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

MTM Clinic Experience With the AACME Model

Many barriers may prevent MTM patients from accessing their medications. The role of the MTM provider is to identify and resolve barriers before the health and welfare of the patient are affected.

Problems related to inability to pay and inadequate prescription coverage are major barriers for many MTM patients and require the MTM pharmacist to have a complete understanding of the various prescription plans and their nuances. Because many patients lack the ability to navigate through coverage problems, the MTM pharmacists must facilitate prior approvals for prescriptions, exception requests, and other coverage-related issues, all time-consuming tasks.

Insurance copayments can be a significant burden for patients with limited resources who take multiple medications. The MTM clinic staff is frequently faced with the decision to provide medication without receiving insurance copayments. This decision has business, ethical, and legal implications. The clinic staff understands the consequences of a patient not receiving and taking critical medications, making it difficult to deny critical medications whose discontinuation would result in significant morbidity and possible mortality. The financial burden to the health system from patients not receiving critical medications may often be more significant than the loss of the copayment revenue. Yet the financial loss (copayments are 10% of the gross revenue for the MTM clinic) is absorbed by the pharmacy, not the health system, and may affect our clinic's financial existence. Our observations mirror what has been reported in the literature. Surveys of Medicare and Medicaid populations have shown that 7-29% do not obtain ordered medications for cost-related reasons.[5,6,7,8,9] In patients with four or more comorbidities who lack prescription drug coverage, skipping ordered prescriptions has been observed to occur up to 52% of the time.[6] The result is poorer health status, increased adverse events, and an increase in use of medical services, including emergency room visits, hospitalizations, and nursing home placement.[10,11,12,13,14] Strategies used by pharmacies such as limiting quantity dispensed or denying more medication until the patient can pay temporarily delays but does not solve the access problem. We request and work with our patients to change behaviors to improve adherence, but when poor adherence is caused by an inability to pay, there are few to no alternatives, particularly for patients covered by Medicare. We currently have no acceptable solutions, other than continued advocacy for the patient.

Transportation issues are another barrier to medication access. Many MTM clinic patients use a mobility aid (e.g., walker, wheelchair); are unable to drive or do not own a car; cannot walk the distance to a bus stop or have difficulty getting on a bus; cannot pay for parking, bus fare, or cab fare; live in neighborhoods where transportation services are unavailable; or have minimal or no family or friend support. In Illinois, a state-sponsored transportation service is available for qualified indigent patients. However, the system is complicated, requiring the patient to possess a telephone and satisfactory communication skills, and is not available for the purpose of picking up medications. The MTM clinic staff have, on occasion, assumed the responsibility of arranging transportation for patients.

"Refill too soon" policies by insurers add an additional barrier to medication access. Patients may be able to get some prescriptions filled but not others, depending on the date a prescription was filled. Since mobility and transportation are significant issues for our patient population, they may not be able to return to the pharmacy when the next set of medications can be dispensed. To resolve this problem, the MTM clinic coordinates all refills to fall on the same day as the MTM clinic appointments. If a patient has a new prescription to be filled between appointments, a partial fill is provided until the next appointment. The result is an extra patient copayment, but we believe the improvement in access and potentially improved adherence outweighs the financial burden of the extra cost.

Health-system issues also affect access. If patients do not visit their physicians, they will not have their prescriptions renewed. Long wait times and multiple visits with multiple providers are barriers for patients who do not have much stamina, need to eat at certain intervals, and need quick and easy access to lavatory facilities due to their conditions and medications. These issues, combined with a patient's potential poor understanding of the purpose and benefit of the visits, may result in many missed visits and lack of necessary medical follow-up. The inflexibility of health systems requires patients to adapt instead of the system adapting to the patient, creating a barrier that MTM clinic patients struggle to manage. Patients may need assistance to get to medical appointments, yet their caregiver is available only certain days of the week to assist them. If the patient's health care provider is not available when the caregiver is available, an appointment will be missed. The MTM pharmacists educate patients on the purpose of each provider's visit and assist them in managing the scheduling of visits, including the MTM visits, to decrease the burden and improve the likelihood they will make the visit. The MTM clinic staff has switched primary providers for patients to ensure the patient receives consistent medical care.

