The rise of credentialing and privileging in all settings: Kaiser’s Price meets criteria, patients
In late 2014, Credentialing and Privileging of Pharmacists: A Resource Paper from the Council on Credentialing in Pharmacy was published simultaneously by three pharmacy association journals: the Journal of the American Pharmacists Association, American Journal of Health-System Pharmacy, and Consultant Pharmacist.
According to the resource paper, a credential is documented evidence of professional qualifications, including academic degrees, state licensure, residency certificates, training certificates, continuing education statements of credit, and board certifications. A privilege is permission or authorization granted by a hospital or other health care institution or facility to a health professional. Clinical privileges, which give the professional the right to treat, are specific to both the facility and the individual.
Credentialing and privileging for pharmacists are already here for health-system, U.S. Public Health Service (USPHS), U.S. Department of Veterans Affairs (VA), and other practice settings. But pharmacists should be aware that credentialing and privileging are part of the future for community practice, too.
“You have to be aware, or try to be somewhat visionary and forecast future trends, and you have to differentiate yourself from other pharmacists who want to do what you do,” said former APhA President Steve Simenson, BSPharm, FAPhA, FACA, who is President and Managing Partner of Goodrich Pharmacy in Anoka, MN, a northern suburb of the Twin Cities. “As we find new avenues of pharmacy professional practice, somebody is a gatekeeper. One of the keys, I think, for pharmacists getting in the door and being able to practice at the top of their education is having the credentials that those other health care providers recognize.”
On the team at Kaiser Permanente: Respect, confidence
Credentialing and privileging are “an area where not everyone does that, but that is starting to come about,” said Lea Price, PharmD, BCPS, Clinical Pharmacy Specialist in Palliative Care for Kaiser Permanente Colorado in Lafayette, CO. Kaiser Permanente doesn’t own the hospital where she works, but instead contracts out with the local health systems. “I am credentialed to work in the hospital setting with my team. That credentialing process allows me to have autonomy and to work at my full scope of practice,” she said. “Physicians and nurses can feel confident that we perform at the highest level with the additional respect provided by the credentialing process.”
For Price, the process was “just me gathering information for the initial credentialing period, and then handing that information to the credentialing team for verification.”
She noted that the credentialing process requires pharmacists to have certain criteria, including a residency and board certification. “All of our pharmacists whom we hire as a clinical pharmacy specialist at Kaiser Permanente Colorado actually meet or exceed that criteria,” Price explained. Every clinical pharmacy specialist there has done a specialty residency on top of a general residency; many of them have not just one but two board certifications; a lot of them also have added qualifications; and some have done nonpharmacy certification in diabetes, asthma, lipids, and so on.
Under the credentialing process, clinical pharmacy specialists are allowed to be privileged to do certain things, Price said. “Because I met all the criteria, I can interview and examine patients face to face, order labs and medications, and provide formal pharmacotherapy consultations. In my role, this translates to obtaining medication and symptom histories related to the patient’s palliative condition, reviewing the [electronic] charts, and providing patient and family education.”
On a palliative care team that includes physicians, a nurse, a social worker, and a chaplain, Price interacts face to face with patients—not only in the clinics but also in the hospital system. Face to face is especially important in palliative care “because you can easily miss things over the phone,” she said. “We meet them where they are, and provide them the total care that they need.”
USPHS: Uniform credentials before reimbursement
U.S. Public Health Service (USPHS) pharmacists have been practicing in expanded clinical roles in primary and preventive care for many years, according to RADM Pamela Schweitzer, PharmD, BCACP, U.S. Assistant Surgeon General and Chief Professional Officer, Pharmacy, for the USPHS.
Schweitzer was in the Indian Health Service (IHS) in 1996 when Michael H. Trujillo, MD, MPH, then a U.S. Assistant Surgeon General, broadened the scope of pharmacy practice by signing a memorandum that said, “Clinical Pharmacy Specialists (CPS) 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.”
At that time, the clinical pharmacists practicing in the IHS were “all over the board in how we were practicing, and how an advanced level of clinical practice was defined,” she said. Pharmacists were practicing using protocols that sometimes were outdated, and pharmacy services provided were not consistent.
“We realized at the time that if we expected to be reimbursed, we would have to have uniformity among credentials and competencies—similar to the medical staff,” Schweitzer said. “We also wanted to have best practices that could be shared among pharmacists.”
In 1998, the USPHS developed a national credentialing system for pharmacists. “I was fortunate to be part of this initial group, and remember it took a couple of years to establish the processes,” she noted. A pharmacist in the group did the credentialing and privileging for the medical staff at his facility, and provided expertise to develop the group’s framework.
