Medication Therapy Management Practice Research Articles

Evaluation of a modified and abbreviated scale for assessing chronic illness care for medication therapy management practice.

The central goals of MTM align with those of the Chronic Care Model (CCM). However, reliable and valid assessments are needed to estimate the extent to which components of MTM care delivery are consistent with the CCM. The Assessment of Chronic Illness Care (ACIC) is a 34-item scale for administration in primary care offices to estimate the extent to which chronic care delivery aligns with the six elements of the CCM. The ACIC appears to be responsive for care delivery interventions aimed at improving various chronic illnesses. However, the potential value of the ACIC as a measure for evaluating MTM delivery is unknown. A modified and abbreviated version of the ACIC could be a useful evaluation tool for pharmacist-provided medication therapy management (MTM). The objective of this study was to assess the construct and criterion-related validity, and internal consistency, of the abbreviated (12-item) "MTM ACIC." The abbreviated MTM ACIC was administered to pharmacists employed at 27,560 community pharmacies. Construct validity and internal consistency were estimated through principal components analysis, item-to-total correlations, and Cronbach's alpha estimate of internal consistency. To assess criterion-related validity, a univariate negative binomial model estimated the association between ACIC scores and pharmacy-level MTM completion rates. A one-component model accounted for 64% of the variance, and Cronbach's alpha was 0.95. Scores on the abbreviated MTM ACIC were associated with MTM completion rates (rate ratio: 1.02; 95% CI: 1.01 to 1.03). The abbreviated MTM ACIC exhibited acceptable construct and criterion-related validity and internal consistency and could serve as a valuable tool for evaluating chronic illness care within the MTM setting.

Positive deviants for medication therapy management: A mixed-methods comparative case study of community pharmacy practices.

To optimize medication use in older adults, the Centers for Medicare & Medicaid Services (CMS) launched Medication Therapy Management (MTM) services as part of Medicare Part D policy; however, strategies for achieving high quality MTM outcomes are not well understood. The objective of this study was to generate hypotheses for strategies contributing to community pharmacies' high performance on policy-relevant MTM quality measures. This mixed-methods comparative case study was guided by the Positive Deviance approach and Chronic Care Model. The study population consisted of pharmacy staff employed by a Midwestern division of a national supermarket-community pharmacy chain. Data consisted of demographics and qualitative data from semi-structured interviews. Qualitative and quantitative data were analyzed deductively and inductively or using descriptive statistics, respectively. MTM quality measures used to evaluate participant pharmacies' MTM performance mirrored select 2017 Medicare Part D Plans' Star Rating measures. Thirteen of 18 selected case pharmacies (72.2%) participated in this study, of which 5 were categorized as high performers, 4 moderate performers, and 4 low performers. Eleven pharmacists, 11 technicians, and 3 student interns participated in interviews. Eight strategies were hypothesized as contributing to MTM performance: Strong pharmacy staff-provider relationships and trust, Inability to address patients' social determinants of health (negatively contributing), Technician involvement in MTM, Providing comprehensive medication reviews in person vs. phone alone, Placing high priority on MTM, Using available clinical information systems to identify eligible patients, Technicians using clinical information systems to collect/document information for pharmacists, Faxing prescribers adherence medication therapy problems (MTPs) and calling on indication MTPs. Eight strategies were hypothesized as contributing to community pharmacies' performance on MTM quality measures. Findings from this work can inform MTM practice and Medicare Part D MTM policy changes to positively influence patient outcomes. Future research should test hypotheses in a larger representative sample of pharmacies.

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 well-being 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. There was no external funding for this manuscript. The 3 authors are employees of Fairview Pharmacy Services. Ramalho de Oliveira had primary responsibility for the concept and design, writing, and revision of the manuscript, with the assistance of Brummel and Miller. Ramalho de Oliveira performed the data collection, and all 3 authors shared equally in data interpretation.

