1. Credentialing and Privileging of Pharmacists: USA Perspective Roger Lander, Pharm.D., FASHP, FCCP, BCACP McWhorter School of Pharmacy Samford University Birmingham, Alabama USA

2. Presentation Goals n Provide overview of clinical pharmacy advanced credentialing in the US

3. Clinical Pharmacy Education in US: An Example n Coursework: –Pharmacotherapy (16 credit hours) –Nonprescription Drugs (5 credit hours) –Drug Information/Literature Evaluation (4 hours) –Infectious Diseases (~4 hours) –Management (7 hours) & Health Care Systems (3hrs) –Early Practice Rotations –Advanced Practice Rotations

4. Pharmacotherapy Course n Disease State Introduction n Pathophysiology n Drug Therapy n Adverse Reaction n Patient Assessment n Patient Monitoring

5. Management Courses n Fiscal Management n Personnel Management n Practice Management n Health Care System, Marketing, etc. n Communication Skills also taught

6. Site Types n Hospital Pharmacies n Clinical Faculty Members (teacher/practitioners) n Community Pharmacies n Ambulatory Clinics

7. Introductory and Advanced Practice Experiences n Each student completes at least 1600 hours n Student observes and participates in pharmaceutical care and medication therapy management n 30 + different types of experiences n Core and elective

8. Continuous Integration and Practice Exposure n For about 5 – 10 years now, integration of practice and classroom learning n Student models responsibility for patient outcome and health n Student learns a technique and puts into practice as soon as possible

9. Clinical Pharmacy Postgraduate Experience n Residency - usually each one year in length, combined education and practice experience n PGY1 - > 3,000/year; PGY2>1000/yr. About 14,000 graduates/yr. n Fellowship - usually two years in length, combined education and research experience. Usually only small amount of practice.

10. Major Issues in Practice n Major Issues – Entry level practitioners: what are the necessary credentials – Advancement of current pharmacy practitioners: increasing the training – Development of Advanced Level practitioners: current trainees and students

11. Entry Level Practitoner n Only PharmD degree graduates since 2004 n Increasing Patient Care Emphasis on Licensing Examination (NAPLEX) n Changing Educational Outcomes discussed at the beginning of this talk

12. Current Practitioners n Board Specialization –APhA developed Board of Pharmaceutical Specialties n National Certification or Credentialing –Many examples from Professional Practice Organizations n Local Based Credentialing: Hospital or Sometimes State Organization

13. Board Specialization-BPS n Nuclear Pharmacy was the first-1978 n Pharmacotherapy (1991) intensive but broad based; now has AQ in ID and Cardiology n Nutrition Support n Psychiatric n Ambulatory Care n Oncology n Pediatric n Critical Care

14. National Certification or Credentialing n CDE, DSM, Immunization, TTS, MTM n Usually Offered by Professional Associations n May provide special access to payment and reimbursement to R.Ph. n Usually a combination of “book learning” and documentation of practice/skill

15. Local Based Credentialing n Usually Done by Employer or Practice Site, e.g., hospital or health system n Sometimes done by state, e.g., licensing agency (state board of pharmacy) n Varies by state or local health system n Health System: policies and procedure based

16. Local Health System n Hospital Credentialing of Pharmacist –May use a national credential as a benchmark or differentiatior –BPS certification may justify certain practice activites –Certificate training (like Immunization) may justify certain practice activities –Or Health System may administer its own competency driven credentialing

17. Local Health System n If they use their own system, typically follow something similar to physician credentialing process –R.Ph. fills out application and requests privileges –A review board (credentialing committee) that reviews application and makes recommendation to Executive Committee

18. Local Health System n As long as functioning is within that health system, they often can expand the roles and activities beyond what might be written in that states professional practice act. n For example, a hospital might say that a RPh with certain training can prescribe certain class of drugs.

19. Local Health System n Often requires a medical practitioner to “approve” or “sign off” on a protocol or written agreement outlining what the pharmacist is allowed to perform. n Liability: shared by RPh and Physician (and hospital) n Based on RPh competency n Parallel to “unlabeled indication of a drug”

20. Examples n VA Hospital: national system where a pharmacist is credentialed with certain ‘privileges’, just like a physician n Local Health System n Private Physician Practice n Cooperative agreement between retail pharmacy and physician practice: Collaborative Drug Therapy Management

21. Activity Examples n Too numerous to list them all n Anticoagulation Management n Cardiac Risk Reduction Services n Nutrition Support – RPh writes orders n Pharmacokinetics- RPh adjusts drug dose n Antibiotic Surveillance: RPh stops drug or changes drug

22. Activity Examples 2 n RPh changes IV med to PO med n RPh adjusts HF medications n RPh prescribes med for cough/cold, allergies n RPh gives immunizations (usu. Adult pt) n RPh operates Internation Travel Medicine Clinic

23. Activity Examples 3 n RPh treats tobacco addiction n RPh prescribes and provides naloxone for opioid overdose prevention or suboxone for opioid addiction n Asthma Treatment: adjusts doses, changes medication choice, etc n HIV clinic: adjusts antiretroviral dose, orders laboratory monitoring

24. What’s the Point n Increases Physician Efficiency n Reduces Drug Therapy Costs and/or Overall Health Care Costs n Improved Patient Outcomes and Adherence n Payment for Service n Increases Patient Throughput and Quality of Care

25. Non Traditional Education n Continuing education – continual learning – longitudinal structure – bundling – credentialing – certification

26. Healthcare Environment n Rapid Change –Managed Care –Changes in Payment Methods –Governmental Influences n Professional Anxieties

27. Changes in Pharmacy Practice n Greater Role in Patient Outcomes –Disease State Management –Drug Utilization Management –Systems Management and Input n Renewed focus on the Patient

28. Credentialing and Certification n May bring about different role and responsibilities for the different health care disciplines n Model of pharmacy and drug delivery may change n Some ideas about the future

29. Present and Future Practice Models n Pharmacist as Consultant n Integrated Group Practice n Pharmacist as Triage Agent n Pharmacist as Outcome Monitoring Agent n Pharmacist as Benefit Manager n Pharmacist as Quality Oversight Agent

30. Pharmacist as Consultant Physician Patient Pharmacist

31. Integrated Group Practice Pharmacist Patient Physician

32. Pharmacist as Triage Agent Pharmacist Patient Physician Patient would normally see pharmacist as their entry into the healthcare system in this model. This makes the pharmacist the gatekeeper, with overide in certain circumstances.

33. Pharmacist as Outcome Monitoring Agent Pharmacist Patient Physician

34. Review of Major Issues n Changing Healthcare Marketplace n Roles and Relationships of Current Pharmacists –Entry level practitioners –Advancement of current pharmacy practitioners n Development of advanced level practitioners n How to produce change rather than react to it

35. Questions and Comments ?