The evolution of an award-winning MTM program

Abstract

For a pharmacy program, it doesn’t get much better than this. In 2010, the Henry Ford Health System (HFHS) Health Alliance Plan’s (HAP) Medication Therapy Management Program (MTMP) received one of URAC’s Gold Awards for Best Practices in Health Care Consumer Protection and Empowerment. URAC, a health care accreditation organization, gives these awards to innovative, results-oriented programs that have made a difference in the lives of patients. Under the direction of Vanita K. Pindolia, PharmD, BCPS, Vice President for Ambulatory Clinical Pharmacy Programs, HAP developed and implemented its own MTM methodology in 2006 as a move toward more patient-centered care for seniors with a multitude of chronic diseases, a timely response to the 2006 CMS requirement of MTM for Medicare Part D individuals. The program continues to grow and evolve. HAP’s first step was to prove its methodology through an institutional review board-approved study to determine how to use pharmacy services to ensure appropriate medications, avoid adverse events, and improve health outcomes. In “Mitigation of medication mishaps via medication therapy management,” published in Annals of Pharmacotherapy in 2009, technology and telephones provided the optimal solution.■The Henry Ford Health System Health Alliance Plan has offered an award-winning MTM program since 2006.■The MTM program involves pharmacist-physician collaboration, telephone counseling, and personalized care. ■The Henry Ford Health System Health Alliance Plan has offered an award-winning MTM program since 2006.■The MTM program involves pharmacist-physician collaboration, telephone counseling, and personalized care. As a member of HFHS, one of the nation’s largest integrated health systems with its own hospitals, medical group, insurance company (HAP), and an assortment of ambulatory services, HAP pharmacists had a distinct advantage in implementing MTM. The Pharmacy Care Management Department was able to query the HFHS Clinical Care Management System (CCMS), an electronic medical record and electronic prescribing database developed by McKesson and customized by HFHS, for listings of eligible patients according to CMS guidelines—multiple chronic diseases, multiple Part D drugs, and annual costs that exceeded a predetermined level. Once identified, these individuals were sent letters introducing the MTM study. After a few days, pharmacy technicians telephoned them to make certain that the letters were received and ask if the person would agree or decline to enroll in the study. In 2006, a total of 16,723 patients enrolled in a HAP Medicare Part D plan; 17,111 enrolled the next year. For the approximately 20% of eligible people who agreed to enroll during those years, HAP staff acquired medical and drug histories from the CCMS database or from the primary care provider. Enrolled patients had a mean of 5.9 qualifying diseases and a mean of 16.7 prescriptions filled. The patient-centered, individualized approach enabled specially trained clinical pharmacists to schedule telephone sessions at each patient’s preferred day and time to go over medications, address concerns, ascertain personal lifestyle habits and health care goals, and determine if any changes were needed to help the patient meet those goals, which were aligned with the evidence-based goals of the patient’s physician. Pharmacists then screened medications for appropriateness, proper dosing, potential drug interactions, adherence issues, or barriers and reviewed patients’ understanding of their medical conditions and treatment plans. The researchers broke down changes made into those that improved efficacy, such as adding medicines that were needed but not prescribed and altering drug regimens to meet health care goals (60%), and those that improved safety, such as deleting prescribed medicines that were no longer needed, were duplicate therapies, or were contraindicated (40%). All changes were documented in the CCMS database. “What drives this program are the patients’ personal health care needs and goals.” A critical last step in the HAP process was the pharmacist’s ability to present findings and suggestions to the patient’s physician and establish a collaborative relationship to develop a revised pharmacotherapy plan. In many cases, although the pharmacist might have identified 15 drug issues, they needed to identify just the top 3 to present for discussion in the interest of time and efficiency. Typically, pharmacists began by addressing cost to the patient by switching one medication to a generic version or a different drug if appropriate. They often then attempted to correct the biggest safety issue and finished with changes that would help meet the patient’s health goals. After meeting with the patient’s physician, the pharmacist sent a comprehensive medication letter to the patient, outlining the changes agreed on and approved by the physician. The letter included the patient’s most current medication list, including OTC products and supplements, key issues addressed in the earlier telephone call, the new drug regimen, and information about how to implement the changes. The pharmacist also telephoned the patient once again to counsel him or her about the physician-endorsed changes and help schedule any needed follow-up physician visits or laboratory studies. The study identified significant benefits in clinical outcomes among MTM enrollees, showing trends toward