“When we first started, very few pharmacists met the standards that we set. Most of the challenges were related to requiring a higher quality of documentation,” Schweitzer recalled. “Over time, by sharing best practices, creating checklists, and continuing education, the quality of the submissions significantly improved. The best part is that through this process, we have documentation of enhanced patient outcomes.”
In the present day, documentation of education for the credentialing process is “quite flexible,” Schweitzer said. USPHS pharmacists must have at least one of the following five postgraduate documents: residency certificate(s), specialty board certification(s), clinician’s state license, disease state management certificate(s), and/or a narrative detailing experience if using clinical experience in lieu of certificate.
VA: Recognition as providers
At VA, credentialing for pharmacists has been in place for several years. “In the early 2000s, we moved into a credentialing system for all of the allied health professionals. Since that time, we’ve moved to a more advanced system for credentialing those pharmacists who have an advanced scope of practice, which includes prescribing”; the process of focused and ongoing reviews at specific intervals for pharmacists is the same as for other prescribers across the system, said Julie A. Groppi, PharmD, National PBM Manager for Clinical Pharmacy Practice and Standards with VA. (In VA, the terminology of privileging does not apply to pharmacists.)
Groppi was one of the primary authors of a complete handbook on clinical pharmacy services that was released on July 1 to provide guidance and policy for pharmacists, pharmacy directors, and medical center directors. The new handbook was developed and reviewed by all key stakeholders within pharmacy and throughout VA, including primary care, specialty care, general counsel, and credentialing and privileging.
“The changes that we made to the credentialing process coincide with the medical staff process and the midlevel practitioner role that you see for nurse practitioners and physician assistants,” Groppi said. “The handbook modernizes the scope of practice process for pharmacists across the system.” It promotes prescriptive authority, lab ordering, informed consent, consults, and the ability for pharmacists to make autonomous decisions based on their individualized scope of practice. It also advances the scope of practice to encompass the practice area where the pharmacist works, including the common disease states of patients in that setting. Not being limited to particular disease states “allows the pharmacist to address the full medication management needs of the veteran in the practice setting,” she explained.
Ensuring that pharmacists are recognized as midlevel practitioners in all practice areas across VA helps to promote practice advancement and recognition as providers, and “supports the pharmacist as additional workforce to improve access to patient care,” Groppi said.
Goodrich Pharmacy: Credentials lead to clinic privileges
Goodrich Pharmacy, a community pharmacy, was founded in 1884. Simenson started working at the pharmacy in 1977 and became a partner there in 1980. Today, five of Goodrich’s pharmacies are actually located within a physician clinic structural space. While the pharmacies are independent and not owned by the clinic, over the years, as medication management and clinical pharmacy have matured, Goodrich has developed relationships with the physician clinic that have allowed the pharmacies to slowly build up a practice, including access to the clinic’s electronic medical records.
“We have contracts with five clinics for different 4-hour blocks of time for pharmacists to work alongside the other health care providers in the clinic,” Simenson said. The pharmacists who have the highest credentials are given privileges to work on the clinic contracts. “Having credentials shows they’ve taken the time and effort to prove to an unbiased audience that they have more knowledge and experience than the average practitioner out there,” he explained. “When it comes to who gets the hours and how we divide up the hours, doing BPS [Board of Pharmacy Specialties], doing a residency—that is proof that helps us sell their qualifications to the clinic and the other medical providers there.”
Goodrich credentials pharmacists when they are hired, and routinely reviews them once a year about any additional training and to make sure they’ve kept up to speed. “We have a minimum level beyond the pharmacy degree, which makes you a generalist without any experience,” Simenson said. “We encourage anything that adds to that experience, and they have to be able to do immunizations. We want all our pharmacists to be able to do a baseline level of medication therapy management,” he continued. “By reviewing those things, encouraging those things, and offering to fund some of those educational efforts, we try to improve the quality of our staff all the time.”
Help wanted: Provider of patient care services
Pharmacists enter pharmacy practice with a professional degree in pharmacy and a license. “Postlicensure education, training, and certification are ways that pharmacists establish their competence to provide patient care services within a defined scope,” according to the resource paper. (To see how forms of education, training, and certification relate to existing scopes of practice for pharmacists, see Figure 1.)
“I think it’s just recognizing that” the time for credentialing and privileging of pharmacists will come, Simenson said. “The question is: When do you want to sign onto it, and when do you want to get on board?”