Medication Therapy Management Pharmacists Research Articles

Impact of a comprehensive pharmacist medication-therapy management service

Objective:This proof of concept study aimed to determine whether a pharmacist-managed medication therapy management (MTM) program in a private endocrinologist physician’s practice reduced healthcare services utilization and related costs 6 months after patients’ discharge from an institution with a transition of care service.Methods:Patients were included in the study if they were English-speaking, ages >18 years, had type 1 or 2 diabetes, and had a recent transition of care experience (inpatient hospital stay or emergency department/urgent care/paramedic or other acute care visit). The study had a non-randomized design where intervention patients, enrolled July 1, 2012–September 30, 2013, were administered MTM at four visits over 6 months and were compared to historical control patients with available electronic medical records from August 8, 2008 to March 15, 2012. The primary study end-point was the rate of 30-day hospital readmissions, as related to the reason for the index admission. Secondary end-points included the cumulative rate of all-cause hospitalizations, emergency department, paramedic and urgent care visits at 30, 60, 90, and 180 days post-discharge as well as imputed total costs, including prescription medication costs, at 180 days. Propensity score weights were constructed to balance covariate characteristics between the intervention and control groups. Weighted multivariate negative binomial and generalized linear regressions were used to model cumulative utilization rates and log-transformed costs, respectively.Results:The intervention (n = 28) and control (n = 73) groups had 0% hospital readmissions at 30 days post-discharge. In propensity score weighted multivariate analyses, cumulative utilization rate was not different between the two groups (IRR = 1.61, p = 0.72 at 180 days) while costs in the intervention group were lower but not statistically different (cost ratio = 0.65, p = 0.13 at 180 days).Conclusions:Further studies should investigate whether the integration of pharmacists in transition of care models could reduce readmission and healthcare utilization rates post-discharge.

Best Practices: Improving Patient Outcomes and Costs in an ACO Through Comprehensive Medication Therapy Management

One of the most important and often overlooked challenges for accountable care organizations (ACOs) is ensuring the optimal use of pharmaceuticals, which can be accomplished by utilizing pharmacists' skillsets and leveraging their full clinical expertise. Developing capabilities that support, monitor, and ensure appropriate medication use, efficacy, and safety is critical to achieving optimal patient outcomes and, ultimately, to an ACO's success. The program described in this article highlights the best practices of Fairview Pharmacy Services' Medication Therapy Management (MTM) program with additional thoughts and considerations on this and similar MTM programs provided by The Working Group on Optimizing Medication Therapy in Value-Based Healthcare. Fairview Pharmacy Services utilizes 23 MTM pharmacists (approximately 18 full-time equivalents) working in 30 locations, who conduct pharmacotherapy workups as part of the MTM services that Fairview provides. Pharmacists focus on patients in a comprehensive manner and assess all of their diseases and medications. Responsibilities include (a) identification of a patient's drug-related needs with a commitment to meet those needs; (b) an assessment and confirmation that all of a patient's drug therapy is appropriately indicated, effective and safe, and that the patient is compliant; (c) achievement of therapy outcomes and ensuring documentation of those outcomes; and (d) collaboration with all members of a patient's care team. Since 1998, pharmacists have cared for more than 20,000 patients and resolved more than 107,000 medication-related problems which, if left unresolved, could have led to hospital readmissions and emergency visits. Since becoming a Pioneer ACO, Fairview pharmacists have focused on the highest-risk members and have seen over 670 ACO patients, resolving over 2,780 medication-related problems. In terms of clinical outcomes, MTM contributed to optimal care in complex patients with diabetes. A review of 2007 data found that the percentage of diabetes patients optimally managed (as measured by a composite of hemoglobin A1c, low-density lipoprotein, blood pressure, aspirin use, and no smoking) was significantly higher for MTM patients (21% vs. 45%, P less than 0.01). The Fairview MTM also showed a 12:1 return on investment (ROI) when comparing the overall health care costs of patients receiving MTM services with patients who did not receive those services. Developing an MTM program to manage and optimize pharmaceuticals will be a cornerstone to managing the health of a population. Important lessons have been learned that may be helpful to other health systems developing MTM programs. In an accountable care environment measuring the return on the investment of all care interventions, including MTM will be essential to maintain the program. The ACO will also have to be able to correctly identify which patients are candidates for MTM services and provide pharmacists with enough autonomy, including scheduling face-to-face interactions with patients and the ability to change prescriptions if necessary, to ensure that timely and effective care is delivered. In order for an ACO to deliver high quality patient-centered medication services, there must be clear lines of communication between providers, pharmacists, and the other care providers within the organization. Finally, a strong and visionary leader is critical to ensuring the success of an MTM program and ultimately the ACO itself. While there is a plethora of literature touting the benefits of either in-person or telephonic-based MTM, there is little research to date that directly compares these 2 MTM delivery types. It is critical for research to address the direct and indirect costs associated with starting and maintaining an MTM program. Information such as technologies required to start a program and length of time until a program breaks even or meets a sufficient ROI can be helpful for health care providers in similar health systems pitching a similar type of program. Finally, there has yet to be significant empirical research into the cost savings of utilizing a pharmacist and MTM services associated with meeting quality and cost benchmarks in an accountable care payment arrangement.

