Clinical Management of patients: The case for Comprehensive Medication Therapy Management Services Professor Djenane Ramalho de Oliveira, PhD Director, Centro de Estudos em Atenção Farmacêutica (CEAF) - UFMG Adjunct Faculty, College of Pharmacy University of Minnesota Belo Horizonte - November 11th, 2014
Outline The problem of medication use Influencing drug-therapy decisions where they occur every day: a patient-centered approach to medication use Medication therapy management as a solution for the quality use of medicines Centro de Estudos em Atenção Farmacêutica- CEAF (Center for Pharmaceutical Care Studies)
The problem of medication use Pharmaceuticals are the most common medical intervention Multiple providers prescribing multiple medications Patients with multiple chronic conditions Lack of coordination of care
The problem of medication use Uncontrolled chronic conditions: poor results High health care costs Increase in use of OTC Non-adherence
The problem of medication use 50% of patients do NOT take their medications as recommended 2002 2006: increase of 9.6% in total health care costs and increase of 123.9% with medications 2007: R$ 4.7 bi with medications 2011: R$ 300 million in the State of Minas Gerais
The problem of medication use In any given week, nearly 1/3 of American adults take 5 or more different medications Drug therapy problems cost as much as $200 billion annually, causing serious quality of life issues in patients 20% of hospital discharges result in adverse event w/in 30 days - 2/3 are drug related 70% of all patients taking medications experience a drug therapy problem By 2018, specialty meds ~ 50% of drug spend
Medications impact everything Physician visits Hospital admissions/readmissions Performance measures Service utilization Patient engagement Patient satisfaction Costs
There is an urgent need to move beyond Guaranteeing access to medications Analyzing prescriptions Educating patients about their prescriptions
To optimize the patient s pharmacotherapy and To improve the patient s daily experiences with their medications
Patients make decisions EVERY DAY, often several times a day, about taking or not taking their medications!!!!
Disease Management Risk Management Counselling & Health education Too many drug program in silos Formulary, Specialty, and Prior Authorization Dissemination of Evidence-based Information Adherence Programs Patient Safety Programs
A Comprehensive Solution Risk Management Counselling and health education Disease Management Comprehensive Medication Therapy Management Services Formulary, specialty and Prior Authorization Dissemination of evidence-based information Adherence Patient Safety
Medication Therapy Management at an Organizational level Clinical service Integrated with medicine Patient centered Integrates and enhances overall care management
Comprehensive Medication Management at a Patient Specific Level A standard of care that ensures each patient s medications are appropriate, effective, safe and able to be taken as intended A care process Ascertain each patient s medication experience Establish goals of therapy Identify drug therapy problems Create care plan Follow-up evaluation A continuum of care with measurable goals and outcomes reflecting a positive return-on-investment
Comprehensive Medication Management at a Patient Specific Level 15
Identifying drug therapy problems Drug therapy problems are undesirable events or risks that the patient experiences that inhibit or delay him/her from achieving the desired goals of therapy. They are identified during the assessment process, so they can be resolved through individualized changes in the patient s drug therapy regimens.
Drug Therapy Problems Unique set of problems Demarcate professional responsibilities Central to MTM practitioners' activities and practice
Noncompliance Noncompliance is defined as the patient s inability or unwillingness to take a drug regimen that the practitioner has clinical judged to be appropriately indicated, adequately efficacious, and able to produce the desired outcomes without any harmful effects.
An integrated MTM Service Unnecessary Drug Therapy Adherence Dosage Too High DRUG THERAPY Clinically Appropriate Effective Safe Convenient Needs Additional Drug Therapy Ineffective Drug Adverse Drug Reaction Dosage Too Low
Unique elements of Medication Therapy Management Services Terminology is consistent with medicine/nursing Based on a professional practice (pharmaceutical care) Recognizes the patient s medication experience Depends on the identification, resolution and prevention of drug therapy problems Add value to the care of patients Applicable to any level of patient care (primary, secondary and tertiary), so it allows care coordination
Indication Effectiveness Safety Convenience Pharmaceutical Care Clinical Service Clear objective Compatible with other services Can be evaluated Sustainable Recognizable Medication Therapy Management (MTM) Bittencourt, M & Ramalho de Oliveira, R (2013)
Success requires that the clinical service: 1. Be described simply, in terms of what it can do for the patient 2. Be based on standards of care so that it can be delivered consistently from one practitioner to the next, and from one patient to the next 3. Integrate with the rest of the health care team in terms of consistent terminology, philosophy, care process, and standards of practice 4. Is able to generate measureable results which are reproducible 5. Be paid for in the same way other patient care is reimbursed
Current approaches to Medication Management Services Distribution Management: Retail Function Episodic MTM Physical therapist Service Management: Patient Care Nutritionist Comprehensive Pharmacy Dispensing MTM
Patient care process in Medication Therapy Management Services (Sardenberg, 2014) SOCIETY COMMUNITY ENVIRONMENT Assessment of drug-related needs Follow-up evaluation Implementation of care plan Medication use in daily life Sujeito ativo Active patient Identification of drug-related problems Construction of care plan
Drug Therapy Problems, Fairview MTM Program 11,904 DTP Resolved in 2013 Indication Unnecessary Drug Therapy 9% Needed Additional Therapy 21% Effectiveness More Effective Drug Available 6% Dosage Too Low 29% Safety Adverse Drug Reaction 11% Dosage Too High 11% Compliance Noncompliance 12% TOTAL 100% Fairview Pharmacy Services, LLC
Associated to the Department of Social Pharmacy, College of Pharmacy at the Universidade Federal de Minas Gerais Personnel: Director 1 Volunteer pharmacist 1 Post-doctorate fellow 4 Doctorate students 10 master students Collaborators: professors; pharmacists; physicians; pharmacy students; Fairview Pharmacy Services LLC; Medication Management Systems Inc.
Mission statement: To reach a higher standard for medication use in Latin America through the delivery of comprehensive medication management services. Vision: To become the most trusted institutional reference in pharmaceutical care practice and comprehensive medication management services in Latin America in 5 years. Goals 1. To deliver care to patients through medication management services 2. To prepare competent pharmacist practitioners to provide quality services through training programs 3. To establish effective and efficient practices through practice development techniques 4. To evaluate and analyze the quality of patient services through sophisticated and state of the art evaluation techniques
What is CEAF doing? Implementation of MTM services Primary care (Belo Horizonte and Lagoa Santa) Secondary care (endocrinology-diabetes; COPD; Breast cancer; Hepatitis) Training Pharmacy students (parallel curriculum) MTM practitioners Consulting on management and quality improvement of MTM services Research
Case study: Providing Comprehensive MTM services for patients with COPD Insulin Glargine Treatment of reumathoid arthritis: adalimumabe Others
OBRIGADA! THANK YOU! djenane.oliveira@gmail.com