National Clinical Pharmacy Specialist (NCPS) Program Indian Health Service Pharmacy Innovation: National Clinical Pharmacy Specialist (NCPS) Program Title: Implementation of the Indian Health Service National Clinical Pharmacy Specialists (NCPS) Program Objective: To develop and implement a program that reviews and recognizes credentials of clinical pharmacists and attempts, assures uniformity of clinical competence through national certification and serves to promote universal recognition of pharmacists as billable providers. Methods: The NCPS Credentialing Committee (NCPSCC) was established in 1998 to develop a mechanism that assures a uniform level of clinical competency. Over the next 10 years, the NCPS Program advanced the level of clinical practice through its development of a set of requirements and processes to obtain certification. NCPS certification recognizes advanced scopes of pharmacist practice that optimize disease state management. It is now strongly recommended that all IHS facilities adopt, at a minimum, the NCPS standards for local credentialing. Results: Currently 104 IHS pharmacists are credentialed IHS-wide via the NCPS Program. Over 200 pharmacists have been credentialed since 1998. NCPS has credentialed more than 20% of IHS pharmacists. Areas of disease management include eight distinct clinical services such as diabetes, dyslipidemia, anticoagulation and smoking cessation. This certification program and outcomes collected have led to successful reimbursement (in specific states) from Medicaid and other third party payers. Implication: A cadre of pharmacists with increased uniformity of clinical competence has been established. The impact includes easier access to primary care - clinics are currently available in over 40 facilities across 12 states – and arguably improved quality of care as demonstrated by collected outcomes. NCPS is expanding to other federal agencies - another step toward uniform competence. This clinical infrastructure can further the goal of widespread pharmacist reimbursement at levels similar to primary care. This is of vital concern as we move toward broader reimbursement. Adaptability of this innovative program is feasible since external organizations are not necessarily required for implementation.

Indian Health Service 561 federalized tribes 600+ health facilities with 46 hospitals and 34 urban clinics across 38 states Comprehensive primary healthcare system Identifiable need and health disparity Large number of ambulatory sites

Overview For decades, IHS pharmacists have practiced in expanded clinical roles. IHS is widely known (private sector and academia) for its innovative pharmacy practice IHS serves as a robust example of successful interprofessional practice supported by Physicians IHS Standards of Practice (1988) #6. A pharmacist shall serve as the principal health care provider in selected patients with certain illnesses (includes discussion of chronic AND acute illness.

IHS Standards of Practice The provision of pharmaceutical care follows the six IHS Pharmacy Standards of Practice Assure Appropriateness of Therapy Confirm Understanding Assure Availability, Control and Preparation of pharmaceuticals Provide Education / Drug Information Provide Health Promotion / Disease Prevention 6. Manage Therapy

Innovation: Past and Present

IHS Pharmacy Practice In 1996, the scope of pharmacy practice in the IHS was officially broadened in Dr. Michael Trujillo’s October 18, 1996 memorandum: “Clinical Pharmacy Specialists will be included in the IHS definition of a primary care provider for the purposes of workload reporting, program planning, and reimbursement from all third party payers. An appropriate primary provider code will be assigned to CPS.” Pharmacy Code 067

Innovation: Past and Present - IHS and PHS leadership meet with HCFA to discuss IHS pharmacy practice and potential for pharmacist reimbursement. - First group of IHS pharmacists receive NCPS and NCPS-PP credentials. - IHS receives the APhA Pinnacle Award for IHS’ contributions to pharmacy profession 1996: IHS Director, Dr. Michael Trujillo codifies pharmacists as primary care providers via a special memorandum regarding Clinical Pharmacy Specialists 1998 (not 1995): The IHS National Clinical Pharmacy Specialist Credentialing Committee (NCPSCC) is born out of discussions surrounding decades of expanded practice 1998: IHS and PHS leadership meet with HCFA to discuss IHS pharmacy practice and potential for pharmacist reimbursement 1998: IHS wins the APhA Pinnacle Award for IHS’ contributions to pharmacy profession 2008: IHS completes 10-years of national credentialing through NCPS. Nearly 200 pharmacists credentialed (over 100 currently active) in 8 different disease state areas.