The barriers and challenges with access are primarily social in nature. A clear need exists to integrate social work support in our MTM clinic. We consult social services when possible but often need to use what we have learned from them to provide the needed services for the MTM patients.

A barrier to providing MTM can be the MTM patients themselves. Our greatest attrition of patients is in the initial referral phase. We often struggle to get patients in for the first appointment. We have not fully investigated this barrier; however, patients seem to have difficulty perceiving and understanding their need for the services the MTM clinic provides. Many do not feel their health issues are related to inadequate management of their medications but rather are related to a confusing and nonsupportive health system. They initially struggle to understand the value of another 20- to 30-minute appointment, especially in a pharmacy. During the referral phase, we highlight the aspects of medication management that patients are more likely to perceive as a benefit, such as coordinating the filling of all their medications for pickup on the same day and assisting them in obtaining refills and managing insurance issues to ensure they always have access to their medications.

The World Health Organization defines adherence as the extent to which a patient's behavior—taking medications, following a diet, and executing lifestyle changes—corresponds with agreed-on recommendations from health care providers.[15] Adherence is one of the core elements of MTM in the MMA legislation. Barriers to adherence are many and are well-defined in the literature ( Appendix C ).[16] The MTM clinic's role in adherence is to identify patient-specific barriers and develop unique solutions for each patient. Two methods we have noted to be successful are the development of a strong provider-patient relationship and use of adherence aids. The importance of developing a caring relationship between patient and provider cannot be overstated. We have found that patients often adhere because they know their MTM pharmacists care about their adherence and they do not want to disappoint or hinder the relationship with their primary pharmacist.

The value of medication boxes to patients with cognitive impairment and complex treatment is equally impressive. This observation has recently been supported in the literature.[17,18] We use a medication box exchange program at each patient visit, providing the monthly medications in prefilled medication boxes. Approximately 60% of patients in the MTM clinic use this system. Some patients or their caregivers can be taught to fill their own boxes, but we have found them to be the minority. We use several sizes and models of medication boxes to meet the needs of our patients. We prefer weekly boxes that are clear, as they provide a visual cue to the patient to see the medications, which aids in adherence. We encourage patients to maintain and clean their boxes. Most sets will last several years. In our experience, medication boxes raise adherence rates to 90-100% for many patients. We have seen remarkable changes in disease management in patients when adherence issues were related to the inability to manage and remember the large number of medications prescribed.

A barrier to the use of medication boxes is medications that are provided to the patients unlabeled. To overcome this problem, we provide patients with a patient-friendly medication list that includes medication name (generic and brand), reason for use, picture or description of tablet or capsule, and instructions on when to take the medications ( Appendix D ). Maintaining the patient-friendly medication list is a challenge. Frequent therapy changes and multiple sources of generic drugs that affect the description of the patient's tablet or capsule are difficult to keep up with in a busy clinic. Many pharmacy dispensing systems have pictures of the drug in their prescription-checking process. An ideal solution would use this technology and pharmacy dispensing data to generate a friendly medication list with each new prescription or change in product. We are unaware of any commercially available pharmacy dispensing system that has this capability. Currently, MTM student interns create and update the patient-friendly medication list at the end of the dispensing process or when requested by the MTM pharmacist.

A dilemma MTM providers face is the optimal manner to measure adherence. No standard accepted method of measurement exists in the literature, and there are pros and cons to the various methods suggested.[6] We use a combination of pill counts and number of days to appointments for scheduled or chronic medications as adherence measures. Adherence rates are calculated as a percentage, either the number of medication doses dispensed minus the number of medication doses missed divided by the number of doses given since the last MTM visit or the number of days' supply of medications last dispensed divided by the number of days from the last MTM visit. An advantage of medication boxes is that medications missed remain in the boxes, allowing us to take an actual count as well as detect patterns of missed medications (e.g., missed bedtime medications because patient fell asleep). Although it occasionally occurs, our patients rarely remove missed medications from their boxes.

Unfortunately, patients are not in the habit of bringing all their medications with them at each health encounter. We encourage patients to do this. It requires behavioral change and a means to transport the medications. Presently we provide various donated pharmaceutical company totes to aid in transport.

