PL Detail-Document #300801 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER August 2014 Medication Therapy Management Hundreds of billions of dollars are wasted every year because of the misuse of medications. Pharmacistprovided medication therapy management (MTM) improves patient outcomes and reduces overall health care costs. MTM can describe a broad range of patient-centered services that optimize therapeutic outcomes for patients such as medication therapy reviews, anticoagulation management, and immunizations. The Medicare Modernization Act of 2003 created more opportunities for pharmacists to provide MTM by requiring all Medicare Part D prescription drug plans to offer an MTM program. A comprehensive medication review (CMR) with standardized written summaries must be offered annually to all Medicare Part D beneficiaries enrolled in an MTM program. This includes enrollees in long-term care settings. A targeted medication review (TMR) is also required at least quarterly for these patients to evaluate and manage specific or possible drug-related problems. For 2014 and 2015, there is a display (i.e., test ) measure for Part D plans that looks at the percentage of MTM-eligible Part D patients who have received a CMR. This display measure is expected to be counted as a quality measure for Part D Star Ratings in 2016 (based on 2014 data), so the number of CMRs provided today is important. But only about 10% of Part D patients eligible for a CMR get one. There are plenty of inspiring success stories of how pharmacists have expanded their services to include MTM, but there are also many considerations for pharmacists when getting started with MTM, which may vary depending on practice setting. Here is a toolbox to help you get started or enhance your MTM services, with helpful tips and links to some great resources from Pharmacist s Letter. Topic Program Development Consider Your Resources and Strengths Network with other pharmacists who provide MTM and look for best practices. Recognize what you already do such as calling prescribers about drug-drug interactions, suggesting less expensive alternatives, or finding ways to improve adherence. Consider how to expand your patient care services from there. Start with disease states you know best. Consider low hanging fruit where you can have a lot of impact, such as cardiovascular conditions, diabetes, COPD, etc. Consider opportunities to engage patients about the use of devices such as inhalers, nebulizers, peak flow meters, insulin pens, needles, syringes, blood glucose meters, testing supplies, etc. Perform a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis for your practice. Use this to identify where changes need to be made to address internal deficiencies and be prepared to handle external challenges. Build Your Clientele Identify patients most likely to benefit from MTM (e.g., those who struggle to afford meds, those who get early or late refills, those who get multiple meds or who have multiple conditions or prescribers, those who need immunizations, those recently discharged from the hospital). Consider using computer-generated reports; recommendations from technicians, pharmacy students, or cashiers; and referrals from other health care providers. Also consider unique opportunities, such as in long-term care settings, when looking to expand services.
Topic Program Development (PL Detail-Document #300801: Page 2 of 9) Consider contracting with online MTM platforms, third party plans, or employers to identify patients who are eligible for reimbursable MTM services. Flag eligible patients in your pharmacy system and watch for computer eligibility alerts. Take action on suggested interventions and schedule CMRs for eligible patients. Look at the Logistics Determine the amount of time required for individual MTM appointments (e.g., usually at least 20 to 30 minutes for a CMR) and staffing required to schedule appointments. Identify a private or semiprivate area from which to conduct MTM sessions. Consider use of a privacy screen if necessary. Assess what equipment you will need, such as a computer and printer, secure filing area for paper records, sphygmomanometer and stethoscope, clipboard, etc. Get Buy-In from Staff, Providers, and Patients Educate staff about the importance of MTM (e.g., improved quality of patient care, improved outcomes, avoided adverse effects, reduced overall health care costs, enhanced patient satisfaction). Build relationships with key local providers and market your service to them. Consider setting up face-to-face appointments with providers to introduce yourself and explain your service, or notifying prescribers about scheduled CMRs. Consider marketing tools, such as a mass mailing to educate patients about the opportunity to make appointments for MTM, professional flyers stuffed in prescription bags, or posters that promote the service. Find out what patients or caregivers expect or desire from MTM. Engage patients and explain the individualized benefit that they will receive from a