Objectives of the NCPS Program To develop and implement a national program that: Reviews and recognizes credentials of clinical pharmacists Attempts to assure and promote uniformity of clinical competence through national certification Serves to promote universal recognition of pharmacists as billable primary care providers. Captures the impact from those services Continues program expansion Promote uniform clinical competency of I/T/U pharmacists on a national basis. Define advanced scopes of practice for I/T/U pharmacists. Serve as the body that reviews the credentials, training, and education of I/T/U pharmacists and grants NCPS certification Establish the above elements to help promote universal recognition of NCPS pharmacists as billable providers Current activity to capture impact of workload reduction, patient outcomes, and cost-savings derived from clinical pharmacy services

Scope Intended to recognize advanced scopes of practice at local level that satisfy uniform national guidelines Involve focused management of disease states Care/Privileges must include: Interview, chart review Laboratory privileges Prescriptive Authority Physical assessment Patient education and follow up NCPS grants a certification. Privileges are granted locally by medical staff. NCPS patient care includes all criteria and responsibilities covered in the IHS Pharmacy Standards of Practice as outlined in the Indian Health Manual, as well as focused management of established problems for selected patients in whom medications are the principle method of treatment. Other primary care providers generate the initial patient referrals to NCPS practitioners. Patient care may include a patient interview, chart review, the ordering of laboratory tests, laboratory test interpretation, limited physical assessment (e.g.. blood pressure, pulse, height, weight, finger stick glucose, patient observation, etc.), prescribing medications, providing patient education, and patient follow-up. Treatment and management are performed through primary care protocols (collaborative practice agreements) approved by the local medical staff. NCPS credentialing is intended to recognize an advanced scope of practice aimed at managing one or more disease states and/or optimizing specific drug therapy. Pharmacists may practice disease state management at a facility after completing local requirements. IHS national certification (NCPS) will be granted only after appropriate application and fulfillment of all NCPS requirements (see below). In order to promote uniform competency and consistency in the credentialing process, it is strongly recommended that all facilities adopt, at a minimum, the national (NCPS) standards for local credentialing of pharmacists for disease state management. NCPS-PP patient management includes all of the criteria and responsibilities discussed under NCPS, and includes diagnosis/assessment of new or established clinical presentations or disease states. (The distinction between NCPS and NCPS-PP is that the NCPS-PP scope includes the assessment of new disease states or clinical presentations.) Another primary care provider may refer patients to the pharmacist, or the patient may present him/herself directly to the pharmacist. Referral patterns to other providers are established within the institution. NCPS-PP certification is intended to recognize an advanced scope of practice aimed at therapeutic management of the patient including assessment, diagnosis, and treatment of new disease states or entities. The NCPS-PP functions as a non-physician primary care provider. At the Service Unit’s discretion, a pharmacist with NCPS qualifications may perform NCPS-PP services under physician supervision (as defined by the Service Unit), while working toward the NCPS-PP qualifications. Pharmacists may practice as Clinical Pharmacy Specialists (CPS-PP) at the local facility after completing local requirements. IHS national certification (NCPS-PP) will be granted only after appropriate application and fulfillment of all NCPS-PP requirements (see below). In order to promote uniform competency and consistency in the certification process, it is strongly recommended that all facilities adopt, at a minimum, the national (NCPS-PP) standards for local privileging of IHS CPS-PP pharmacists.

Certification Process

Collaborative Practice Agreements For each NCPS pharmacist, the Committee first approves a collaborative practice agreement (CPA) to assure national uniformity and standards are met CPAs are reviewed for these critical elements: Rationale, Purpose Clinic (Policy and Procedures) Clear indication of pharmacist privileges (advanced scope) QA and outcomes Training and Local Attestation/Privileging/Re-Privileging Clinical Information: Accordance with National Guidelines Appropriate Signatures 1. Rationale/Purpose for clinic Statement of need 2. Clinic information Process for obtaining referrals and determining clinic eligibility Clinic procedures Criteria for referral to clinic/primary care provider 3. Clear statements that the pharmacist can: Order laboratory tests Interpret laboratory tests Perform limited physical assessment Prescribe medications per the protocol. It should be clear that the pharmacist is responsible for dosing of the medications. Provide patient education Provide follow-up of the patient 4. Quality Assurance & Outcomes Description of continuous pharmacist and program performance improvement processes At a minimum, annual program and pharmacist outcomes will be collected and evaluated 5. Training and Local Certification: Define pharmacist training requirements and other qualifications to practice in a disease state management practice. Describe the process for annual evaluation and documentation of competencies. 6. Reference National Clinical Practice Guidelines (if available) are referenced 7. Protocol Approval Appropriate signatures Original date of approval Revision and/or review dates

