indian health service pharmacy innovation: national clinical pharmacy specialist (ncps) program...
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Indian Health Service Pharmacy Innovation:
National Clinical Pharmacy Specialist (NCPS) Program
Indian Health Service Pharmacy Innovation:
National Clinical Pharmacy Specialist (NCPS) Program
Indian Health ServiceIndian 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
• 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
OverviewOverview
• 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
• 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 PracticeIHS Standards of Practice
The provision of pharmaceutical care follows the six IHS Pharmacy Standards of Practice
1. Assure Appropriateness of Therapy
2. Confirm Understanding
3. Assure Availability, Control and Preparation of pharmaceuticals
4. Provide Education / Drug Information
5. Provide Health Promotion /
Disease Prevention
6. Manage Therapy
The provision of pharmaceutical care follows the six IHS Pharmacy Standards of Practice
1. Assure Appropriateness of Therapy
2. Confirm Understanding
3. Assure Availability, Control and Preparation of pharmaceuticals
4. Provide Education / Drug Information
5. Provide Health Promotion /
Disease Prevention
6. Manage Therapy
Innovation: Past and PresentInnovation: Past and Present
1931
Edwin M. Holt is the first commiss-ioned officer to be assigned to the Office of Indian Affairs, Department of Interior.
Allen J. Brandsbecomes the first CPO for
IHS
1955 1962 1969 1974 1983 1988 1990
IHS shift from distribution to clinical services. Begin to counsel patients and use health record, not Rx pad. Such practice does not exist before
this time
IHS Program Planning meeting in Rockville –pharmacists start serving as primary careproviders 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.
IHS Pharmacy PracticeIHS 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.”
• 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.”
Innovation: Past and PresentInnovation: 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
1995
IHS Business Committeemeetings 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
IHS receives Roche D.R.E.A.M. award for
NCPS-pharmacist managed Traineeship in Anticoagulation Management
IHS completes 10-years of credentialing through NCPS. Over 200 pharmacists credentialed (over 104 currently active) across 40 states and 8 different disease state areas in IHS. NCPS expands to Bureau of Prisons
1998 2007
IHS receives the ASHP Award of Excellencefor theimplementationof a pharmacist CHF clinic
National Clinical
Pharmacy Specialist
(NCPS) Program
Established by CPO after IHS Business
Committee meetings
Objectives of the NCPS ProgramObjectives 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
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
ScopeScope
• 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.
• 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.
Certification ProcessCertification ProcessPharmacists practice locally
under local privileging to obtain all required
credentials for NCPS*
Pharmacists practice locally under local privileging to
obtain all required
credentials for NCPS*
Re-certification occurs every 3 years and requires ongoing practice hours as well as
required credentials and CE
Re-certification occurs every 3 years and requires ongoing practice hours as well as
required credentials and CE
Pharmacists are notified and continue to practice locally, now as NCPS
pharmacists.
Pharmacists are notified and continue to practice locally, now as NCPS
pharmacists.
NCPS Committee meets to review submissions and certify pharmacists
and/or CPAs
NCPS Committee meets to review submissions and certify pharmacists
and/or CPAs
Pharmacists submit either/both CPA and/or credentials to NCPS Committee
Pharmacists submit either/both CPA and/or credentials to NCPS Committee
* Required Credentials:
1. Two experiential components:
i. 2-4 yrs in IHS pharmacy practice
ii. > 1 year in clinical practice with requested disease state as local clinical pharmacy specialist
2. Attestation letters of clinical competence from physician
3. Didactic Credentials may include (disease management certificate, BPS, additional PE courses, etc.)
4. Patient contact hours each year
5. NCPS Committee approved Collaborative Practice Agreement (CPA) that contains all critical elements
* Required Credentials:
1. Two experiential components:
i. 2-4 yrs in IHS pharmacy practice
ii. > 1 year in clinical practice with requested disease state as local clinical pharmacy specialist
2. Attestation letters of clinical competence from physician
3. Didactic Credentials may include (disease management certificate, BPS, additional PE courses, etc.)
4. Patient contact hours each year
5. NCPS Committee approved Collaborative Practice Agreement (CPA) that contains all critical elements
Pharmacists practice locally under local privileging to
obtain all required
credentials for NCPS*
Pharmacists practice locally under local privileging to
obtain all required
credentials for NCPS*
Re-certification occurs every 3 years and requires ongoing practice hours as well as
required credentials and CE
Re-certification occurs every 3 years and requires ongoing practice hours as well as
required credentials and CE
Pharmacists are notified and continue to practice locally, now as NCPS
pharmacists.
