Indian Health Service Pharmacy Innovation: National Clinical Pharmacy Specialist (NCPS) Program

1. Indian Health Service Pharmacy Innovation: National Clinical Pharmacy Specialist (NCPS) Program

2. 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

3. 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

4. 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

5. Innovation: Past and Present

6. 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.”

7. 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

8. 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

9. 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.

10. Certification Process

11. 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

12. Disease States with NCPS • Anticoagulation • Nicotine Dependence • Diabetes • Dyslipidemia • Asthma • Hypertension • Pain Management • HIV/AIDS • Family Practice (Practitioner)

13. 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%

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

15. CHF Clinic Results: All patients

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

17. 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

18. 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.

19. 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

20. 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.

21. 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