Disease States with NCPS Anticoagulation Nicotine Dependence Diabetes Dyslipidemia Asthma Hypertension Pain Management HIV/AIDS Family Practice (Practitioner) * Anticoag - highest number of credentialed NCPS pharmacists

Example of Patient Outcomes Congestive Heart Failure Clinic (Claremore, OK) Run by NCPS pharmacists Over 110 patient referrals across 4 years Resulted in decreased Hospital Admissions Missed Referals adjusted Improved referral of patients for ICD/CRT when indicated Improvements in medication usage from point of admission per indication and prescriptive authority of NCPS pharmacist: ACE / ARB 100% Aldosterone Antagonists – 78% Antiplatelet Therapy – 100% Since starting the clinic we have had 110 pts referred to the clinic.  Almost half have been systolic pts.  The clinic has resulted in a decrease in the hospital readmissions and improvements in the following medications.  In addition we have referred several pts for ICD/CRT whom should have been referred earlier. Ace-Inhibitor/ARB-100% Beta-blocker-100% Aldosterone antagonist-78% Antiplatelet-100% Each of these are the percentages of pts with an indication whom were prescribed the medicine by the CHF clinic.  All were improvements from the point of admission. The Claremore CHF clinic showed a reduction in readmission rates and resulted in readmission rates lower than national average. More appropriate utilization of CHF medications Improved referral of patients for ICD/CRT when indicated

Results: % of Patients on Target Doses *Includes patients that have attained target or maximum tolerated dosage 14

CHF Clinic Results: All patients 15

CHF Clinic Readmissions Total readmissions= 5 Months Until Admission Individual Patient Readmissions 16

NCPS Impact by the Numbers Cumulative Pharmacists Certified as NCPS ~ 210 Cumulative Non-Redundant ~ 156 Active, Non-Redundant Certifications ~ 104 NCPS IHS pharmacists > 22% * of IHS pharmacists! Many more practice as Clinical Pharmacy Specialists (CPS) at local levels Improved patient access to care – clinics available in over 40 hospitals and 12 states * Estimate based on roughly 450 IHS Commissioned Corps Pharmacists

Impact on Pharmacy Practice Uniformity of expanding scope and local documentation of outcomes. Collection of best practice models and standardization could enhance quality of care. Provides a national uniform system for pharmacists that reviews training, attests to knowledge and education, and helps assure clinical competence Recent NCPS expansion to Bureau of Prisons was another step to uniformity of clinical practice & promotion of competence across agencies for future recognition and reimbursement. Limited costs for further expansion since most of the work is done at the local level.

Advancing the Profession Change the Paradigm: NCPS Pharmacists are Primary Care Providers Credentials include competence Involve and supported by physicians Patient Outcomes are demonstrated Demonstrate (in some states) that reimbursement is received with appropriate documentation to support a particular level of service IHS and PHS Pharmacy will continue to advance the profession and seek recognition and reimbursement for pharmacists as primary care providers Advance the profession Uniformity of message – we DO provide primary care. Give example of MD visits once Dx is made. How does it differ? How are those primary care providers reimbursed? Reimbursement: based on level of service first, then service in and of itself, then tied to a product.

The years teach much which the days never knew." -Ralph Waldo Emerson Analogous somewhat to “Common Law”, IHS (and other federal systems such as the VA) have demonstrated across decades of interprofessional practice that it can become usual to have pharmacists as disease managers in a non-territorial environment with other primary care providers, supported by those same primary care providers.

Thank you for your time…. CAPT Scott Giberson 301-443-2449 Scott.giberson@ihs.gov LCDR Michael Lee 918-342-6298 Michael.lee@ihs.gov PHS Clinical Webpage: http://www.hhs.gov/pharmacy/clinpharm/practices/index.html