Community pharmacist workflow and medication therapy management delegation: An assessment of preferences and barriers

ObjectivesThe role of community pharmacists continues to evolve to meet the changing medication-related needs of patients in the United States, requiring a fundamental shift in the pharmacist’s workflow and tasks including medication dispensing and medication therapy management (MTM). To compare community pharmacists’ current and idealized time allocation. Barriers to, and potential facilitators of, typical and specific pharmacist functions are also reported, with an emphasis on MTM practices. A secondary objective included interpreting how pharmacists perceived the value of social determinants of health to the MTM process. MethodsCommunity pharmacists practicing in Tennessee were surveyed online with 3 distinct foci: time allocation and delegation, MTM barriers, and the perceived value of health-related and social data to the MTM process. For the first 2 sections, the respondents provided responses in 2 different scenarios: (1) current workflow and (2) an idealized workflow. Paired Wilcoxon signed-rank and chi-square tests compared the responses to workday items, and Spearman correlations assessed the relationships between preferences and perceived barriers. ResultsThe pharmacists reported spending the largest share of time verifying product (32.8% [SD 19.28]), and most indicated that they spent no time in either point-of-care testing (POCT) or physical patient assessment. In an ideal work environment, more patient-focused roles would be preferred (e.g., health screening, POCT, MTM, and vaccinations), with more than 80% indicating that they would delegate register activities, data entry, and product verification to technicians. In performing MTM, the pharmacists indicated that they would prefer delegating more data collection and patient management activities to technicians to reserve time for patient assessment and care plan creation. Key barriers to MTM included a lack of time, staff support, and patients’ willingness to participate. ConclusionIdeally, pharmacists would prefer to do no prescription filling or selling or register activities. Facilitating community pharmacy practice evolution will require focusing on building teams around support personnel.

Pharmacists in Federally Qualified Health Centers: Models of Care to Improve Chronic Disease.

IntroductionPharmacists are underused in the care of chronic disease. The primary objectives of this project were to 1) describe the factors that influence initiation of and sustainability for pharmacist-provided medication therapy management (MTM) in federally qualified health centers (FQHCs), with secondary objectives to report the number of patients receiving MTM by a pharmacist who achieve 2) hemoglobin A1c (HbA1c) control (≤9%) and 3) blood pressure control (<140/90 mm Hg).MethodsWe evaluated MTM provided by pharmacists in 10 FQHCs in Ohio through qualitative thematic analysis of semi-structured interviews with pharmacists and FQHC leadership and aggregate reporting of clinical markers.ResultsFacilitators of MTM included relationship building with clinicians, staff, and patients; regular verbal or electronic communication with care team members; and alignment with quality goals. Common MTM model elements included MTM provided distinct from dispensing medications, clinician referrals, and electronic health record access. Financial compensation strategies were inadequate and varied; they included 340B revenue, incident-to billing, grants, and shared positions with academic institutions. Of 1,692 enrolled patients, 60% (n = 693 of 1,153) achieved HbA1c ≤9%, and 79% (n = 758 of 959) achieved blood pressure <140/90 mm Hg.ConclusionThrough this statewide collaborative, access for patients in FQHCs to MTM by pharmacists increased. The factors we identified that facilitate MTM practice models can be used to enhance the models to achieve clinical goals. Collaboration among clinic staff and community partners can improve models of care and improve chronic disease outcomes.

Variation in Medication Therapy Management Delivery: Implications for Health Care Policy.