improved adherence to drug therapy in patients with arthritis, heart failure, and diabetes. The greatest improvement was seen in patients with arthritis—a 60% reduction rate in gastrointestinal bleeds 6 months after enrollment compared to 6 months prior. Researchers also observed a greater reduction in bleeds in enrolled patients with arthritis compared with patients with arthritis who declined to enroll. “However, because this included any and all disease states, it was like finding a needle in a haystack to get enough people in a subgroup to analyze what kind of impact was made in any one disease state,” Pindolia explained. “What drives this program are the patients’ personal health care needs and goals.” For example, a patient with diabetes enrolled in the study may have received counseling from the investigating pharmacist on medication for overactive bladder, because the patient identified it as a need. Overall, patients were greatly satisfied with the telephone-based program. Short questionnaires mailed to all enrollees in both years found that 95% considered the MTM program to be helpful and 90% felt the telephone discussion with the pharmacist was convenient and provided in-depth information without the need for travel to the pharmacy.Responsible use of medicinesIn October 2012, the IMS Institute for Health Informatics released a landmark report, “The responsible use of medicines: Applying levers for change” (www.responsibleuseofmedicines.org). The report was originally intended for a global summit of 30 health-system leaders, including ministers of health and senior policy makers, from around the world. Many of the case studies in the report, such as those about adherence, polypharmacy, and prevention of medication errors, are of interest to pharmacists as well. In a series of articles running from July through September, Pharmacy Today will examine some of the cases in the report from the perspective of the pharmacy professional. In October 2012, the IMS Institute for Health Informatics released a landmark report, “The responsible use of medicines: Applying levers for change” (www.responsibleuseofmedicines.org). The report was originally intended for a global summit of 30 health-system leaders, including ministers of health and senior policy makers, from around the world. Many of the case studies in the report, such as those about adherence, polypharmacy, and prevention of medication errors, are of interest to pharmacists as well. In a series of articles running from July through September, Pharmacy Today will examine some of the cases in the report from the perspective of the pharmacy professional. The relative straightforwardness of HAP’s MTM method makes it easy to replicate in similar ambulatory settings, Pindolia suggested, as long as there is access to a substantial and complete database of patient infor- mation—which will only be as good as the data that are entered—and adequate staff. Pindolia’s experience has shown her that certain intangible qualities are necessary too. Having the right staff is essential, she told Pharmacy Today. Ideally, the MTM pharmacists will have completed a residency with a focus on ambulatory care. Good motivational interviewing skills are important for quickly identifying key medication issues. Equally vital is the ability to identify and integrate the patient’s personal health care goals and concerns. In the HAP MTM program, 25% of the patients are on 20 or more drugs, Pindolia said, making the pharmacists’ ability to listen and modify medication regimens to meet individual needs central to achieving patient buy-in and satisfaction. Since 2011, all HAP patient have received at least one follow-up telephone call after implementation of the MTM protocol to see if they are meeting their goals for medication-related outcomes, including improved drug efficacy, safety, and adherence and lower drug costs. Pharmacists enrolled 1,663 people in the MTM program in 2011, and 75% of their changes were related to drug efficacy and safety. The program uses follow-up telephone calls timed to individual needs. For example, if a pharmacist makes a change for a new blood pressure medication, the patient would be scheduled for a physician visit 2 to 4 weeks after initiation to allow the time needed for the medication to take effect. After the visit, the pharmacist would call the patient to discuss the outcome. The pharmacist, physician, and patient also collaborate to make additional changes if the patient is not meeting the agreed- on goals. “When we were trying to measure based on disease states such as improving [glycosylated hemoglobin], there was concern from physicians and nurses about who was responsible for the improvement,” Pindolia explained. “We were the ones to suggest changing the drug, but there was also the diabetes educator, the physician who wrote the prescription, the nurse practitioner who provided medical follow-up. It is truly a team effort.” The MTM program has grown from just Medicare Part D patients to HFHS’s own employees and United Auto Workers Union retirees. The program has also been modified for two geriatric clinics, several neuroscience clinics, a hospital readmission avoidance MTM program launched in January 2012, and a collaborative transition of care program that is in process. “Progress is very fluid,” Pindo- lia told Today. “Anything done even a year ago has been modified. We do a quarterly review and make major changes to improve the program every year.”