Report of the 2013 AMCP Partnership Forum on electronic solutions to medication reconciliation and improving transitions of care.

The Affordable Care Act (ACA) is driving the evolution of reimbursement from a fee-for-service model to an outcomes-based system. Accountable care organizations (ACOs) are 1 component of this evolution, and 1 of their charges is to reduce hospital readmission rates for key diagnoses such as congestive heart failure (CHF) and other cardiovascular comorbidities. Lack of patient follow-up and adherence are 2 major causes of readmission. Providing strong medication management is 1 of the common factors in successful readmission programs. We discuss here how electronic solutions might strengthen these medication management programs. To explore the key issues and strategies that affect the use of electronic medication reconciliation processes and to identify the role the Academy of Managed Care Pharmacy (AMCP) can play in spearheading the adoption of electronic solutions. This was a descriptive analysis of the medication reconciliation process and the factors that promote or limit the application of electronic solutions to medication reconciliation and transitions of care processes. AMCP convened a panel of managed care, hospital, community, ACO, and medication therapy management pharmacists; technology vendors; and other health care stakeholders with an expertise or interest in transitions of care. In the last few years, there has been considerable uptake of electronic solutions to the admission medication reconciliation process, largely due to increasing penetration of vendors using sophisticated medication history tools. The current electronic solutions to the admission medication reconciliation record are remarkably similar in content. Some pilots for electronic solutions to discharge medication reconciliation are emerging. The focus group recommended specific programs AMCP can pursue to increase the adoption of electronic solutions for medication reconciliation. One important aspect to address is developing a business case that documents the return on investment (ROI) for electronic solutions. Besides electronic efficiencies, the ROI needs to include hospital readmission penalties, loss of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) incentives, avoidance of duplicative efforts, and payer costs for readmissions. Managed care pharmacy needs to be engaged in assessing its incentives for promoting electronic solutions.

Primary Care–based, Pharmacist–physician Collaborative Medication-therapy Management of Hypertension: A Randomized, Pragmatic Trial