Medication therapy management (MTM) program evaluations have revealed mixed outcomes, with some studies finding favorable outcomes and others finding no differences between patients who received MTM versus those who did not. One possible reason for outcomes variability is differences in delivery of MTM programs. The Chronic Care Model (CCM) provides a framework for how health care organizations can improve care for the chronically ill through 6 elements: organization of health care, delivery system design, clinical information systems, decision support, self-management, and linkages to community resources. To apply the CCM to understand variation in MTM delivery and formulate policy recommendations. This study used a mixed-methods descriptive analysis of MTM delivery. Investigators conducted visits to a purposeful sample of MTM practices to observe MTM and interview participants. The pharmacists and staff of these practices completed a modified Assessment of Chronic Illness Care (ACIC). Pairs of investigators analyzed interview transcripts to identify themes. Demographics and ACIC scores were summarized using descriptive statistics. After analysis, investigators discussed overarching themes and policy implications organized by CCM elements. Seven practices participated, and 87 participants were interviewed. Based on ACIC scores, MTM patient volume, and payer mix, practices were categorized as Early Maturity Level or Later Maturity Level. From the model, organization of health care themes included whether MTM was the practice's core competence, belief/confidence in the MTM process, lack of formal rewards, and the influence of organizational goals and external environment. Delivery system design themes pertained to the extent that MTM processes were formalized. Clinical information systems themes were the extent to which systems were influenced by payers, efficiency strategies, and the accuracy and availability of information. In considering clinical decision support themes, alert design limitations and variation in user approaches to alerts based on experience were noted. We observed strong support for patient self-management; when present, barriers were attributed to the patient, MTM provider, or payer. Referral to community resources was minimal. Numerous policy implications were identified. Our research identified numerous ways by which MTM delivery varies, particularly by MTM practice maturity level. These findings provide evidence for several policy changes that could be considered to optimize MTM delivery, encourage alignment with the CCM, and promote practice maturation. This research and a portion of Snyder's salary were supported by grant number K08HS022119 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Snyder reports consulting fees from Westat for an evaluation of the CMS Enhanced MTM program. The other authors have nothing to disclose. Portions of this research have been presented as abstracts at the following conferences: (a) 2017 Academy Health Annual Research Meeting; June 25-27, 2017; New Orleans, LA; (b) 2015 American Society of Health-System Pharmacists Clinical Midyear Meeting; December 4-8, 2015; New Orleans, LA; and

Characterization of actions taken during the delivery of medication therapy management: A time-and-motion approach

ObjectivesTo characterize actions performed by pharmacists and support staff during provision of medication therapy management (MTM) and to compare actions performed according to practice characteristics. MethodsA purposeful sample of 7 MTM practices (2 call centers and 5 community practices) was identified and visited by investigators. Pharmacists and support staff were observed during their routine provision of MTM. Investigators characterized “major” (e.g., preparation for a comprehensive medication review) and “minor” (i.e., specific steps in overarching major action) actions with the use of a time-and-motion approach. ResultsA total of 32 major and 469 minor actions were observed. Practices were characterized as Later Maturity Level or Early Maturity Level on the basis of their self-reported MTM appointment volume, self-assessment of the extent of integration of chronic care model principles, and payer mix. Later Maturity Level practices were more likely to deliver follow-up medication therapy reviews and comprehensive medication reviews (CMRs) as opposed to targeted medication reviews (TMRs) and to receive physician referrals for MTM. Later Maturity Level practices were also more likely to use paid interns than pharmacy rotation students. CMR activities observed at Later Maturity Level practices lasted a median of 30.8 minutes versus 20.3 minutes for CMR activities at Early Maturity Level practices. Similarly, TMR activities observed at Later Maturity Level practices were longer: a median of 31.0 minutes versus 12.3 minutes. At Later Maturity Level practices, pharmacists spent a greater proportion of time providing patient education, while support staff spent a greater proportion of time on tasks such as capturing demographics and introducing or explaining MTM. ConclusionMTM activities were longer at Later Maturity Level practices, and these practices were more likely to use paid pharmacy interns and to receive physician referrals for MTM. This work provides a foundation for future research.

Experiential Education Builds Student Self-Confidence in Delivering Medication Therapy Management.

