The Collaborative Agreement That Wasn't Signed
A hygienist in a state that allows collaborative practice without a dentist on-site has a written collaborative agreement with a dentist who practices 60 miles away. The agreement specifies the services she may provide, referral protocols, and an annual review. Six months in, the collaborating dentist relocates out of state and stops responding to calls. The hygienist continues seeing patients in a public health clinic, including performing prophylaxis and applying fluoride varnish, because "the agreement is still on file." A new patient with uncontrolled diabetes and severe periodontal disease needs referral. The hygienist also wants to place locally delivered antimicrobials, which the agreement does not list. The clinic director tells her to "just keep going, we're short-staffed."
1. Can the hygienist continue practicing under the collaborative agreement after the dentist relocates and stops responding?
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Not on autopilot. A collaborative agreement is a live relationship, not a filed document. Most collaborative-practice statutes require an identified, licensed, in-state collaborating dentist who is available for consultation and referral and who participates in the required review. If the dentist has relocated out of state and is unreachable, the conditions of the agreement likely can no longer be met.
The hygienist should: (1) verify the statute's requirements - in-state licensure, availability, review frequency, and whether the agreement terminates automatically on the dentist's departure; (2) attempt documented contact with the dentist; (3) notify the clinic director and, if needed, the board, and seek a replacement collaborating dentist; (4) in the interim, determine whether any services (e.g., certain preventive care) may lawfully continue under a different provision, and suspend services that depend on the collaboration. 'The agreement is still on file' is not a legal basis. The director's staffing pressure is not a defense to the licensee.
2. How should she handle the diabetic patient's referral and the request to place locally delivered antimicrobials?
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Referral: uncontrolled diabetes with severe periodontal disease is a medical/periodontal co-management situation. The referral protocol in the agreement should be followed, but with the collaborating dentist unavailable, she must use an alternative documented pathway - refer to the patient's physician and to a periodontist/dentist able to assume care, document the findings and the referral, and ensure the patient is not left without follow-up. Do not let the broken agreement become a reason the patient goes unreferred.
Locally delivered antimicrobials: placing them is a scope question. If the procedure is within hygienist scope only when authorized in the collaborative agreement or by direct supervision, and the agreement does not list it, she cannot perform it. She should not expand her own scope because the clinic is short-staffed. Options: obtain an amended agreement with a qualified collaborating dentist that expressly includes the procedure (if state law permits hygienists to perform it at all), or refer the patient for that treatment. Document the scope determination and the reason for deferral.