PurposeA collaborative pharmacist–primary care provider (PharmD-PCP) team approach to medication-therapy management (MTM), with pharmacists initiating and changing medications at separate office visits, holds promise for the cost-effective management of hypertension, but has not been evaluated in many systematic trials. The primary objective of this study was to examine blood pressure (BP) control in hypertensive patients managed by a newly formed PharmD-PCP MTM team versus usual care in a university-based primary care clinic. MethodsThis randomized, pragmatic clinical trial was conducted in hypertensive patients randomly selected for PharmD-PCP MTM or usual care. In the PharmD-PCP MTM group, pharmacists managed drug-therapy initiation and monitoring, medication adjustments, biometric assessments, laboratory tests, and patient education. In the usual-care group, patients continued to see their PCPs. Participants were aged ≥18 years, were diagnosed with hypertension, had a most recent BP measurement of ≥140/≥90 mm Hg (≥130/≥80 mm Hg if codiagnosed with diabetes mellitus), were on at least 1 antihypertensive medication, and were English speaking. The primary outcome was the difference in the mean change from baseline in systolic BP at 6 months. Secondary outcomes included the percentage achieving therapeutic BP goal and the mean changes from baseline in diastolic BP and low- and high-density lipoprotein cholesterol. FindingsA total of 166 patients were enrolled (69 men; mean age, 67.7 years; PharmD-PCP MTM group, n = 75; usual-care group, n = 91). Mean reduction in SBP was significantly greater in the PharmD-PCP MTM group at 6 months (–7.1 [19.4] vs +1.6 [21.0] mm Hg; P = 0.008), but the difference was no longer statistically significant at 9 months (–5.2 [16.9] vs –1.7 [17.7] mm Hg; P = 0.22), based on an intent-to-treat analysis. In the intervention group, greater percentages of patients who continued to see the MTM pharmacist versus those who returned to their PCP were at goal at 6 months (81% vs 44%) and at 9 months (70% vs 52%). No significant between-group differences in changes in cholesterol were detected at 6 and 9 months; however, the mean baseline values were near recommended levels. The PharmD-PCP MTM group had significantly fewer PCP visits compared with the usual-care group (1.8 [1.5] vs 4.2 [1.0]; P < 0.001). ImplicationsA PharmD-PCP collaborative MTM service was more effective in lowering BP than was usual care at 6 months in all patients and at 9 months in patients who continued to see the pharmacist. Incorporating pharmacists into the primary care team may be a successful strategy for managing medication therapy, improving patient outcomes and possibly extending the capacity of primary care. ClinicalTrials.gov identifier: NCT01973556.

Bridging the Location Gap: How Can Pharmacists and Physicians Collaborate for Delivering Patient Care? (BRIDGE Study Phase I)

Background: Research has shown that collaboration between physicians and pharmacists improves health outcomes and prevents adverse drug events. Pharmacists providing medication therapy management (MTM) services in local stand-alone MTM clinics have experienced significant difficulty collaborating with physicians. However, MTM pharmacists who practice in the same facility with the physician self-rate their practices as highly collaborative. The purpose of this study is to determine if collaboration varies based on MTM practice location.Methods: A convenience sample of 15 physicians who had received documentation of patient care from both an internal and external MTM pharmacist was surveyed to assess pharmacist-physician collaboration. Each physician was asked to complete the same survey for both an internal and an external MTM pharmacist, and to provide background and demographic information.Results: Eleven surveys were returned by physicians for a 73% response rate (11/15). Four surveys were completed in their entirety. Seven surveys were returned with only the internal MTM pharmacist portion completed. The total score for external MTM pharmacists ranged from 52 to 87 with a mean score of 73.25 and standard deviation (SD) of 15.28. The total score for internal MTM pharmacists ranged from 74 to 98 with a mean score of 87.90 and SD of 9.12. Total mean scores resulting from summing items for the three domains of trustworthiness, role specification, and relationship initiation were higher for internal MTM pharmacists versus external MTM pharmacists (p = .03).Conclusion: Based on our results, it appears the level of collaboration between physicians and MTM pharmacists tends to be higher when they practice in the same facility.

Team-based care and provider status

The health care system appears to be moving from fee for service to pay for performance with emerging models of care such as patientcentered medical homes and accountable care organizations (ACOs). Many pharmacists are providing medication therapy management (MTM) in these new models, based on data in the 2013 Medication Therapy Management Digest: Pharmacists Emerging as Interdisciplinary Health Care Team Members, released in March.

The impact of medication therapy management in older oncology patients

This project aimed to identify common drug-related problems (DRP) among elderly cancer patients, to determine the effectiveness of medication therapy management (MTM) service in resolving DRP, to determine the clinical significance of pharmacist interventions, and to determine patients' satisfaction level of MTM service. Elderly cancer patients (age ≥65) who were at least on one chronic medication would be eligible for the MTM service. Any DRP that was detected would be recorded and steps to resolve it were taken. Pre- and post-service patient satisfaction surveys (PSS) were conducted before and after MTM. All interventions performed by MTM pharmacists were subjected to independent evaluation by a panel of three judges. One hundred eighteen patients received at least one session of MTM. We identified and attempted to resolve 361 DRPs, and the most common DRPs were drug interactions (117 cases, 32.4 %), adverse effects (114 cases, 31.6 %), and non-adherence (48 cases, 13.3 %). Forty-four interventions were performed by pharmacists and forty cases (91 %) were accepted by physicians. Almost two third of these interventions were deemed significant (or higher) by the judges. Seventy-two patients completed PSS. There was statistically significant improvement in patients' satisfaction level after the service was provided. MTM is an important platform in identifying and managing DRPs. Patients are generally satisfied with MTM services.