To determine the impact of advanced pharmacy practice experiences (APPE) on student self-confidence related to medication therapy management (MTM), fourth-year pharmacy students were surveyed pre/post APPE to: identify exposure to MTM learning opportunities, assess knowledge of the MTM core components, and assess self-confidence performing MTM services. An anonymous electronic questionnaire administered pre/post APPE captured demographics, factors predicted to impact student self-confidence (Grade point average (GPA), work experience, exposure to MTM learning opportunities), MTM knowledge and self-confidence conducting MTM using a 5-point Likert scale (1 = Not at all Confident; 5 = Extremely Confident). Sixty-two students (26% response rate) responded to the pre-APPE questionnaire and n = 44 (18%) to the post-APPE. Over 90% demonstrated MTM knowledge and 68.2% completed MTM learning activities. APPE experiences significantly improved students’ overall self-confidence (pre-APPE = 3.27 (0.85 SD), post-APPE = 4.02 (0.88), p < 0.001). Students engaging in MTM learning opportunities had higher self-confidence post-APPE (4.20 (0.71)) vs. those not reporting MTM learning opportunities (3.64 (1.08), p = 0.05). Post-APPE, fewer students reported MTM was patient-centric or anticipated engaging in MTM post-graduation. APPE learning opportunities increased student self-confidence to provide MTM services. However, the reduction in anticipated engagement in MTM post-graduation and reduction in sensing the patient-centric nature of MTM practice, may reveal a gap between practice expectations and reality.

Incorporation of Herbal Supplements into a Pharmacogenomic Medication Therapy Management Practice.

Personalized medicine, including direct-to-consumer (DTC) testing, is becoming a more common patient-centered approach to pharmacotherapy. However, DTC testing companies may not provide adequate information and follow-up to patients after genetic testing is done. This article is the first report describing a medication therapy management pharmacotherapy service that specializes in pharmacogenomic counseling, specifically geared toward identifying implications of dietary and herbal supplements. A pharmacist provides a comprehensive review of pharmacokinetic and pharmacodynamic consequences of a patient's herbal substances, and counseling is provided on subsequent drug therapy effects. If properly implemented, offering a pharmacogenomic medication therapy management service that specializes in the use of herbal supplements provides patients with education on the safe use of these substances based on their genetic factors.

Pharmacists' roles in oncology pharmacy services: Results of a global survey.

Background Oncology pharmacists are capable of providing medication therapy management (MTM) because of their level of training, practice experiences, and responsibilities. Very little data exist about their current practice, including changing roles in the multidisciplinary team, overall impact, and effects in the education of patients and healthcare professionals. Methods A 70-item survey about oncology pharmacists' activities in oral chemotherapy programs, MTM, and collaborative practice agreements (CPAs) was deployed using a web survey tool (Qualtrics, Provo, UT, USA), targeting pharmacist members of American College of Clinical Pharmacy (ACCP) Hematology/Oncology Practice and Research Network (PRN). The objective of this study was to determine oncology pharmacists' activities in areas of oral chemotherapy programs, MTM, and CPAs. A cross-sectional survey was distributed to the ACCP Hematology/Oncology PRN membership. Investigational Review Board approval was obtained. Results Of the 795 members who were sent the survey, 81 members (10%) responded; 33 respondents (47%) are involved with an oral chemotherapy program; with 42% measuring outcomes of programs. Only six pharmacists (19%) have published or presented their data. A total of 28 (35%) respondents provide MTM services, with almost half (43%) of these MTM services being dictated by CPAs. A small fraction of these pharmacists (21.4%) reported conducting quality assurance evaluations of their MTM services and three pharmacists (10.7%) reported publishing their results. Those pharmacists practicing under CPAs ( n = 28) were surveyed as to activities included in their CPA. The most common activities included adjusting medication, ordering, interpreting, and monitoring lab tests, developing therapeutic plans and educating patients. Reimbursement for providing these services was uncommon: MTM (4%), oral chemotherapy program (6%), and CPA services (11%). Reported obstacles to reimbursement included lack of understanding, administrative assistance, or time with setting up reimbursement models within the institution. Conclusion Many oncology pharmacists are participating in oral chemotherapy programs, MTM, and/or CPAs and perceived barriers were identified. Increased efforts should be directed toward prospectively reporting and assessing the impact these services have on patient care.