CMR, so they understand the value. For example, getting all health care providers on the same page, answering all medication-related questions, being able to stay healthier and save money, etc. Explain how MTM will help address the patient s top concerns. Develop a 30-second pitch for your entire pharmacy team to quickly and clearly explain the benefits of MTM and what the patient can expect. Here is an example script: Did you know your pharmacist can provide a medication check-up to look at all the medicines you take, including prescriptions, over-thecounter products, vitamins, herbal products, and supplements? We ll work as a partner with you and your prescriber to make sure you re getting the most benefit from your medicines. We ll also look at whether there are any less expensive alternatives that might help save you money, make sure you re taking the right meds in the right way and at the right doses, and answer any questions you may have about your medicines. You ll get a complete medication list after the visit. Would you like to schedule an appointment? Don t become discouraged by small setbacks such as recommendations that are not accepted by a prescriber. Roles Find ways techs can help prompt pharmacists to speak to patients about for MTM throughout the dispensing process, such as identifying eligible patients at Pharmacy Staff drop-off or flagging completed prescriptions. Encourage techs and other pharmacy staff to use the 30-second pitch and other
Topic Roles for Pharmacy Staff Billing and Reimbursement (PL Detail-Document #300801: Page 3 of 9) marketing tools to recruit patients. Train techs to perform tasks such as getting intake forms from patients, filling out medication history forms, obtaining vital signs (if appropriate), etc. Delegate administrative tasks to pharmacy staff, such as scheduling appointments, prepping paperwork, making reminder calls, faxing info to providers, billing, and documenting, as appropriate. Incorporate pharmacy students into the process where possible. Share success stories with pharmacy staff to ensure they see the value of MTM and to keep them engaged and motivated. Apply for a National Provider Identifier (NPI) number in order to bill for MTM services covered under Medicare Part D (https://nppes.cms.hhs.gov/nppes/staticforward.do?forward=static.npistart) Determine your fees. These may be negotiable with some payers and you will need to establish pricing for self-paying patients. Check with third party payers about how to bill for pharmacists services, such as what services are covered, what billing codes must be used (e.g., CPT, ICD), and where to submit the claims. If you are contracted with an online MTM platform, make sure all staff complete any necessary training and understand all documentation and billing requirements. Delegate billing to pharmacy staff when possible. MTM Workflow Setting It Up Develop a systematic process for providing MTM. For targeted interventions, build steps into your existing workflow if possible (i.e., identification of a problem, discussion with the patient, contacting the prescriber if necessary for interventions and/or to let him/her know that a medication review has been completed, and following up with the patient). Map it out with a flow chart. Consider having a point person who can lead the implementation of patient care services. Find out the capabilities of your available technology such as collecting data, identifying eligible patients, guiding the pharmacist through the MTM interaction, and generating patient education materials. Schedule appointments for CMRs during pharmacist overlap or off-peak times if possible. Consider whether telephone-based services are an option. Create a system for timely follow-up with patients and/or providers, such as with computer reminders or a binder divided by day of the month. Involve your entire pharmacy staff in follow-up to ensure that patient and provider recommendations are accepted and effective, to evaluate med changes and ensure problems are resolved, and identify new concerns. For Each CMR Appointment When scheduling the appointment and making reminder calls, ask patients to bring the meds they take (e.g., inhalers, samples, OTC products, vitamins, herbals, supplements, etc), an updated med list, any recent lab results, and a list of questions or concerns. Encourage the patient to bring a friend or family member if that person helps with the patient s care or with managing his or her meds. Have techs gather needed paperwork, equipment, and lab results (e.g., A1C,
