Community Health Medic.  A Community Health Medic (CHM) is a graduate of one of the IHS intramural physician assistant training programs at the Gallup Indian Medical Center (1971-1983) or the Clinical Support Center (formerly the "Clinical Continuing Support Center" [1971-1977]).  All CHMs become eligible to take the Physician Assistant national certification exam upon graduation.
 

Physician Assistant.  A PA is a trained health care professional who has completed an American Medical Association accredited PA program. The PA is qualified to practice medicine within limits determined by State law, a supervising physician, or a health care organization by virtue of his/her educational, professional, and clinical experience.
 

Standing Orders. A document that specifically identifies decision processes and treatment regimens; utilization, interpretation, and application of diagnostic tests; and requirements for consultation or referral for individual medical complaints and situations.
 

BACKGROUND. Physician Assistants employed by the IHS are often required to practice in isolated settings where on-site physician consultation is not always available. For this reason, the IHS has found it necessary to clarify the requirements for PA credentialing, privileging, and quality assessment.
 

POLICY. The IHS shall utilize the PA to extend health services and improve the quality of medical care provided to American Indians and Alaska Natives, and to more effectively utilize the education and skills possessed by physicians. Physician Assistants employed by the IHS must be certified by the National Commission on Certification of Physician Assistants and must maintain that certification throughout their employment with the IHS.

Tribes that contract/compact with the IHS to provide health' care are responsible for ensuring that all health care providers employed by the tribe meet the minimal licensure requirements and adhere to the statutory practice act of the State. Tribal organizations are encouraged to adopt this policy or a similar policy appropriate to the State in which the tribal program is located.
 

PROCEDURES.

Position Descriptions. Each facility must develop and maintain position descriptions that outline the scope of work and the administrative and/or supervisory responsibilities for PAS employed at that facility.
 

Certification. Physician Assistants must be nationally certified and present evidence of certification or be eligible for national certification at the time of employment.
 

Physician Assistants who have obtained a qualifying degree within 12 months of their appointment and those who are new graduates, not certified at the time of employment:
 

Must sign an acknowledgment of this condition.

Must become certified within 1 year from date of employment or be separated from Federal service.
 

Physician Assistants and CHMs who were hired prior to February 1, 1990, may remain in their present positions without certification; however, they must become certified in order to transfer to a new position.
 

Licensure. Health care professionals who are employed by the IHS are required to be licensed, registered, or nationally certified. Physician Assistants employed by the IHS must be nationally certified (unless exempted). The IHS does not require PAS to be licensed in the State(s) in which they will be performing their official duties. Based upon Federal sovereignty and supremacy principles, a State may not require that an IHS employee who provides health care within the State as part of his or her Federal duties be licensed in that State. However, Drug Enforcement Administration regulations require the PA be authorized to prescribe controlled substances by the jurisdiction (e.g., State) in which he/she is licensed, registered, or otherwise specifically recognized to practice his/her profession. (See Section G. Prescribing Privileges herein.)
 

Credentials Review. The credentials of health care professionals, including PAS, must be reviewed and verified. The Clinical Director at each IHS facility is responsible for ensuring that the credentials review process is carried out for every member of the medical staff. The review is conducted according to the medical staff by-laws, as approved by the Governing Body or Administration of the Facility. (Ref. IHS Circular No. 95-16)
 

Privileging.
 

Each PA will be granted clinical privileges in accordance with that facility's medical staff by-laws. The privileging statement will delineate the approved clinical functions and level of practice of the PA, including the degree of clinical supervision. The granting of clinical privileges for PAS shall be based on their documented education, training, experience, and current competence. 
 

The use of standing orders (in addition to the privileging document) is not required, but standing orders may b&utilized if requested by a PA or the medical staff. The extent to which these documents detail the work of the PA will be left to the discretion of the credentialing committee of the facility's medical staff.
 

Clinical Supervision.  All PAS hired either as independent contractors or under the authority of a personal services contract must have a supervising physician. The process by which a supervising physician is appointed shall be left to the discretion of the facility's medical staff; The supervising  physician will be responsible for the clinical oversight-of the PA. The degree of clinical supervision provided will be dependent upon the PA's training, experience, and current competence.
 

The supervising-physician must meet in person with the PA on a periodic, basis to discuss patient management. The frequency of these meetings' shall be defined by the local medical staff.
 

The PA may practice at remote sites or after hours without a supervising or consultative physician on-site as long as voice telephone or-two-way radio contact with an advising physician is available. The advising physician must be the PA's clinical supervisor or a designated alternate active or temporary medical staff member. In addition, quality assurance mechanisms must be in place to ensure and document that the PA is practicing within his/her defined privileges.
 

Prescribing Privileges. Prescribing privileges that may include prescribing all classes of pharmaceuticals, shall be included in the PA medical staff privileging process. All privileges shall be granted based on the PA's education. and clinical experience.
 

Prescribing privileges include writing prescriptions, inpatient chart orders (if so privileged), dispensing of medications (as may be required in remote settings), and the administration of pharmaceuticals, where appropriate to do so.
 

Prescribing privileges for Drug Enforcement Agency (DEA) Controlled Substances (Schedules II-V) may be granted to PAS in accordance with the Indian Health Manual Part 3,Chapter 7, a Pharmacy," Section 3-7.3D (2a), dated 6/26/95:
 

The facility has authorized the PA to dispense or prescribe designated Schedules of Controlled Substances under its DHA registration.
 

The PA-must be. registered, licensed; or otherwise specifically recognized by any State as having authority to prescribe designated Schedules of Controlled Substances.
 

The PA adheres to all local facility policies regarding-the prescribing of controlled substances.
 

The implementing regulations of the Controlled Substances Act, Title 21, CFR, Section 1306.03 state (in part): "A prescription for controlled substances may be issued only by an individual practitioner who is authorized to prescribe controlled substances by the jurisdiction in which he is licensed to practice his profession."
 

Quality Assurance/Peer Review. Physician Assistants  will be subject to the same quality assurance/peer review (QA/PR) process that is used at the local level for all other health care providers. The QA/PR process must be identified by medical staff by-laws; in accordance with standards that were developed by a national accrediting organization or the Joint Commission on Accreditation of Healthcare Organizations.
 

The clinical competence of PAS will be reviewed and documented at least annually and will include patient care review in accordance with local policies and procedures.
 

In facilities where more than one PA is employed, PAS may participate in the review and evaluation of their peers clinical performance.
 

Medical record and prescription co-signatures for PAS are not an IHS requirement, but may be used when necessary in some States for third-party billing purposes. Co-signatures for PAS may be required on an individual basis, e.g., during the initial appointment until certification is received or if clinical privileges have been restricted or reduced.
 

Review of prescribing practices shall be employed for PAs in the same manner as for other members of the facility's medical staff.
 

Medical Staff Membership. The medical staff includes physicians (M.D. and D.O.), dentists, and other health care providers who are licensed or otherwise. permitted by a State and by the health care facility to provide ,patient care services independently within the scope 0f the-profession and in accordance with individually. granted clinical privileges.- Medical staff membership .requirements are found in the Indian Health Service 95-l6 Section D.