Continuity of care relating to the patient's medication is a major responsibility of the MTM pharmacist. Patients receiving multiple medications for multiple conditions see multiple providers. The providers may include their primary physician, physician specialists, podiatrists, dieticians, home-care nurses, and other health care professionals, and coordination may entail some or all of the listed providers. Primary care, cardiology, neurology, and renal staff may all be involved in hypertension management, or primary care, neurology, and anesthesiology staff may be addressing a patient's pain. This can frequently result in duplication of or conflicting medication orders and unclear plans of care. MTM patients are vulnerable to this situation, as they have difficulty identifying, understanding, and managing the discrepancies. Critical to the MTM pharmacist performing this role is a complete knowledge of the patient's clinical information and current issues, as well as effective communication channels among the various providers to develop one plan of care. Since there is no one standard communication channel, the MTM pharmacist may use one or all of the following to connect to providers: telephone, paging system, e-mail, written note to the provider delivered by the patient, or personal visit to the clinic with or without the patient. The choice often depends on the provider's preferred method. The process is time-consuming, as workload is influenced by the ability to identify the appropriate providers, their availability, and the ability to facilitate communication among all parties. The EMR allows us to review the provider's reasoning and plans, the patient's laboratory test values and vital signs, and any additional patient information and therefore better direct the intervention. Coordination of care clearly affects patient safety and is a significant responsibility for the MTM pharmacist.

Medication discrepancies are a common and potentially serious problem in patients taking multiple medications. New referrals to our clinic routinely have discrepancies between medication lists documented in the EMR by the various providers, as they often differ from the medications the patient possesses and the prescriptions the pharmacy may have on record. It may take several MTM visits and multiple communications to patients' providers to achieve a reconciled medication list. The MTM pharmacist must make the best medication-use choices for the patient until discrepancies can be resolved. All interventions and decisions made are documented in the EMR under the MTM note and medication list. The medication list generated by the MTM service (in the EMR or given to the patient) is an accurate reflection of what medications the patient is receiving from the pharmacy and is stated as such at the top of the EMR medication list.

Transitioning in and out of institutions and extended-care facilities is particularly problematic for MTM patients. Medication discrepancies arise because of formulary differences between the ambulatory care and institutional settings; incomplete knowledge of the patient's medical condition, needs, or plans of care by the institution's providers; inability to completely review the patient's medical history; or discomfort in altering another provider's medication orders. The primary care provider is ultimately responsible for resolving these issues; however, significant barriers make it difficult for the primary care provider to perform this function, including time constraints, remuneration, and poor communication. The MTM pharmacist is in a position to be the first to identify these problematic situations and is relied on by the primary care provider to gather the necessary information to resolve the discrepancies and, often in our clinic, delegated the authority to resolve them. At UIMCC, it is easier to gather information and communicate because of the EMR. When the patient returns to our service from an outside institution, the barriers are formidable. The patients often bring only prescriptions or discharge papers with insufficient information to fully understand the rationale for the changes. Unfortunately, our typical MTM patient provides minimal assistance in the process due to poor health literacy and cognition. Medication reconciliation is difficult and time-consuming, but it is a definite responsibility of the MTM pharmacist.

The ASHP Continuity of Care Task Force recommended a number of strategies to tackle medication reconciliation issues, including recommending a common data set that follows the patient.[19] Processes to allow efficient communication among all entities are critical. In our model, the MTM pharmacist is positioned to have a significant role in the process of medication reconciliation in the ambulatory care setting.

Medication therapy review is performed at each patient contact. At each visit, the effectiveness of a patient's medications and any drug-related problems are evaluated. Every disease and drug are not necessarily reviewed at each visit but are routinely addressed. The patient's primary concerns and issues are always acknowledged, followed by diseases that are not well controlled. We make every effort to ensure that evidence-based guidelines are followed. We check for resolution or minimization of disease signs and symptoms. The medication regimen for each of the patient's conditions is evaluated to determine if the patient's drug therapy is optimal. Access to physicians' notes is key, as it helps the MTM pharmacist understand the physicians' reasoning and care plans. We identify conditions where additional drug therapy may be required and instances where medications are unnecessary. To ensure consistency of care and improve our ability to measure the clinical outcomes of our service, the MTM clinic is developing monitoring standards for the most common diseases and drug therapies in our population.

