Model for Medication Therapy Management in a University Clinic

Mary Ann Kliethermes, B.S., Pharm.D.; Anne Marie Schullo-Feulner, Pharm.D.; Jessica Tilton, Pharm.D.; Shiyun Kim, Pharm.D.; Annette Nicole Pellegrino, Pharm.D.


Am J Health Syst Pharm. 2008;65(9):844-856. 

In This Article

Program Description

The MTM clinic's mission is to assist patients who take multiple long-term 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 tenets defined in the MTM definition provided by the Pharmacist Provider Coalition[3] and other documents[4] offered a foundation to establish the services provided by UIMCC's MTM clinic. By using these guidelines, observing patients' needs, and understanding the skills, knowledge, and capabilities of the MTM clinic pharmacist, the clinical services provided at the clinic evolved into a comprehensive program providing five distinct service areas: access, adherence, coordination of care, medication therapy review, and education (AACME). Clinic patient care services provided and patient goals are listed in Appendix A . Patients may enter the MTM clinic by referral from any UIMCC health care professional using the following admission criteria:

  • Have multiple medications, diseases, or health care providers and subsequent diminished coordination of care,

  • Have difficulty in self-management of medications,

  • Have difficulty adhering to long-term medication regimens,

  • Have a significant lack of understanding or knowledge of long-term drug therapy, and

  • Agree to have their prescriptions filled at the UIC pharmacy.

When a patient is referred to the MTM service, he or she is assigned to a primary MTM pharmacist who has ultimate responsibility for the patient. This allows the patient to develop a consistent relationship with one pharmacist and provides the patient improved continuity of care. Our goal is for patients to see their primary pharmacist at least 80% of the time for scheduled visits. Efforts are made to match the needs of the patient with the interest, specialty, and skills of the pharmacist. The most common reasons for referral to the MTM clinic are (1) a patient's medication needs cannot be met with the resources available in the clinic of the referring provider and (2) the patient has been hospitalized at least once due to poor self-medication management. The acuity of patients referred to and entered in the MTM clinic generally is high.

Step 1: Collecting Information. The pharmacist speaks with the referring health care professional to determine the needs and expectations he or she has for the patient's involvement in the program if not adequately addressed on the referral form. The pharmacist reviews the patient's electronic medical record (EMR) for medical history, diagnosis, number of providers, demographic data, laboratory test data, and medication lists generated by the various providers or the hospital. During this step, the pharmacist begins to identify the drug-related issues and problems that may be associated with the patient.

Step 2: Initial Patient Interview. The program is explained to the patient at the initial interview. Admission is voluntary. If the patient agrees to participate, further information is gathered directly from the patient. The pharmacist continues to assess the patient's medication-related problems. We use our five-step AACME model for detecting drug-related problems derived from the services we provide. Once problems are identified, the pharmacist initiates a patient-specific plan of care. The MTM clinic's role and the patient's role in his or her care related to the program are discussed. Each patient is given an MTM clinic folder containing an MTM clinic patient brochure, a patient health self-assessment form, and a statement of the patient's rights and responsibilities. The patient must sign an informed-consent form agreeing to receive the services provided by the MTM clinic and, if needed, have medications placed in medication boxes. The informed-consent form also clearly defines sharing of medical information among the patient's family and caregivers, which may include outside organizations, such as nursing agencies and other hospitals.

Step 3: Medication Reconciliation. The patient is instructed to bring all of his or her medication bottles to the initial MTM visit. The medications the patient brings are compared with the prescriptions from the patient's previous pharmacy and the medication lists generated by the patient's various providers (listed on the EMR). Medication reconciliation is a major issue for nearly every patient, as discrepancies are common. The pharmacist contacts other UIMCC health care professionals and outside health care providers to reconcile any discrepancies in the medication lists and provide the patient with a definitive medication regimen. The patient is provided with a patient-friendly hard copy of the medication list.

