# Presentation: 581044

## Indian Health Service (IHS) National Clinical Pharmacy Specialist (NCPS) 

- Re: May 2008

## 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

**Notes:**
Purpose 
The purpose of the Indian Health Service (IHS) National Clinical Pharmacy Specialist Credentialing Committee (NCPSCC) is to establish a national system for credentialing Indian Health Service, Tribal, and Urban (I/T/U) pharmacists in an effort to promote enhanced patient outcomes.  The Committee will accomplish the following:
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 National Clinical Pharmacy Specialist certification.
II.	Authority
The October 18, 1996 memorandum from the Indian Health Service Director established
prescriptive authority,  an advanced scope of practice for IHS pharmacists as primary care providers. The Committee was established by the Chief Pharmacy Officer in 1997 to provide a mechanism to assure that all IHS National Clinical Pharmacy Specialists display a uniform level of competency. 

## 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**

## 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

- 1955

**1962**

- 1969

**1974**

**1983**

- 1988

- 1990

- 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.

## Evolution of Expanded Practice: IHS Innovation

- 1995

**IHS Business Committee** meetings to discuss reimbursement 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.

**1996**

**1997-98**

- 2001

**2008**

- 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

**Notes:**
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.

## Committee Charge

- National 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

## 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.

**Notes:**
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.

## 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.

## 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

## NCPS Credentials By IHS Area 

| Oklahoma | 38 |
| --- | --- |
| Phoenix | 33 |
| Alaska | 15 |
| Albuquerque | 14 |
| Navajo | 11 |
| Aberdeen | 8 |
| Bemidji | 8 |
| Nashville | 7 |
| Portland | 4 |
| Billings | 2 |
| HQ and Tucson | 2 |

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- (Active)

| Oklahoma | 30 |
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| Phoenix | 23 |
| Alaska | 12 |
| Albuquerque | 9 |
| Navajo | 8 |
| Bemidji | 6 |
| Aberdeen | 5 |
| Nashville | 4 |
| Portland | 2 |
| HQ-Rockville | 1 |

## NCPS Credentials By IHS Facility 

| Tahlequah  | 15 |
| --- | --- |
| Whiteriver | 15 |
| Claremore  | 13 |
| Phoenix  | 11 |
| Talahina | 11 |
| Cherokee  | 7 |
| Gallup, Idabel, Juneau, Pine Ridge, San Fidel, Warm Springs, Zuni | 4 |
| Many facilities with <4 | QS to ~ 200 |

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| Whiteriver | 14 |
| --- | --- |
| Claremore | 10 |
| Anchorage | 9 |
| Tahlequah | 9 |
| Phoenix | 5 |
| Talihina | 5 |
| Many facilities with < 4 | QS to ~ 100 |
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## 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

**Notes:**
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

## 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 the local level
- Expansion will be another step to uniformity of clinical practice and promotion of competence across agencies

## Contact Information /  NCPS Committee

- _Committee Members_
- LCDR Mike Lee, Chair		_[michael.lee@ihs.gov](mailto:michael.lee@ihs.gov)_
- CAPT Don Ahrens, Ex-Officio 	_[don.ahrens@ihs.gov](mailto:don.ahrens@ihs.gov)_
- CAPT1 Scott Giberson		_[scott.giberson@ihs.gov](mailto:scott.giberson@ihs.gov)_
- CDR Linda Schrand-Crosby	_[linda.schrand@ihs.gov](mailto:linda.schrand@ihs.gov)_
- LCDR Brian Campbell		_[brian.campbell@ihs.gov](mailto:brian.campbell@ihs.gov)_
- LCDR Maya Thompson		_[maya.thompson@ihs.gov](mailto:maya.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
- CAPT1 Scott Giberson @ (301) 443-2449
- 							1 Effective 1 Oct 2008