Considerable attention is given to the assessment and management of ADEs and drug interactions. Variability exists on how best to define, measure, and evaluate ADEs. We use the approach recently outlined by Nebeker et al.,[20] incorporating their definition and evaluations of ADEs into our research and quality-assurance program. Currently, sparse and inconsistent data are available to define a baseline for occurrences of ADEs in ambulatory care patients with multiple medications and conditions. Gurwitz et al.[21] reported an ADE incidence of 50 per 1000 patient years in the ambulatory Medicare patient. A recent analysis of 29 studies of preventable ADEs conducted over the past 30 years suggests a rate of 14.9 ADEs per 1000 patient months (178 ADEs per 1000 patient years).[22] Data from a 3-year retrospective trial we are completing suggest a rate almost 5-10 times the rates described in these two reports. To understand the impact of MTM on ADEs, more research is needed to adequately define baseline occurrence of ADEs in the MTM population and define standard ADE evaluation terminology.

Interacting drugs are present in a majority of MTM patients' medication regimens. Some of these interactions can be eliminated; however, most interactions involve medications that are essential for disease management. The benefit of therapy often outweighs the risk of the interaction. The MTM pharmacist's role is to monitor and manage these drug interactions and facilitate appropriate adjustments when some aspect of the patient's care changes that affects the drug interaction.

Educating patients with multiple conditions is a formidable challenge. Low literacy, cultural issues, poor cognitive skills, and poor health status of MTM patients affect their ability to learn. The amount of information the patient must understand based on the number of diagnoses and the number of medications required can be overwhelming. Adding to the complexity, teaching strategies for one disease or medication may conflict with those of another. The MTM pharmacist must prioritize the many educational needs of the patient, as they cannot be practically or effectively covered in one visit.

The use of commercially available educational material in our MTM patient population has been disappointing. In an effort to be comprehensive, too much information is often provided to the patient, which can overwhelm an already-overwhelmed patient. In our experience, our typical MTM patient may require several education sessions or visits to understand one concept, such as morning fasting blood glucose level goal. Once the concept is adequately learned, we can then move to the next concept, such as what to do if the blood glucose level is not in that range.

Wide variations in learning abilities exist in our MTM patient population. Patients with poor cognitive skills and varying levels of dementia may never learn or remember the names of their medications or understand why they are taking them. They struggle to understand their diseases, the importance of disease management, the complexities of management, dietary restrictions, or how their behaviors affect their health. Educational strategies vary greatly for such patients compared with patients who can learn the details of their drugs or disease states. As we have gained experience in educating the MTM patient, we have identified a need to improve our knowledge and skills in educational principles among various types of learners, in understanding behavior and motivation, and in understanding how to set reasonable learning goals for the wide range of patients we see, so that we can maximize what they learn over time.

The MTM clinic at UIMCC does not work under any formal collaborative agreement. Creating one standard agreement would be difficult because our patients are referred from a number of different physician groups and specialties. The referring physician may request certain levels of care for their patient; in such cases, an agreement on a patient-specific basis is established. We hope to develop improved formality to these types of opportunities as we further define our role and build relationships with the various medical groups (e.g., geriatrics, cardiology, psychiatry) that refer patients to our clinic.

Documentation of MTM services is equally critical and challenging. We use the MTM clinic documentation to accomplish four goals. Foremost, the clinic note is a vehicle of communication to other health care providers to ensure continuity of care, convey important patient information discovered, and document the interventions provided during the MTM visit. The MTM note serves medical and legal purposes, documenting activities such as provision of education and instruction. The MTM staff also use the note as a tool to communicate among themselves so that another MTM pharmacist can effectively conduct the next patient visit if needed. Finally, the note must meet our needs for data collection so that we can determine the value of our program, measure patient outcomes, and ensure quality of care. The resulting lengthy note negatively affects the main purpose of the documentation: effective communication. The use of templates is helpful but not a satisfactory solution. The documentation process needs automation beyond simple word processing. Two of the four goals of our documentation are not vital to other health care providers and can be accomplished using an internal system. The structure of an ideal documentation system would be similar to the concept of a disease registry.[23] An ideal MTM automated registry would meet multiple documentation needs and provide monitoring queues guided by evidence-based medicine, collect data, and have the ability to produce an MTM clinical note providing only the information needed to be downloaded into an EMR or forwarded to other health care providers.


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