Pharmacist-operated disease state management clinics are meeting with wide success in IHS facilities. However, expanding the role of the pharmacist in a variety of IHS practice settings, from small health clinics to major medical centers, can also pose several challenges to the pharmacy staff. Balancing distributive and clinical workloads is an initial challenge once a clinic has been implemented. There may also be some resistance from the physicians and medical staff if pharmacists attempt to practice in a primary care setting. The physicians and medical staff may perceive the pharmacy staff as caring for patients in their service, and they may feel a loss of control over patient outcomes. Gallup Indian Medical Center (GIMC), for instance, is one of the largest medical centers in the Indian Health Service. Captain Robert Parrish, R.Ph., director of several disease state management clinics, has successfully developed and implemented many disease state management clinics at GIMC. His experience in dealing with some of these issues on a daily basis may help others initiate clinics in similar practice settings. “When dealing with distributive vs. clinical issues, you must initially provide every pharmacist with the opportunity to participate and receive training to work in a clinical setting. Everyone will then feel more comfortable at times of increased distributive workload, knowing the opportunity is there to also perform clinical function,?says Parrish. Commenting on physician approval, Parrish adds, “At a major medical center with many physicians, you must find each physician’s level of acceptance of the pharmacist’s expanded roles, then broaden the pharmacist’s scope of practice together with that physician.?This is an issue of commanding respect rather than demanding respect. 7 Clinical Pharmacy Specialists Another innovation of the Indian Health Service is the credentialing of National Clinical Pharmacy Specialists. In October 1996, the IHS Director, Rear Admiral Michael Trujillio, M.D., granted pharmacists prescriptive authority and an expanded scope of practice. In 1998 the National Pharmacy Credentialing Committee introduced the Clinical Pharmacy Specialists requirements. 8 The goal of this credentialing program is threefold: 1. Foster and promote standardized competencies among IHS pharmacists; 2. Broaden the scope of practice to include total therapeutic management of the patient; 3. Improve patient outcomes through better therapeutic management. There are three levels of service recognized by the National Pharmacy Credentialing Program: Basic Level, Clinical Pharmacy Specialist Level I and Clinical Pharmacy Specialist Level II. The CPS Basic Level skills include assessing patients?over-the-counter medication needs; refilling medications for chronic conditions at the pharmacist’s discretion; verifying the patient’s understanding of therapy; ordering laboratory tests at the pharmacist’s discretion; adjusting doses of medications in consultation with a primary care provider; providing patient education, patient follow-up, pharmacokinetic consultation, and total parenteral nutrition; and other consulting with primary care providers as needed.8 To qualify as a pharmacist at the Basic Level, a pharmacist must be with the IHS a minimum of three months and must complete the certification course at the Clinical Support Center Pharmacy Practice Training Program or its equivalent. Clinical Pharmacy Specialist Level I incorporates the basic level while expanding the focus on therapeutic management for selected patients for whom medications are the principal method of treatment. Primary care providers generate the initial patient referral, while pharmacists may provide interviews, chart reviews, ordering and interpretation of laboratory tests, limited physical assessments (e.g., blood pressure, pulse, height, weight, finger stick glucose measures), prescriptive authority, patient education and patient follow-up. Treatment management is performed through primary care guidelines approved by the local medical staff. 8 Many CPS Level I providers have developed and implemented disease state management clinics for the IHS. Some of the requirements to qualify for the CPS Level I include practice within the Indian Health System for a minimum of two years at the Basic Level and advanced training in the specialty areas. CPS Level II care includes the former criteria plus diagnostic capabilities. A patient may present directly to the pharmacist on a walk-in basis or during a clinic. Level II care is intended for total therapeutic management of the patient, including diagnosis as a midlevel provider.8 Recognition is given by the National Credentialing Committee but credentialing and privileging is granted by the medical staff at the facility of the Clinical Pharmacy Specialist. The general qualifications for a CPS Level II include two years practicing at CPS Level I, four years in the IHS, training in physical assessment, and an extensive internship under the supervision of a physician. These rigorous standards ensure the highest quality of patient care. As of January 2000, there were five pharmacists at the CPS Level II and 10 pharmacists at the CPS Level I. There is an ongoing applicant pool to be credentialed by the Committee, which meets twice a year. These levels allow pharmacists to choose a scope of practice and train to achieve that clinical level. At Tohatchi Health Clinic, the pharmacy has established a walk-in clinic staffed by a privileged CPS II pharmacist. Physicians were asked which days or times of the week the “walk-in?patient was hardest to accommodate. Consensus was that full appointment schedules on Tuesdays and Thursdays made these walk-ins a challenge for staff and an opportunity for pharmacy to assist in providing direct patient care. A walk-in clinic was established during those periods of increased workload. After a six-month period, a review of the CPS Level II clinic showed the service decreased physician workload, provided pharmacists with ongoing experience as privileged providers, and gave pharmacy interns an opportunity to experience a primary care setting. Implementing these types of clinics involves the support of the pharmacy and medical staff. At times when a practitioner is seeing patients, the remaining pharmacy team will have an increased distributive role. The physicians must also be supportive of the clinic and work with the pharmacist to consult on complicated walk-in cases. The pharmacist-operated walk-in clinic has met with favorable patient satisfaction and documented decreased waiting time. The pharmacy walk-in clinic distributed satisfaction surveys to all patients after being seen by the CPS II provider. In 37 surveys, collected over a 4- month period, 97% of patients reported being “very happy?or “happy?with their care. Only 3% said the care was “satisfactory.? None were “dissatisfied.?br> Conclusion Along with a culturally enriching work environment, the innovations and pioneering of the Indian Health Service provide pharmacists with unique and expanding opportunities. The motivation and interest of individual pharmacists drives them to develop, initiate and implement disease state management clinics if they are not already available in their practice setting. Likewise, the Clinical Pharmacy Specialist Credentialing Program is now available to promote primary patient care opportunities, assuring quality and competency of pharmacy practitioners. Positive patient outcomes are commonplace among Indian Health System pharmacy-based disease management clinics. The expanding role of the pharmacist can be beneficial to providers, pharmacists and
Posted on: Sun, 05 Oct 2014 06:35:29 +0000
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