(PL Detail-Document #300801: Page 4 of 9) Topic MTM Workflow lipids, serum creatinine) in advance of patient appointments. Once the patient arrives, have a tech get the patient started with paperwork; gather all medications; document allergies, vaccines, medical and social history, labs and vital signs if available; help create the personal medication list; etc. Review available patient information from the patient profile or claims data provided by third parties. Rely on the patient to give you additional details. Find out how the patient uses his or her meds. Ask open-ended questions about why, how, and when the patient takes each med to find problems as you create the personal medication list in patient-friendly language. Use probing questions to get more info if needed. Ask about the patient s beliefs regarding their medications, including cultural or religious beliefs, whether they believe the medications are helpful, etc. Consider the patient s health literacy and address potential barriers. Evaluate the patient s medication-related concerns. Prioritize and focus on those that impact the patient most (e.g., high costs, complicated regimen, etc), and use this information to help guide the medication action plan. Find and prioritize medication-related problems. For example, match up medications with conditions to find unneeded meds or undertreated conditions. Consider whether other medications may be more effective, safer, or less expensive, or if the patient s regimen can be simplified. Use our helpful tool, Worksheet for Med Review, to get started with the above steps. Develop a plan based on the high-priority problems. Ensure patients understand your recommendations, and what information you ll be sharing with prescribers. Collaborate with the patient s health care provider(s) and communicate visit findings and documentation (including medication action plan and personal medication list), even if medication changes are not being recommended. Use a standardized format, such as a SOAP note, for documentation. Keep notes clear and concise. (See Resources from the Web section for more information.) Use templates for med lists, action plans, and communication with providers. (Note that beginning on January 1, 2013, Medicare Part D requires use of the CMS Standardized Format, which includes a cover letter, Medication Action Plan [MAP], and Personal Medication List for the Comprehensive Medication Review [CMR]. These documents must be provided to the patient within 14 calendar days of the visit.) o The above templates can be downloaded at http://www.cms.gov/medicare/prescription-drug- Coverage/PrescriptionDrugCovContra/MTM.html. o Other sources for med list templates include: Making a Medicine List Makes You Medicine Smart (www.talkaboutrx.org/assocdocs/task/754/making_medicine_ List.pdf) My Medication Record (www.wapatientsafety.org/downloads/my-medicationrecord.pdf) How to Create a Pill Card (http://www.ahrq.gov/patientsconsumers/diagnosistreatment/treatments/pillcard/pillcard.html#template)
Topic MTM Workflow (PL Detail-Document #300801: Page 5 of 9) My Medicine List (www.safemedication.com/safemed/mymedicinelist.aspx) My Medicine Record (www.fda.gov/drugs/resourcesforyou/ucm079489.htm) Empower patients with information about self-care, medical conditions, and medications. Use patient handouts to help educate patients. Liability Remember that documentation serves as a risk prevention tool. Document information that s correct and necessary and be consistent in your documentation. Be aware of local, state, and federal regulations that may apply with MTM services, such as HIPAA, CLIA, and OSHA certifications if they apply. Maintain records as required by payers and your employer. Credentialing and Education Determine if third party payers require special training or credentialing for pharmacists who provide MTM Consider training such as the certificate course for MTM that is available through the American Pharmacists Association (APhA). Stay up-to-date with evidence-based recommendations and guidelines Consider mechanisms for quality assurance like staff training, peer-review of clinical notes, etc. Resources from Pharmacist s Letter Communication, Development, and Education PL Patient Education Handouts Precepting in the Community Pharmacy Part 3: Incorporating Students into the Development and Implementation of Pharmacy Services (focuses on involving students in the establishment of an MTM program) Enhancing Patient Counseling with Effective Communication Skills Using Motivational Interviewing to Create Change Guide for Helping Patients Afford Their Medications Medication Adherence Toolbox Collaborative Drug Therapy Management (CDTM) Technician Training Tutorial: Helping Patients with Medication Lists (includes a medication list template) PL Colleagues Interact (to network with others who provide MTM) Quality Measures for Pharmacists Quality Measures: What Pharmacy Teams Need to Know Drug Therapy Formulary/Drug Comparison (includes dosage comparison charts, drug class comparison charts, device comparison charts, and a template letter for sending to prescribers to request drug switches) Potentially Harmful Drugs in the Elderly: Beers List STARTing and STOPPing Medications in the Elderly Clinical Guidelines: Selection, Use, and Implications for Healthcare Lab Monitoring for Common Medications Liver Function Test Scheduling Improving Patient Safety: Medication Reconciliation Basics Appropriate Use of Oral Anticoagulants