Caring behaviors can make a difference

The other day, a patient approached me with a concerned expression on her face. When I asked if I could help, she asked if she could talk to me privately. I directed her to one of our patient consultation areas and sat down to talk with her. She was concerned about her husband who has several chronic medical conditions including pain. She wanted my opinion regarding his medication regimen and advice about his pain meds. The other day, a patient approached me with a concerned expression on her face. When I asked if I could help, she asked if she could talk to me privately. I directed her to one of our patient consultation areas and sat down to talk with her. She was concerned about her husband who has several chronic medical conditions including pain. She wanted my opinion regarding his medication regimen and advice about his pain meds. Although this scenario is common in many pharmacies, it caused me to pause and think about my value to her and her husband. She said that she had switched to our pharmacy 6 years ago because she believed I was a caring and knowledgeable pharmacist. To be honest, I do not remember my early interactions with her or her husband, but something I said or did must have made a difference in their lives. ■Patients react positively to pharmacists who demonstrate empathy and care.■Good pharmacy leaders create a culture of caring within their practice. ■Patients react positively to pharmacists who demonstrate empathy and care.■Good pharmacy leaders create a culture of caring within their practice. Questions came to my mind. How do our patients perceive us? Why did they choose our practice instead of other pharmacies? I remembered the adage, “People don’t care how much you know until they know how much you care.” Perhaps it is the caring aspects of our behaviors that affect patients’ preferences for one pharmacist or pharmacy over another. I reviewed the literature to see what has been studied about caring behaviors of pharmacists and came across an interesting article published in the Journal of the American Pharmacists Association that provided me with some answers to my questions. ■The study observed caring pharmacists (as determined by their pharmacy managers) and identified caring behaviors demonstrated during interactions with patients.■Observation and interviews were used to assess caring attitudes of pharmacists who practiced in cor- porately owned community pharmacies in greater Chicago.■The following four categories of caring behaviors emerged:•Physical behaviors: pharmacists’ body language and reflection•Relationship behaviors: pharmacists’ interactions with patients•Task behaviors (nonpharmacy): helping patients find items or explaining their costs/receipts•Task behaviors (pharmacy): pharmacists’ counseling and education of patients■The pharmacy manager was essential in creating the caring culture of the pharmacy. This made a difference in how the pharmacy staff interacted or related to their patients.■Mentors were a powerful influence in developing caring pharmacists.■Caring pharmacists treated their patients holistically. They knew many of their patients by their first names. Patients were treated as individuals.■Caring pharmacists enabled their patients to take control of their health. As pharmacists make strides in reengineering their practices to provide medication therapy management (MTM) services, we must remember that patients respond favorably to pharmacists who demonstrate empathy and care. MTM services are just that—ser- vices. They alone do not provide care. Patients judge the quality of MTM services by the outward behaviors demonstrated by pharmacists during the MTM session. It is the patients’ perceptions that become their reality. They need to experience the caring behaviors of pharmacists in order to know that pharmacists do care about their health and that the pharmacists see them as unique individuals. Comprehensive MTM services focus on the entire patient— all medications and medical conditions. MTM is a great vehicle for pharmacists to demonstrate care to patients. Comprehensive MTM services focus on the entire patient—all medications and medical conditions. The Medication Action Plan provides patients with their own road map to achieve optimal benefits of their medications. By working with MTM pharmacists, patients are better-informed consumers of medications and are in more control of their medications and health outcomes. Last, pharmacy managers and supervisors should set an example for the rest of the staff. Good leaders create a culture of caring within their practice so that staff knows what is expected of them when interacting with patients. As more pharmacies and providers provide MTM services, patients will have a variety of choices for care. I am betting that they will choose those who they believe are the most caring.

