollment link for your team is here: [link].”

19.2.3 The Art of the Actionable Update: Moving Beyond “It’s Pending”

One of your most frequent and important interactions with the nursing team will be providing status updates on pending PAs. This communication is an opportunity to either reduce their workload and build confidence, or to create more questions and frustration. The phrase “it’s pending” is technically true but functionally useless. It gives the nurse no information to relay to an anxious patient and no sense of a timeline or next steps.

An expert CPAP provides actionable updates. These updates are concise, specific, and always answer three key questions: 1. What is the current status? 2. What is the specific barrier or next step? 3. What is the Expected Timeframe? By providing this level of detail, you transform a passive status check into a proactive communication that manages expectations for the entire team, including the patient.

The Communication Killer: Vague vs. Actionable Updates

Let’s compare two updates for the same situation: a PA for Jardiance is held up because the payer needs a recent eGFR lab value.

The Vague (Bad) Update

“Hi, just wanted to let you know the Jardiance PA is still pending. The insurance needs more info.”

Result: The nurse now has more questions than answers. What info? Who provides it? When? They have to start a new investigation, possibly interrupting the provider. The patient gets told, “We don’t know.”

The Actionable (Good) Update

“EHR Message to RN Pool: Update on Jardiance PA for J. Smith: Submission is on hold pending a recent eGFR. I see labs were drawn this morning. As soon as the eGFR posts to the chart, I will complete the submission. Expect determination within 24-48 hours after that.”

Result: The nurse knows exactly what is needed (eGFR), who is acting next (you), and the timeline. They can confidently tell the patient, “The pharmacist is just waiting for your lab results from this morning and will send everything in once those are back.”

19.2.4 Leveraging Care Managers as Strategic Allies

While nurses are your partners in the immediate, day-to-day workflow, care managers are your partners in long-term, complex case strategy. Their expertise lies in understanding the patient’s holistic situation beyond the confines of a single diagnosis or prescription. Engaging them early and often on difficult cases can be the difference between a frustrating denial and a successful approval.

The Care Manager Consultation: Questions to Ask

When you have a complex case—a patient with multiple comorbidities, a history of non-adherence, or facing a difficult formulary—schedule a brief call or send a detailed message to the patient’s care manager. Your goal is to gather the non-clinical context that strengthens your case. Frame your questions to tap into their unique expertise:

  • “I see the plan wants the patient to try Tablet X, but the doctor has prescribed Patch Y. From your perspective, are there any adherence barriers with a daily oral medication for this particular patient?” (This might reveal memory issues, caregiver schedules, or swallowing difficulties that make a patch clinically preferable.)
  • “The PA for this injectable was denied, and one of the preferred alternatives requires refrigeration. Do you have any insight into the patient’s housing stability or access to a reliable refrigerator?” (This addresses social determinants of health that can be a key part of a medical necessity argument.)
  • “We are trying to get approval for a long-acting injectable antipsychotic. Can you provide any context on the patient’s support system or transportation challenges that would make monthly clinic visits for an injection more successful than relying on daily oral adherence?” (This connects the choice of formulation directly to the patient’s real-world environment.)
  • “This medication has a high copay even after approval. Are you already working with this patient on financial assistance, or would you like me to send over the copay card information I’ve found?” (This shows you are thinking ahead and positions you as a collaborative partner in solving the patient’s financial access issues.)

19.2.5 Closing the Loop: Documentation and Follow-Through

Effective partnerships are built on reliability. When you tell a nurse or care manager you are going to do something, you must do it. And just as importantly, you must let them know it has been done. Every communication loop that you open must be formally closed. This final step in the communication workflow is essential for building trust and ensuring the entire team has a shared, accurate understanding of the case status.

Your organization’s EHR or case management platform is your primary tool for this. Every substantive interaction—a phone call where a decision was made, a crucial piece of information received, a submission sent to a payer—must be documented in a concise, professional note in the patient’s chart. This is not just administrative busywork; it serves several critical functions:

  • It Creates a Single Source of Truth: Anyone on the care team can look at the chart and know the exact status of the PA without having to track you down.
  • It Prevents Duplication of Work: A clear note prevents a nurse or MA from unknowingly starting the same work you have already completed.
  • It Builds a Historical Record: For future PAs or appeals for the same patient, this documentation provides a clear history of what was tried and what was communicated.
  • It Demonstrates Your Value: A consistent record of professional, effective interventions makes your contribution to the team tangible and visible.

Masterclass Table: “Closing the Loop” Communication Templates

Event Documentation / Communication Template Audience Purpose
PA Submitted “PA for Entresto submitted to Aetna on 10/15/25 at 2:30 PM. Case #12345. Standard turnaround time is 3-5 business days. Will update with determination.” Chart Note / EHR Message to RN Pool Confirms the action is complete and sets a clear expectation for the timeline.
PA Approved “PA for Entresto approved by Aetna, effective 10/17/25 for 12 months. Approval is on file at CVS Caremark. Prescription has been transmitted. Patient has been notified.” Chart Note / EHR Message to RN Pool & Care Manager Provides a definitive resolution and confirms all necessary downstream actions (sending Rx, notifying patient) have been completed.
PA Denied “PA for Entresto denied by Aetna. Reason: Lack of trial of preferred SGLT2 inhibitor. Formulary alternatives are Jardiance and Farxiga. Will discuss with Dr. Halpert this afternoon to determine next steps (appeal vs. formulary switch).” Chart Note / EHR Message to Prescriber, CC RN Pool & Care Manager Clearly states the reason for the denial, presents the available options, and outlines the immediate next step in the plan.
Information Received “Spoke with RN Kevin Malone at 11:00 AM. He confirmed patient failed metformin due to severe GI distress in May 2024. This information has been added to the PA submission and sent to the payer.” Chart Note Documents the receipt of critical information from a team member and confirms that the information has been acted upon.