Step 4: Action and Plan. After completing the initial assessment, the pharmacist identifies and attempts to solve any immediate problems and concerns. The need to use adherence aids is also addressed. A follow-up MTM clinic visit is scheduled. The length of time until the next visit is based on multiple factors, including the need for refills, coordination of refills to fall on the same day, anticipated medication changes, administration of narrow therapeutic range medications, the patient's mental and physical capacity, the patient's clinical stability, and any other issues identified by the pharmacist.

The patient's data and his or her primary pharmacist's name are entered into the pharmacy dispensing software, and the patient is tagged as an MTM clinic patient. The interviewing pharmacist will document patient information obtained during the initial visit using an MTM SOAP (subjective, objective, assessment, plan) style note template in the EMR, including the date and reason for referral; the referring provider; the patient's current status or chief complaint; a list of current medical conditions and past medical history; a list of the patient's medications; assessment of the patient's adherence; social issues (i.e., transportation; financial; living situation; use of alcohol, drugs, or tobacco; disabilities); objective data (i.e., patient height, vital signs, allergies, estimated creatinine clearance, laboratory test values); actions and plans; medications dispensed with next refill due dates; and next MTM appointment. The pharmacist will also create a current medication list using the MTM medication template for documentation in the EMR ( Appendix B ).

Routine visits are scheduled monthly to coincide with a patient's medication refills; however, visits may be scheduled more frequently to meet the patient's needs. For example, patients referred from psychiatry are usually seen weekly because adherence to their regimen must be closely monitored. As patients' adherence improves, their visits may become less frequent. Patients taking warfarin who use medication boxes may be seen more frequently based on their International Normalized Ratio (INR). Patients' visits must be scheduled to coincide with every INR test to appropriately adjust the warfarin dosage.

Preparation for the Visit. One week before a patient's routine visit, the pharmacist reviews documentation from the EMR of any clinic visits, emergency room visits, hospitalizations, and laboratory tests since the last MTM visit, noting any changes in the care plan. The pharmacist then completes a medication-refill sheet generated from the pharmacy dispensing software that determines what medications should be processed for that patient for the month and resolves any identified issues before the patient's visit. The MTM clinic pharmacy technician then coordinates the prescription-filling process such that it is completed two days before the patient's visit. This allows adequate time for refills to be processed, medication boxes to be filled, and problems related to prescription processing (e.g., refills too soon, noncovered items) to be identified and solved before the patient's appointment. Prescriptions are filled and checked through the outpatient pharmacy according to standard policy and procedure. The MTM clinic pharmacy technician or students update the patient-friendly medication list as needed and fill the patient's medication boxes one day before the patient's visit, with a double-check by a pharmacy resident or MTM clinic pharmacist.

Patient Visit. During the patient's visit, the pharmacist reviews the patient's status, addressing any ongoing problems and identifying any new problems. Using patient-focused care and the AACME model, the MTM pharmacist assesses the patient's current condition and problems with medication access or adherence, addresses any continuity-of-care issues, reviews the patient's medication therapy, evaluates the patient's response to drug therapy, and identifies any drug-related problems. The MTM pharmacist incorporates evidence-based monitoring and guidelines (e.g., blood pressure readings obtained at each visit) when indicated. If there is an emergent issue, the pharmacist will direct the patient to take the appropriate steps and assist as needed or will contact the patient's appropriate health care provider. Examples include interventions such as sending patients to the emergency room for suspected deep vein thrombosis, resolving a drug-related problem, assisting in obtaining needed social services, or setting up needed follow-up medical appointments. When warranted, the MTM pharmacists make every effort to contact the patient's appropriate health care provider, usually the physician, before any action is taken. Education continues to be provided to patients and new educational needs are addressed at routine visits. An updated patient medication list is provided as needed. If a patient does not show up for the scheduled visit, a telephone call is made the next day to check his or her status and reschedule the visit. Telephone consultations are available if transportation is an issue. In this situation, medications are mailed to the patient, and any clinical assessment that cannot be done over the phone is performed at the next MTM clinic visit. Several attempts are made to contact a patient by telephone who has missed a visit. If unsuccessful, a letter is sent requesting the patient to reschedule a visit. After approximately 60 days, the patient is considered lost to follow-up. The percentage of patients lost to follow-up at our clinic is approximately 7%.