Development of a pharmacist–psychiatrist collaborative medication therapy management clinic

ObjectiveTo describe a needs assessment, practice description, practice innovation and reimbursement of a psychiatric pharmacist medication therapy management (MTM) clinic with related challenges and opportunities. SettingAn MTM clinic established in collaboration with the Outpatient Psychiatric Services (OPS) at the University of California San Diego (UCSD), under contract with the San Diego County Health and Human Services Agency Adult and Older Adult Mental Health Services (A/OAMHS). Practice descriptionTwo board-certified psychiatric pharmacists provided direct patient care using a collaborative practice protocol 3days per week. Clinical services included pharmacotherapy management, laboratory monitoring, medication counseling, and psychosocial referrals to other providers. Practice innovationPayment to UCSD OPS for clinical services was based on a contract between the San Diego County A/OAMHS and the clinic. Two pharmacists co-managed mental health patients and billed for medication management based on face-to-face contact time (medication minutes) and documentation time with each patient. Main outcome measuresNumber of patients comanaged, dropout rates, visit duration, and billed minutes. ResultsFrom May 2009 to December 2010, two pharmacists comanaged 68 patients, mean (± SD) age 48.6±11.6years, diagnosed with major depressive, schizophrenic, schizoaffective, and/or bipolar disorder. A total of 56 (82.3%) patients were clinically stable and remained on the pharmacist caseload, but 12 (17.6%) patients were lost to follow-up (10 lost contact, 1 moved, 1 expired). On average, patients had 7.7 patient visits , for 491 total visits (with an average of 26minutes per visit) that were billed at a rate of $4.82 per minute for medication minutes, translating to $84,542.80. ConclusionWith provider education and appropriate physician champions, pharmacists are able to work collaboratively with psychiatrists in a mental health clinic.

Challenges to implementation of MTM services

Challenges to implementation of MTM services

Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting

To determine the effect of formal medication therapy management (MTM) services on pharmacist workload, as well as to describe the population receiving MTM, describe the services provided, and determine the reimbursement rate for billed MTM services. MTM Current Procedural Terminology (CPT) code claims, electronic medical records, and pharmacist MTM logs. A retrospective review of all MTM charges from January 1, 2010, to March 31, 2010, was performed. Data collected included location of the MTM visit, age, gender, insurance, primary malignancy, comorbidities, home medications, time to complete and document the MTM visit, and rate of reimbursement. In the 3-month period, 239 MTM visits were completed. It took pharmacists a median of 20 minutes (range 15-127) of face-to-face time and 18 minutes (5-90) for documentation per visit. To date, no claims for MTM have been rejected, and reimbursement rates range from 47% to 79% depending on the insurance provider. MTM in the ambulatory clinic is feasible despite the increase in pharmacist workload from documenting and billing. The increased visibility of clinical pharmacy services justifies the extra time required for formal MTM.

Primary Care Providers' experiences with Pharmaceutical Care-based Medication Therapy Management Services

This study explored primary care providers' (PCPs) experiences with the practice of pharmaceutical care-based medication therapy management (MTM). Qualitative, semi-structured interviews were conducted with six PCPs who have experiences working with MTM pharmacists for at least three years. The first author conducted the interviews that were audio-taped, transcribed, and coded independently. The codes were then harmonized via discussion and consensus with the other authors. Data were analyzed for themes using the hermeneutic-phenomenological method as proposed by Max van Manen. Three men and three women were interviewed. On average, the interviewees have worked with MTM pharmacists for seven years. The six (6) themes uncovered from the interviews included: (1) "MTM is just part of our team approach to the practice of medicine": MTM as an integral part of PCPs' practices; (2) "Frankly it's education for the patient but it's also education for me": MTM services as a source of education; (3) "It's not exactly just the pharmacist that passes out the medicines at the pharmacy": The MTM practitioner is different from the dispensing pharmacist; (4) "So, less reactive, cleaning up the mess, and more proactive and catching things before they become so involved": MTM services as preventative health care efforts; (5)"I think that time is the big thing": MTM pharmacists spend more time with patients; (6) "There's an access piece, there's an availability piece, there's a finance piece": MTM services are underutilized at the clinics. In conclusion, PCPs value having MTM pharmacists as part of their team in ambulatory clinics. MTM pharmacists are considered an important source of education to patients as well as to providers as they are seen as having a unique body of knowledge äóñmedication expertise. All PCPs highly treasure the time and education provided by the MTM pharmacists, their ability to manage and adjust patients' medications, and their capability to address patients' medication experiences. MTM pharmacists are seen as being different from dispensing pharmacists, and PCPs usually highlight that difference to patients as they refer them to MTM services. Lastly, it is apparent that MTM pharmacists struggle to explain what their role is within the healthcare team and they need to find a more effective way to explain the unique value they add to the care of patients.&#x0D; &#x0D; Type: Original Research

