National Clinical Pharmacy Specialist NCPS Program:

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National Clinical Pharmacy Specialist (NCPS)
Program Innovation and Opportunity
CAPT Scott Giberson RPh, PhC, NCPS-PP, MPH USPHS
Scientific Symposium Category Day June, 2009
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Objectives

• Describe the purpose behind implementation of the
  NCPS Program as well as its evolution
• Discuss the process of NCPS implementation and
  scope of NCPS practice
• Describe outcomes and impact of the NCPS Program
  and future implications

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IHS Pharmacy Overview

• Comprehensive primary healthcare system
• Large number of ambulatory sites
• Identifiable need and health disparities
• 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

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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 Info
• Provide Health Promotion /
• Disease Prevention
• 6. Manage Therapy

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Innovation Past and Present
1962
1988
1931
1955
1969
1974
1983
1990
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
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 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 care
providers in many IHS facilities
IHS Standards of Practice to provide
pharma-ceutical care to patients. Coined the term.
IHS distributes Patient Consultation videos to
academia nationwide.
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IHS Pharmacy Practice

• In 1996, the scope of pharmacy practice in the
  IHS was officially broadened in Dr. Michael
  Trujillos 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.

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Innovation Past and Present
1995
1996
1997-98
2001
2008
1998
2007

• - 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 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.
IHS receives Roche D.R.E.A.M. award for
NCPS-pharmacist managed Traineeship in
Anticoagulation Management
IHS receives the ASHP Award of Excellence for
the implementation of a pharmacist CHF clinic
National Clinical Pharmacy Specialist (NCPS)
Program Established by CPO after IHS Business
Committee meetings
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
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Purpose 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

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Scope

• Intended to recognize advanced scopes of practice
  at local level that satisfy uniform national
  qualifications
• Involves focused management of disease states
• Care/Privileges must include
• Interview, chart review
• Laboratory privileges
• Prescriptive Authority
• Physical assessment
• Patient education and follow up
• Pharmacists often develop therapeutic plans and
  patient assessments
• NCPS grants a certification. Privileges are
  granted locally by medical staff.

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Qualifications

• Experiential
• 2 to 4 years in Agency
• Didactic
• May include certificates, BPS, PE, etc)
• IHS-recognized trainings
• Quality-Based
• Practice Component
• Patient contact hours (pre and post
  certification)
• Competence Attestation
• Physician attestation to competence/quality of
  care locally
• NCPS approved CPA

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Certification Process
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
Pharmacists submit either/both CPA and/or
credentials to NCPS Committee
Pharmacists are notified and continue to practice
locally, now as NCPS pharmacists.
NCPS Committee meets to review submissions and
certify pharmacists and/or CPAs
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Collaborative Practice Agreements

• 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
• QA and outcomes
• Training and Local Attestation/Privileging
• Clinical Information

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Disease States with NCPS

• Anticoagulation
• Nicotine Dependence
• Diabetes
• Dyslipidemia
• Asthma
• Hypertension
• Pain Management
• HIV/AIDS
• Family Med (Practitioner)

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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
• Improved referral of patients for ICD/CRT
• Improvements in medication usage from point of
  admission per indication and prescriptive
  authority of NCPS pharmacist

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Results of Patients on Target Doses
Includes patients that have attained target or
maximum tolerated dosage
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Opportunity NCPS Impact Numbers

• Cumulative Pharmacists Certified 210
• Active, Non-Redundant Certifications 104
• gt 20 of IHS pharmacists are NCPS!
• Many more practice locally as CPS
• Improved patient access to primary care clinics
  available in over 40 hospitals and 12 states

Estimate based on roughly 450 IHS Commissioned
Corps Pharmacists
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Improve Consumer Outcomes

• Patient
• Clinical indicators
• HPDP / Patient Satisfaction
• Provider
• Increase utility of other providers
• Administrator
• Cost-effectiveness/containment
• Pharmacy
• Support Health Reform
• Improve Access
• Performance-Based
• Medically Disenfranchised

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Impact on Our Practice

• Consistency Documentation/Scope
• Quality - Best Practices - Enhanced care.
• Uniformity - Provides a national uniform system
  for pharmacists that reviews training, attests to
  knowledge and education, and helps assure
  clinical competence Innovation
• Expansion to Bureau of Prisons was another step
  to uniformity of clinical practice
• promotion of competence across
• agencies.
• Further Expansion of Program?

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Advancing the Profession

• Change the Paradigm
• NCPS Pharmacists provide primary care
• Certification includes competence
• Involve and supported by MDs
• Patient Outcomes are required
• Demonstrate (in some states) that compensation is
  possible to support a particular level of service
• IHS / PHS Pharmacy will continue to advance the
  profession and seek recognition and compensation
  as NPPs
• The opportunity for PHS Pharmacy to continue to
  lead practice innovation

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Getting Involved
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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. Weve developed Common
Practice
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Thank you for your time.
CAPT Scott Giberson 301-443-2449 Scott.giberson_at_ih
s.gov

LCDR Mike Lee 918-342-6298 Michael.lee_at_ihs.gov
PHS Clinical Webpage http//www.hhs.gov/pharmacy/
clinpharm/practices/index.html