Medication Management

Pharmacists Demonstrate Value of a Problem-Focused Practice Model

Comprehensive medication management may improve outcomes in medical homes

Thomas Reinke

When the Medicare Part D program was launched, pharmacists successfully promoted the idea that beneficiaries needed more than a way to pay for their medications. And so medication therapy management (MTM) gained a real foothold, sort of.

Pharmacists thought they were on their way to realizing a high-priority goal, but Part D MTM services have fallen far short of the expectation that they would be able to move away from their benches into a direct patient care role.

Experts say pharmacists providing Part D MTM services are simply too far removed from the care that patients are receiving to deliver meaningful services. MTM is often provided remotely through call centers operated by the Part D pharmacy plans. Call center pharmacists and those in community pharmacies do not have the medical record information that is necessary for them to evaluate patients and make therapy management decisions.

The lack of patient information leads to inconsistency in the scope and quality of Part D MTM services. Pharmacists find themselves in the frustrating position of not being able to address important therapy problems such as undertreatment; they are left to go after low-hanging fruit such as nonadherence or switching to lower-cost formulary alternatives, things that can be done without access to the medical record.

The underlying issues are that the call center setting for Part D MTM services is wrong and that tools are not available for pharmacists to deliver optimal services. No wonder health plans have not bought into MTM for their commercial plans.

“If you’re going to be a high-performing medical home or ACO, you have to get the medications right,” says Edwin Webb, PharmD, of the American College of Clinical Pharmacy.

The American College of Clinical Pharmacy (ACCP) is working on a system that overcomes the problem of Part D MTM services being in the wrong setting. ACCP promotes the role of pharmacists in ambulatory care and is an active member of the Patient Centered Primary Care Collaborative. The two organizations have clearly defined the nature and role of MTM services for all patients, which they call comprehensive medication management, in patient-centered medical homes.

“There’s a mismatch between the Part D MTM service expectations and how the services are presently delivered,” says Edwin Webb, PharmD, of the ACCP. “Part D MTM is done in isolation from the health care team and without access to patient-specific information.”

Medical homes are one logical setting for MTM services, Webb says. He adds that the inconsistency in providing MTM is in part due to lack of a clear definition of the service and lack of tools to conduct it. Resolving these problems will advance the role of pharmacists in ambulatory care.

Webb adds, “Physicians say, It makes sense that pharmacists have a role in patient care but I need to better understand your patient process and how it fits into patient-centered care.”

Program for comprehensive MTM

A consistent approach to MTM services being designed at the University of North Carolina, UNC, Eshelman School of Pharmacy and implemented and studied in primary care medical practices is an attempt to clearly define MTM services with a focus on resolving medication-related problems and improving patient outcomes. It is for use in patient-centered medical homes and accountable care organizations.

The Individualized Medication Assessment and Planning (IMAP) practice model is a 10-step medication assessment and planning process that clearly lays out problem identification and resolution within MTM services. “The program is intended to be a road map which has been missing in MTM services,” says Mary Roth, PharmD, associate professor at the university’s Eshelman School of Pharmacy. A test of the program was published in a recent issue of Pharmacotherapy.

The protocol or intervention used in the IMAP study leads the pharmacist through a process of preparing for the patient visit, conducting the comprehensive medication review, assessing and identifying medication-related problems, collaborating with the patient’s primary care provider to arrive at a plan for optimizing drug therapy, and working with the patient to implement the plan and ensure understanding. The process also allows for pharmacists to manage therapy according to collaborative practice agreements in place with physicians. This process of care is consistent with the process described by the Patient Centered Primary Care Collaborative in its publication “Integrating Comprehensive Medication Management to Optimize Patient Outcomes.”

IMAP is intended to meet the challenges facing medical homes and accountable care organizations. “IMAP is being developed with an eye on health reform issues,” says Roth. “We have to demonstrate an ROI and the improvements we are making in patient outcomes. Those are the outcomes that everyone is interested in.”

The ACCP’s Webb says, “If you’re going to be a high-performing medical home or ACO, you have to get the medications right. That’s where the value proposition is for earning bonuses or shared savings. Eighteen of the initial quality measures for ACOs have some implication for pharmacy services and therapy management.”

Solving problems

Two core elements in the IMAP model are a clear list of all medication-related problems (MRPs) and equally clear recommendations for resolving them. Roth says this helps deliver better outcomes.

There are six classes of problems: under­treatment, suboptimal dosing, medication monitoring needed, suboptimal drug, adverse drug event, and nonadherence. The problem categories are broken down into additional detail and the program includes specific recommendations for resolving each problem.

Payment difficulties are a major impediment to expansion of MTM services in all settings. “We’re still living in a fee-for-service world and these services are generally not recognized and billable to third-party payers,” says Roth.

The study

In a small pilot study involving 64 elderly patients with multiple chronic illnesses and multiple medications, the comprehensive MTM program led by a clinical pharmacist working in collaboration with a primary care team, reduced medication-related problems and acute health services utilization.

The cohort had many of the medication concerns that are common to the elderly. The mean number of prescription and non- prescription medications was 13.9, (range 5­–31), with a mean of 8.6 (range 2–17) prescription medications. The mean number of chronic conditions was 8.5 (range 3–14).

In one study, physicians accepted 94% of pharmacists’ therapy recommendations.

During the six months, the pharmacists identified 419 MRPs — an average of 4.2 per patient. At baseline the most common problems were suboptimal drug use — the drug had no indication or a safer alternative was available; undertreatment — underuse of proven therapies, suboptimal dosing; and nonadherence.

Thus, actual problems related to therapy were much more common than adherence problems, which receive much attention.

The program was used in three- and six-month follow-up visits to reassess problems and fine tune action plans developed through the initial assessment. Physicians accepted 94% of pharmacists’ therapy recommendations. At the end of the six-month study, most of the problems identified during that period were resolved. The mean number of outstanding MRPs/patient was 1.0 at the close of the study. The study also claims a 35% reduction in use of acute health services during the period.

The take-away for health plans is that pharmacists remain committed to demonstrating their value in direct patient care roles and are taking steps to establish themselves in more appropriate settings with a practice model that leads to improved outcomes.

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