1. Indian Health Service (IHS) National Clinical Pharmacy Specialist (NCPS) Re: May 2008

2. Overview For decades, Indian Health Service (IHS) pharmacists across the nation have practiced in a variety of expanded clinical roles to provide primary care IHS pharmacy is widely known (in both the private sector and academia) for its innovative pharmacy practice, which includes privileges in disease management The provision of pharmaceutical care follows the IHS Pharmacy Standards of Practice: Chapter 7 of the Indian Health Manual The Indian Health Service (IHS) officially recognizes IHS pharmacists as primary care providers. Refer SGM 10-18-96

3. Expanded Practice Evolution In 1996, the scope of pharmacy practice in the IHS was officially broadened to include prescriptive authority. Dr. Michael Trujillo (former IHS Director) recognized IHS pharmacists as primary care providers in his October 18, 1996 memorandum: “Clinical Pharmacy Specialists (CPS) will be included in the IHS definition of a primary care provider (PCP) 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

4. Evolution of Expanded Practice: IHS Innovation 1931 Edwin M. Holt is the first commiss- ioned officer to be assigned to the Office of Indian Affairs, Department of Interior. Allen J. Brands becomes the first CPO for IHS 1955196219691974198319881990 IHS shift from distribution to clinical services. Begins to counsel patients and use health record, not Rx form. Such practice does not exist before this time IHS Program Planning meeting in Rockville – pharmacists start serving as primary care providers in many IHS facilities IHS begins Pharmacy Practitioner Program – teaching IHS pharmacists physical assessment and disease management IHS establish- ment of the IHS Clinical Pharmacy Training Program (CPTP ) – training pharmacists in managing chronic disease IHS Standards of Practice to provide pharmaceutical care to patients. Coined the term. IHS distributes Patient Consultation videos to academia nationwide.

5. Evolution of Expanded Practice: IHS Innovation 1995 IHS Business Committee meetings to discuss reimbursem ent for services and contacts HCFA (now CMS) Director of Indian Health Service, RADM Michael Trujillo, signs special memorandum, which codifies Clinical Pharmacy Specialists (CPS) as primary care providers (PCPs) with prescriptive authority. 19961997-9820012008 The IHS National Clinical Pharmacy Specialist Credentialing Committee (NCPSCC) is born out of discussions surrounding decades of expanded practice - 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 IHS receives Roche D.R.E.A.M. award for NCPS- pharmacist managed Traineeship in Anticoagulation Management IHS completes 10-years of national credentialing through NCPS. Nearly 200 pharmacists credentialed (over 100 currently active) across 40 states and 8 different disease state areas. 1998 2007 IHS receives the ASHP Award of Excellence for the implementation of a pharmacist CHF clinic

6. Committee Charge N ational Clinical Pharmacy Specialist Credentialing Committee (NCPSCC) - officially est. 1998 by Chief Professional Officer in response to IHS Business Committee meetings and interest in recognition of expanded scope: 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

7. Scope Intended to recognize advanced scopes of practice at local level that satisfy uniform national guidelines Includes NCPS and NCPS- Pharmacist Practitioner (NCPS-PP) Involve focused management of disease states (may involve established or new patients) Care/Privileges to include: Interview, chart review Laboratory privileges Prescriptive Authority Limited (or potentially more general) physical assessment Patient education and follow up NCPS grants certification. Privileges are granted locally.

8. Impact by the numbers… Cumulative Pharmacists Credentialed ~ 200 Cumulative Non-Redundant ~ 156 Active, Non-Redundant Certifications ~ 100 Currently, 100 IHS pharmacists credentialed out of ~452 IHS pharmacists. NCPS IHS pharmacists ~ 22% * of IHS pharmacists! Many more practice as CPS at local levels * Denominator (n=452) includes all IHS positions including non-clinical, multidisciplinary and those in administrative roles.

9. Disease States with Credentialed Pharmacists Anticoagulation* Nicotine Dependence Diabetes Dyslipidemia Asthma Hypertension Pain Management Primary Care/Family Med (NCPS-PP) Disease State with the highest number of credentialed NCPS pharmacists

10. NCPS Credentials By IHS Area Oklahoma38 Phoenix33 Alaska15 Albuquerque14 Navajo11 Aberdeen8 Bemidji8 Nashville7 Portland4 Billings2 HQ and Tucson 2 (Cumulative) (Active) Oklahoma30 Phoenix23 Alaska12 Albuquerque9 Navajo8 Bemidji6 Aberdeen5 Nashville4 Portland2 HQ-Rockville1

11. NCPS Credentials By IHS Facility Tahlequah15 Whiteriver15 Claremore13 Phoenix11 Talahina11 Cherokee7 Gallup, Idabel, Juneau, Pine Ridge, San Fidel, Warm Springs, Zuni 4 Many facilities with <4 QS to ~ 200 (Cumulative) (Active) Whiteriver14 Claremore10 Anchorage9 Tahlequah9 Phoenix5 Talihina5 Many facilities with < 4 QS to ~ 100

12. Critical Elements of Protocol For each NCPS pharmacist, the NCPSCC also approves a collaborative practice agreement (CPA) to assure national uniformity/standards are met CPAs are reviewed for: 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

13. 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. Improved patient access to care – clinics available in over 40 hospitals and clinics across 10 states Provides a national uniform system for pharmacists that reviews training, attests to knowledge/education, and helps assure clinical competency at local level Expansion will be another step to uniformity of clinical practice & promotion of competence across agencies

14. Contact Information / NCPS Committee Committee Members LCDR Mike Lee, Chairmichael.lee@ihs.govmichael.lee@ihs.gov CAPT Don Ahrens, Ex-Officio don.ahrens@ihs.govdon.ahrens@ihs.gov CAPT 1 Scott Gibersonscott.giberson@ihs.govscott.giberson@ihs.gov CDR Linda Schrand-Crosbylinda.schrand@ihs.govlinda.schrand@ihs.gov LCDR Brian Campbellbrian.campbell@ihs.govbrian.campbell@ihs.gov LCDR Maya Thompsonmaya.thompson@ihs.govmaya.thompson@ihs.gov Dr. Charles Rhodes, MD CAPT Marty Smith, Consultant CDR Chris Lamer, Consultant For additional information, please email or phone LCDR Mike Lee @ (918) 222-2222 or CAPT 1 Scott Giberson @ (301) 443-2449 1 Effective 1 Oct 2008