Comparison of two Medication Therapy Management Practice Models on Return on Investment

Objective: To compare the return on investment (ROI) of an integrated practice model versus a “hub and spoke” practice model of pharmacist provided medication therapy management (MTM). Methods: A cohort retrospective analysis of MTM claims billed in 76 pharmacies in North Carolina in the 2010 hub and spoke practice model and the 2012 “integrated” practice model were analyzed to calculate the ROI. Results: In 2010, 4089 patients received an MTM resulting in 8757 claims in the hub and spoke model. In 2012, 4896 patients received an MTM resulting in 13 730 claims in the integrated model. In 2010, US$165 897.26 was invested in pharmacist salary and $173 498.00 was received in reimbursement, resulting in an ROI of +US$7600.74 (+4.6%). In 2012, US$280 890.09 was invested in pharmacist salary and US$302 963 was received in reimbursement, resulting in an ROI of +US$22 072.91 or (+7.9%). Conclusion: The integrated model of MTM showed an increase in number of claims submitted and in number of patients receiving MTM services, ultimately resulting in a higher ROI. While a higher ROI was evident in the integrated model, both models resulted in positive ROI (1:12-1:21), highlighting that MTM programs can be cost effective with different strategies of execution.

Build a successful practice using interprofessional communication skills

Building a successful medication therapy management practice requires pharmacists to communicate drug therapy problems to prescribers along with appropriate clinical recommendations to resolve the problems. Communication with other health care providers should be more than just transactional (i.e., in response to a problem). It should be relational so that a collaborative working relationship (CWR) is developed.

Creation of a Bariatric Surgery Medication Therapy Management Model.

To describe how pharmacist-provided medication therapy management (MTM) services can be applied to bariatric surgery. A pharmacy MTM consult service located in a multispecialty medical clinic with a bariatric department attached to a hospital where bariatric surgeries are performed. MTM bariatric surgery office practice where patients are seen before surgery by a pharmacist to identify medication problems and determine how best to administer alternative dosage forms post-operatively to patients. Practice innovations are a creation of a specialized service and accompanying specialized medication database within a pharmacotherapy practice. Outcome measures are number of patients referred per month and polypharmacy consults scheduled downstream from the bariatric surgery. Improved patient outcomes and prescribing efficiency from usage of the newly developed database of drugs that can be crushed. All bariatric patients are now referred to the pharmacist MTM pharmacotherapy service for medication review before bariatric surgery. Bariatric surgery is a source of another useful MTM practice model. Utilizing MTM pharmacists to consult with bariatric patients presurgery helps ease the physician burden of writing alternative dose prescriptions and helps identify medication problems with patients before their surgery.

Patient care services: What pharmacists do

Patient care services: What pharmacists do

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.

Clinical and Behavioral Impact of Pharmaceutical Care Services in Community Pharmacies in Puerto Rico

Background: Medication Therapy Management (MTM) is an area in which pharmacists have the opportunity to provide pharmaceutical care by working directly with the patients and their physicians to optimize the patient’s pharmacological therapy. The objective of this research is to determine the relationship between MTM practices and changes in clinical markers of disease and behavioral attitudes of Puerto Rican patients at community pharmacies. Methods: The study is a retrospective chart review design. A total of thirty-five patients participated in the first encounter, which consisted in an individualized clinic visit following a standardized MTM format. Follow-up was provided as appropriate for clinical evaluation. A trend analysis and paired t-test was planned to assess the impact of MTM interventions on blood pressure, lipid levels, and hemoglobin A1C with respect to baseline measurements. Adherence was assessed by calculating the medication possession ratio for all medication filled from the initial MTM clinic visit to the end of the study period. Results: An average positive trend for clinical markers of de could be observed. Adherence in general improved from an average of MPR of 0.54 to an MPR of 0.63. However, the desired level for adherence was not reached in all patients. Conclusion: Although recruitment was low this study showed an average improvement in clinical markers of disease and adherence of patients receiving MTM services in three community pharmacies in the metropolitan area of Puerto Rico. Due to the lack of statically significant data the results cannot be extrapolated to

Pharmacy innovation across the nation

Pharmacy innovation across the nation

Stories we can tell

Stories we can tell

Making pharmacists’ patient care services consistent, predictable, measurable

Making pharmacists’ patient care services consistent, predictable, measurable

Challenges to implementation of MTM services

Challenges to implementation of MTM services