Pharmacists are notified and continue to practice locally, now as NCPS
pharmacists.
NCPS Committee meets to review submissions and certify pharmacists
and/or CPAs
NCPS Committee meets to review submissions and certify pharmacists
and/or CPAs
Pharmacists submit either/both CPA and/or credentials to NCPS Committee
Pharmacists submit either/both CPA and/or credentials to NCPS Committee
* Required Credentials:
1. Two experiential components:
i. 2-4 yrs in IHS pharmacy practice
ii. > 1 year in clinical practice with requested disease state as local clinical pharmacy specialist
2. Attestation letters of clinical competence from physician
3. Didactic Credentials may include (disease management certificate, BPS, additional PE courses, etc.)
4. Patient contact hours each year
5. NCPS Committee approved Collaborative Practice Agreement (CPA) that contains all critical elements
* Required Credentials:
1. Two experiential components:
i. 2-4 yrs in IHS pharmacy practice
ii. > 1 year in clinical practice with requested disease state as local clinical pharmacy specialist
2. Attestation letters of clinical competence from physician
3. Didactic Credentials may include (disease management certificate, BPS, additional PE courses, etc.)
4. Patient contact hours each year
5. NCPS Committee approved Collaborative Practice Agreement (CPA) that contains all critical elements
Collaborative Practice AgreementsCollaborative 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
• 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
Disease States with NCPSDisease States with NCPS
• Anticoagulation• Nicotine Dependence• Diabetes• Dyslipidemia• Asthma• Hypertension• Pain Management• HIV/AIDS• Family Practice (Practitioner)
• Anticoagulation• Nicotine Dependence• Diabetes• Dyslipidemia• Asthma• Hypertension• Pain Management• HIV/AIDS• Family Practice (Practitioner)
• 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%
• 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%
Example of Patient OutcomesExample of Patient Outcomes
Results: % of Patients on Target DosesResults: % of Patients on Target Doses
*Includes patients that have attained target or maximum tolerated dosage
19%
84%
38%
75%
31%
81%
0%
20%
40%
60%
80%
100%
BeforeAfter
19%
84%
38%
75%
31%
81%
0%
20%
40%
60%
80%
100%
BeforeAfter
CHF Clinic Results: All patientsCHF Clinic Results: All patients
CHF Clinic Results: All patients (67)
Before After
Readmissions 18 5
Smoking status
documentation 57/67 67/67
Heart failure stage
documentation 29/67 65/67
Correct heart failure stage
documentation 29/29 65/65
Documentation pt
education: 39/67 52/67
CHF Clinic ReadmissionsCHF Clinic Readmissions
Months Until Admission
Individual Patient Readmissions
Total readmissions= 5
3 4
910
12
1
6
11
16
21
3 4
910
12
1
6
11
16
21
NCPS Impact by the NumbersNCPS 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
• 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 PracticeImpact 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.
• 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.
Change the Paradigm:1. NCPS Pharmacists are Primary Care
Providers
2. Credentials include competence
3. Involve and supported by physicians
4. Patient Outcomes are demonstrated
5. Demonstrate (in some states) that reimbursement is received with appropriate documentation to support a particular level of service
6. IHS and PHS Pharmacy will continue to advance the profession and seek recognition and reimbursement for pharmacists as primary care providers
Change the Paradigm:1. NCPS Pharmacists are Primary Care
Providers
2. Credentials include competence
3. Involve and supported by physicians
4. Patient Outcomes are demonstrated
5. Demonstrate (in some states) that reimbursement is received with appropriate documentation to support a particular level of service
6. IHS and PHS Pharmacy will continue to advance the profession and seek recognition and reimbursement for pharmacists as primary care providers
Advancing the ProfessionAdvancing the Profession
The years teach much which the days never knew."
-Ralph Waldo Emerson
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….Thank you for your time….
PHS Clinical Webpage:
http://www.hhs.gov/pharmacy/clinpharm/practices/index.html
CAPT Scott Giberson
301-443-2449
CAPT Scott Giberson
301-443-2449
LCDR Michael Lee
918-342-6298
LCDR Michael Lee
918-342-6298