Pharmacists within the United States Public Health Service (USPHS) provide comprehensive medication and disease state management services for patients within the Indian Health Service, Federal Bureau of Prisons, Immigration and Customs Enforcement, and United State Coast Guard. Federal Pharmacists serving in clinical USPHS assignments complement team-based care models and fill critical gaps in the continuum of care to optimize patient outcomes and improve value-based care. The National Clinical Pharmacy Specialist (NCPS) certification program recognizes advanced scopes of practice for pharmacists to promote a uniform level of competency and proficiency with clinical pharmacy services. Pharmacists practicing under collaborative practice agreements (CPAs) are required to obtain medication prescriptive authority, order and interpret laboratory tests, perform limited physical assessment, and document and report outcomes. The CPA along with credentials, training, and education are reviewed by the NCPSC, which is composed of physician and pharmacist subject matter experts to ensure uniformity of scope and competence.
The Federal Bureau of Prisons utilizes pharmacists to expand access to patient care and improve health outcomes. The success story below illustrates unique ways pharmacists have been integrated into the primary care team utilizing NCPS certification as a backbone to illustrate competence with peers and providers.
With an aging patient population and the accompanying challenges of patients with multiple comorbidities and complicated therapeutic regimens, primary care physicians (PCPs) working at an institution in Butner, North Carolina, face many of the same problems common to practices throughout the country. One notable difference is these physicians work exclusively with incarcerated persons, patients who live in a structured, secure environment with many unique aspects.
As a multi-facility complex within the Federal Bureau of Prisons (BOP), the Federal Correctional Complex in Butner, North Carolina (FCC Butner), consists of five different facilities with varying levels of security designation and specialty populations, including specific medical missions such as oncology and mental health. The medical center is capable of accommodating any level of security, as well as the complicated medical patients, and the surrounding complex, in turn, houses patients with significant medical needs. Each facility is serviced by separate teams which consists of PCPs, physician assistants (PAs), and nurse practitioners; however, the same pharmacist team operates throughout the complex.
In the early 2000s, pharmacists were identified as a solution to address specific therapeutic activities that were consuming large amounts of provider time, such as managing pharmacokinetics of inpatient antibiotics and anticoagulation. These two areas were quite narrow in scope; however, the focused interventions provided an opportunity for the PCPs to practice in integrated care teams that included pharmacists as well as define workflows and communication standards. As part of practicing medicine with a complex population, PCPs would spend considerable time researching answers to questions which they found readily in a phone call to the pharmacy. When PCPs realized pharmacists consistently produce evidence-based answers and excellent clinical application of medication management knowledge, the question of improving efficiency in the delivery of care was raised. Why not have the pharmacist conducting patient interviews, assessing lab results, and making therapeutic adjustments with the oversight of the PCP?
Moving from consultants to care providers, pharmacists at FCC Butner established CPAs in specialized areas, such as HIV and pain management. FCC Butner pharmacists specializing in specific disease states pursued additional education and credentialing. One particular tool that offered a recognizable standard of care was the NCPS certification. PCPs with concerns regarding oversight of clinical pharmacists could look to the NCPS certification with clear expectations. The NCPS Committee reviews CPAs to ensure the processes within a pharmacist-managed clinic are standardized, and outcomes relative to the care provided are collected on an annual basis.
The BOP clinical pharmacists possess a firm understanding of patients' disease states and available therapies, as well as the unique challenges and opportunities presented by living in the prison environment. Specialty consultation by providers outside the prison system is available for patients; however, it is advantageous to the patient to work with providers who are already familiar with the unique opportunities and challenges of living in incarceration. It is also beneficial if patients can remain within their designated institution to receive care. Patients in any environment may spend time waiting for specialist's availability due to multiple competing priorities. Instead of waiting for this availability and assuming the risks of taking an incarcerated person back into the community for consultation, pharmacists at FCC Butner have been able to offer secure and timely follow-up care.
As PCPs became more comfortable with pharmacists participating in the care team, pharmacy services expanded further. By the early 2010s, FCC Butner established comprehensive diabetes management services utilizing a pharmacist-physician partnership outlined by a CPA which met NCPS certification criteria. Physicians would identify high risk patients with an A1c >9% to meet with a pharmacist to discuss blood sugar, cardiovascular risk reduction, immunizations, and other aspects of comprehensive diabetes care. Diabetes management requires an intensive understanding of a patient's daily life to provide appropriate counseling and planning related to exercise and dietary choices. Pharmacists working within the prison are particularly well-suited to appreciate the opportunities and challenges presented by the environment and culture. Needles and syringes are meticulously accounted for in an incarcerated environment, which requires insulin therapy be administered as Directly Observed Therapy (DOT) at designated times at each facility. Meals are provided on a schedule and through controlled movement. Pharmacists are aware of the food items available for sale in institutional commissaries, can recommend recreational activities, and appreciate ways in which security concerns can impact daily routine. In this way, the pharmacists at FCC Butner have proven their value in assisting physicians and patients in pursuit of their health goals.
As pharmacists working at FCC Butner have demonstrated the benefits of their work within primary care practice, there may be other practices for which unique cultural understandings are better appreciated by local pharmacists relative to outside specialty consultants. For those practices who want to embed pharmacy services with a demonstrated standard of care, they may consider investigating the National Clinical Pharmacy Specialist certification.
Opinions expressed in this article are those of the authors and do not necessarily represent the opinions of the Federal Government, the Federal Bureau of Prisons, or the Department of Justice.
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