Follow-up and Documentation. After a patient's visit, the MTM pharmacist completes any needed activity that cannot be done during the visit due to time constraints. After each visit, an MTM SOAP style note is entered in the patient's EMR, including the patient's current status, any current or potential drug-related problems, test results, changes to the patient's medications, any social issues, allergies, medication adherence assessment, interventions made, and an action plan for each medical condition and treatment addressed. This information is forwarded to the appropriate physician or health care provider as warranted. The medication list in the EMR is updated monthly or more frequently as needed for prescription changes.

On a typical day in the MTM clinic, 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. We serve as a site for fourth-year pharmacy students on six-week ambulatory care clinical rotations. We have at least one fourth-year student 10 months out of the year. The student is expected to function as a pharmacist with supervision before the patient visit and before completion of the visit. We also have pharmacy residents completing four- to eight-week rotations (pharmacy practice, advanced ambulatory care, and community practice residents) one or two days per week in our clinic. The MTM clinic averages 9-13 scheduled patient visits per day. Throughout the day, the pharmacists complete follow-up and document visits, see patients scheduled for that day, address patients' needs, document actions and plans, and prepare for patients to be seen in the future. The daily workload includes new referrals, unscheduled walk-in patients, patients discharged from the hospital, and telephone calls.

A summary of MTM clinic demographics is provided in Table 1 . The average monthly prescription charges for current MTM patients are $800-$900, easily exceeding the CMS threshold of $4000 per year. The top MTM diagnoses of patients seen in our clinic include hypertension, hyper-lipidemia, diabetes mellitus, depression, arthritic conditions, asthma or chronic obstructive pulmonary disease, gastroesophageal reflux disease, anemia, coronary artery disease, heart failure, thrombotic disorders, atrial fibrillation, constipation, and osteoporosis.

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. The pharmacy operation runs on a closed system and therefore may only service UIMCC clients. The MTM clinic does generate revenue for the pharmacy from new referrals and prescription refills. A majority of new patients referred to the MTM clinic use outside pharmacies. Their prescriptions are transferred to the UIMCC pharmacy with the patients' consent. Due to improved adherence and follow-up, our data indicate that MTM prescription refills are consistently stable, potentially providing consistent monthly revenue for the pharmacy.

Currently, the MTM clinic has little opportunity to participate in Medicare Part D PDP MTM programs. Our MTM patient population consists primarily of dual-eligible beneficiaries and is limited to the PDPs affiliated with the state's wraparound coverage. The plan sponsors have elected to keep their MTM programs within their organizations. Before 2007, the clinic was not eligible for facility billing, as it was not located on health system property. With the recent move to the ambulatory care clinic building, we are investigating this billing option. We hope to explore other opportunities with PDPs that support face-to-face MTM services.

The MTM clinic's largest expenses are personnel salaries and benefits. Other clinic expenses include medication boxes, mailing, and general office expenses. Efficiencies are related to the number of patients one pharmacist can manage. In our model, with high-acuity patients, one FTE MTM pharmacist working in the clinic four days a week can manage a patient load of 40-50 patients. We are exploring how improvements in our processes or the health care system can increase the number of patients seen by one pharmacist. The clinic workload is driven primarily by the acuity of the MTM patients; understanding the determinants of acuity will be essential. In our experience, acuity of the MTM patient is more closely associated with the patient's cognitive skills and available social support than with the number of medications or diagnoses. Other factors contributing to a patient's workload include the number of providers, type of conditions, and fluctuations in health status. Areas to address that may increase the number of patients seen by one pharmacist include shifting most technical duties to a specially trained MTM pharmacy technician, improved systems for continuity of care, improved clinic workflow, and better and more innovative use of technology for documentation and clinic evaluation.


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