Patient-perceived value of Medication Therapy Management (MTM) services: a series of focus groups

Objective: To determine the patient-perceived value of MTM services and non-financial barriers preventing patients with insurance coverage from receiving MTM services.&#x0D; Design: Focus groups.&#x0D; Setting: Fairview Pharmacy Services, Minneapolis, MN.&#x0D; Participants: Three focus groups, each with five to nine participants, consisting of different participant populations: (i) patients who paid out-of-pocket to receive MTM services; (ii) insurance beneficiaries, under which MTM is a covered benefit and participants may have received incentives for receiving MTM services; (iii) patients with an insurance plan which covers MTM services who were recruited to receive MTM services but declined. Intervention: MTM services.&#x0D; Main Outcome Measure: Patient-perceived value of MTM services and non-financial barriers.&#x0D; Results: Seven themes were identified relating to the patient-perceived value of MTM services: collaboration of the health care team, MTM pharmacist as a supporter/advocate/confidant, MTM pharmacist as a resource for questions and education, accessibility to the MTM pharmacist, financial incentives for participation in MTM services, MTM pharmacy as a specialty field, and the MTM pharmacist as a coordinator. Three themes were identified regarding patient-perceived non-financial barriers to receiving MTM services, including: availability of the MTM pharmacist, patient/physician lack of knowledge of MTM services, patient's belief that MTM services are not needed.&#x0D; Conclusion: MTM is a service which patients identify as valuable. Patients are able to identify non-financial barriers that may prevent some patients from receiving MTM services. This study provides preliminary evidence of both the value and barriers perceived by patients.&#x0D; &#x0D; Type: Original Research

Implementing a Pharmacist-Led Medication Management Pilot to Improve Care Transitions

Purpose: The purpose of this project was to design and pilot a pharmacist-led process to address medication management across the continuum of care within a large integrated health-system.&#x0D; Summary: A care transitions pilot took place within a health-system which included a 150-bed community hospital. The pilot process expanded the pharmacist's medication management responsibilities to include providing discharge medication reconciliation, a patient-friendly discharge medication list, discharge medication education, and medication therapy management (MTM) follow-up.&#x0D; Adult patients with a predicted diagnosis-related group (DRG) of congestive heart failure or chronic obstructive pulmonary disease admitted to the medical-surgical and intensive care units who utilized a primary care provider within the health-system were included in the pilot. Forty patients met the inclusion criteria and thirty-four (85%) received an intervention from an inpatient or MTM pharmacist. Within this group of patients, 88 drug therapy problems (2.6 per patient) were identified and 75% of the drug therapy recommendations made by the pharmacist were accepted by the care provider. The 30-day all-cause readmission rates for the intervention and comparison groups were 30.5% and 35.9%, respectively. The number of patients receiving follow-up care varied with 10 (25%) receiving MTM follow-up, 26 (65%) completing a primary care visit after their first hospital discharge, and 23 (58%) receiving a home care visit.&#x0D; Conclusion: Implementation of a pharmacist-led medication management pilot across the continuum of care resulted in an improvement in the quality of care transitions within the health-system through increased identification and resolution of drug therapy problems and MTM follow-up. The lessons learned from the implementation of this pilot will be used to further refine pharmacy care transitions programs across the health-system.&#x0D; &#x0D; Type: Original Research

The medication experience: Preliminary evidence of its value for patient education and counseling on chronic medications

ObjectiveTo describe medication therapy management (MTM) pharmacists’ encounters with patients’ medication experiences, to examine the utility of the medication experience in practice, and to explore the value of the medication experience in patient education and counseling on medications. MethodsA focus group of 10 MTM pharmacists, and 1 pharmacist's 9-month practice diary were analyzed to reveal patients’ medication experiences and the utility and value of the medication experience in practice. ResultsMTM pharmacists commonly encountered patients’ medication experiences in their practices. The medication experience was often at the root of drug therapy problems (DTPs) the practitioners identified. The pharmacists identified several examples of drug therapy problems with an associated medication experience at the root. The medication experience was a meaningful construct to guide patient education and counseling on new chronic medications to ultimately prevent DTPs, and valuable for tailoring patient education and counseling on medications to resolve DTPs. ConclusionOur study provides preliminary evidence of the value of the medication experience for patient education and counseling on chronic medications in practice. Practice implicationsThe medication experience is a valuable tool for practitioners to understand patients’ needs, identify and resolve DTPs, and tailor patient education and counseling for chronic medications.

Integration of Remote Blood Glucose Meter Upload Technology into a Clinical Pharmacist Medication Therapy Management Service

A pharmacist-delivered, outpatient-focused medication therapy management (MTM) program is using a remote blood glucose (BG) meter upload device to provide better care and to improve outcomes for its patients with diabetes. Sharing uploaded BG meter data, presented in easily comprehensible graphs and charts, enables patients, caregivers, and the medical team to better understand how the patients' diabetes care is progressing. Pharmacists are becoming increasingly more active in helping to manage patients' complex medication regimens in an effort to help detect and avoid medication-related problems. Working together with patients and their physicians as part of an interdisciplinary health care team, pharmacists are helping to improve medication outcomes. This article focuses on two case studies highlighting the Diabetes Monitoring Program, one component of the Meridian Pharmacology Institute MTM service, and discusses the clinical application of a unique BG meter upload device.

Medication therapy management: 10 years of experience in a large integrated health care system.

Medication therapy management (MTM) was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries. Even though the term "MTM" was first used in 2003, pharmacists have provided similar services since the term "pharmaceutical care" was introduced in 1990. Fairview Health Services, a large integrated health care system, implemented a standardized pharmaceutical care service system in 1998, naming it a pharmaceutical care-based MTM practice in 2006. To present the clinical, economic, and humanistic outcomes of 10 years of delivering MTM services to patients in a health care delivery system. Data from MTM services provided to 9,068 patients and documented in electronic therapeutic records were retrospectively analyzed over the 10-year period from September 1998 to September 2008 in 1 health system with 48 primary care clinics. Patients eligible for MTM services were aged 21 years or older and either paid for MTM out of pocket or met their health care payer's criteria for MTM reimbursement; the criteria varied for Medicaid, Medicare, and commercially insured enrollees. All MTM was delivered face to face. Health data extracted from the electronic therapeutic record by the present study's investigators included patient demographics, medication list, medical conditions, drug therapy problems identified and addressed, change in clinical status, and pharmacist-estimated cost savings. The clinical status assessment was a comparison of the first and most recent MTM visit to measure whether the patient achieved the goals of therapy for each medical condition (e.g., the blood pressure of a patient with diabetes and hypertension will be less than 130/80 millimeters mercury [mmHg] in 1 month; the patient with allergic rhinitis will be relieved of his complaints of nasal congestion, runny nose, and eye itching within 5 days). Goals were set according to evidence-based literature and patient-specific targets determined cooperatively by pharmacists, patients, and physicians. Cost-savings calculations represented MTM pharmacists' estimates of medical services (e.g., office visits, laboratory services, urgent care visits, emergency room visits) and lost work time avoided by the intervention. All short-term (3-month) estimated health care savings that resulted from addressing drug therapy problems were analyzed. The expenses of these avoided services were calculated using the health system's contracted rates for services provided in the last quarter of 2008. The return on investment (ROI) was calculated by dividing the pharmacist-estimated savings by the cost of MTM services in 2008 (number of MTM encounters times the average cost of an MTM visit). The humanistic impact of MTM services was assessed using the results from the second patient satisfaction survey administered in 2008 (new patients seen from January through December 2008) for the health system's MTM program. A total of 9,068 patient records were in the documentation system as of September 30, 2008. During the 10-year period, there were 33,706 documented encounters (mean 3.7 encounters per patient). Of 38,631 drug therapy problems identified and addressed by MTM pharmacists, the most frequent were a need for additional drug therapy (n = 10,870, 28.1%) and subtherapeutic dosage (n = 10,100, 26.1%). In the clinical status assessment of the 12,851 medical conditions in 4,849 patients who were not at goal when they enrolled in the program, 7,068 conditions (55.0%) improved, 2,956 (23.0%) were unchanged, and 2,827 (22.0%) worsened during the course of MTM services. Pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter) and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 per $1 in MTM administrative costs. In the patient satisfaction survey, 95.3% of respondents agreed or strongly agreed that their overall health and wellbeing had improved because of MTM. Pharmacist estimates of the impact of an MTM program in a large integrated health care system suggest that the program was associated with improved clinical outcomes and cost savings. Patient satisfaction with the program was high.

Model for medication therapy management in a university clinic

Experience with a referral-based medication therapy management (MTM) clinic in a university medical center is described. The MTM clinic's mission is to assist patients who take multiple medications due to multiple chronic conditions with the management of their drug therapy to improve or maintain their health and prevent or minimize drug-related problems. The clinical services provided at the clinic have evolved into a comprehensive program providing five distinct service areas: access, adherence, coordination of care, medication therapy review, and education. During initial visits, patient information is collected, patients are interviewed, medications are reconciled, and the pharmacist identifies and attempts to solve any immediate drug-related problems and concerns. Routine visits are scheduled monthly to coincide with a patient's medication refills. On a typical day, a minimum of two MTM pharmacists and one pharmacy technician staff the clinic. On two days of the week, three MTM pharmacists are available in the clinic. The clinic averages 9-13 scheduled patient visits per day. The MTM clinic functions as a subset of the outpatient pharmacy and is merged financially in the general operational budget of the ambulatory care pharmacy. This model of MTM patient care is intensive and comprehensive and is significantly different from the majority of MTM models currently provided by Medicare Part D plans. A referral-based MTM clinic managed by pharmacists at a university medical center outpatient pharmacy provides care to patients with the goal of improving medication access, medication adherence, continuity of care, medication therapy management, and patient education.

Cognitive Services Provided by Pharmacists: Is the Public Willing to Pay for Them?

The primary objective of this study was to determine if the respondents were willing to pay out-of-pocket for specific pharmacist medication therapy management services and patient education services. Secondary objectives were to determine the extent to which the respondents were willing to pay for these services based on percentage of out-of-pocket payment and to differentiate willingness to pay among demographics (age, gender, income). A cross-sectional study. Three cities in Florida. Individuals volunteering to complete a survey instrument. Participants were asked if they would be willing to pay for certain services based on the proportion of payment that would be out-of-pocket. "Willingness to pay" was measured on a five-point Likert scale. The payment scale of 0%, 20%, and 100% was used to mirror other medical and professional expenses and comparable insurance coverage for those services. The majority of the sample population, 70%, was willing to pay 20% out-of-pocket for pharmacist cognitive services. Income and age versus willingness to pay 20% varied from 64% to 78% and 50% to 79%, respectively. Males were slightly less willing to pay 20% than females, 68% versus 71%. Respondent's willingness to pay for pharmacist cognitive services appeared to be correlated with insurance coverage and out-of-pocket expense and inversely proportional to the amount of out-of-pocket expense to the patient. Of those willing to use pharmacist cognitive services, 47% of the sample were willing to pay 100% out-of-pocket for pharmacist cognitive services, 70% were willing to pay a copay of 20%, and 85% were willing to use these services if insurance paid 100% of the cost.

Exploring Medication Problems and Strategies for Future Medication Therapy Management in an Outpatient Psychiatric Center

Medication therapy management (MTM) for Medicare Part D beneficiaries offers new practice opportunities for pharmacists and insight in designing new modes of pharmaceutical care delivery for all patients. The authors' goal was to identify medication-related problems in an outpatient behavioral health care center, and other important considerations in designing a reimbursable, collaborative, pharmacist-coordinated MTM program. Nine months of medication use evaluation data obtained from medical record review, medication inventory audits, transcription records, patient, and staff were examined for variances from organizational standard of care. Of the 592 documented variances, a majority of them were in the areas of medication prescribing and transcription (508; 85%), patient self-administration (46; 8%), and dispensing (38; 6%). Medication-related problems were identified that could be addressed with pharmacist MTM. MTM design should include elements of pharmacotherapy effectiveness and program quality. Important considerations for reimbursement are the priorities of health care organizational stakeholders, promotion of the nondispensing role of pharmacists, capacity to integrate the workflow processes and billing codes of pharmacists and other health professionals, and newly emerging trends and service demands in health care. Although these experiences occurred in an outpatient psychiatric setting, they are generally applicable to future MTM program design.