(PL Detail-Document #300801: Page 6 of 9) Topic Resources from Pharmacist s Letter Disease States Improving Outcomes After Myocardial Infarction Improving Diabetes Outcomes Improving COPD Care Preventing and Treating Community-Acquired Pneumonia Improving Heart Failure Care The Current Cholesterol Controversy Treatment of Hypertension: JNC 8 and More Resources from the Web Medication Therapy Management: Utilizing the Pharmacists to Control Our Health Care Costs, a short video, is available at http://www.youtube.com/watch?v=qncgd05u58k Information about APhA s MTM certificate program is available at http://www.pharmacist.com/apha-certificate-training-programs Some currently available systems that can help with documentation and/or billing for MTM services: o Mirixa, founded by the National Community Pharmacists Association (www.mirixa.com) o OutcomesMTM (www.outcomesmtm.com) o PharmMD (www.pharmmd.com) o ConXus MTM, from Protocol Driven Healthcare, Inc. (www.pdhi.com) o Medication Management Systems/Assurance Pharmaceutical Care Documentation Software, from the University of Minnesota Peters Institute of Pharmaceutical Care (www.medsmanagement.com) o Medication Pathfinder, from Clinical Support Software (www.medicationpathfinder.com) More information on billing in non-hospital based settings at http://www.ashp.org/doclibrary/policy/ambulatory-care/pharmacist-billing-in- Physician-Based-Clinic-FAQ.pdf APhA MTM Central, with comprehensive info on MTM and resources for everything from clinical to business, is available at http://www.pharmacist.com/mtm Integrating Comprehensive Medication Management to Optimize Patient Outcomes Resource Guide (from the Patient-Centered Primary Care Collaborative) http://www.accp.com/docs/positions/misc/cmm%20resource%20guide.pdf Medicare Part D MTM info, including required forms, is available at http://www.cms.gov/medicare/prescription-drug- Coverage/PrescriptionDrugCovContra/MTM.html MTM toolkit from Agency for Healthcare Research and Quality (AHRQ) is available at http://effectivehealthcare.ahrq.gov/ehc/products/33/1186/decide38_toolkit_201 20711.pdf Information about writing SOAP notes is available at http://www.ashp.org/doclibrary/membercenter/shaccp/anticoag_clinical_do cumentation.pdf
(PL Detail-Document #300801: Page 7 of 9) Topic Resources from the Web Patient Assessment Tools Mini-Mental State Exam (MMSE) is available at http://www.framinghamheartstudy.org/share/protocols/mm1_8s_protocol.pdf Pain scales including Wong-Baker FACES and multiple language scales are available at http://www.partnersagainstpain.com/measuring-pain/assessmenttool.aspx Patient Health Questionnaire (PHQ-9) for depression is available at http://www.cqaimh.org/pdf/tool_phq9.pdf Definitions Comprehensive medication review (CMR): According to the Centers for Medicare and Medicaid Services (CMS), MTM includes an interactive person-to-person or telehealth consultation performed by a pharmacist or other qualified provider and an individualized, written summary in CMS standardized format. The summary includes a personalized medication action plan and medication list. CMR involves the systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient, caregiver, and/or prescriber. Some examples of recommendations that might result from CMR include a need for additional drug therapy, identification of an unnecessary drug therapy, identification of a drug dose that is too high or too low, availability of a more effective drug, identification of an adverse drug reaction, and identification of medication adherence issues. Also referred to as a comprehensive medication therapy review (MTR). The American Pharmacists Association (APhA) defines comprehensive MTR as a process where the pharmacist collects patient-specific information including all current medications including prescription and nonprescription products, herbals, and other dietary supplements. The pharmacist assesses the regimen to identify any medication-related problems, prioritizes problems, and then works with the patient and/or prescriber to create a plan to resolve any problems. Medication action plan (MAP): This is a document the patient receives at the end of an MTM visit. It should be a simple guide, written in patient-friendly language, for patients to keep track of their meds and health concerns, what they need to do to address those concerns, and associated actions that already have been taken. Medication therapy management (MTM): In addition to being described as a broad range of patientcentered services provided by pharmacists, MTM is also described more specifically by a framework consisting of five core elements: a medication therapy review (MTR), a personal medication record (PMR), a medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up. This model is based on a set of standards adopted by APhA/NACDS (National Association of Chain Drug Stores), which can be found at http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf. Personal medication record or list (PMR or PML): Another document the patient receives at the end of an MTM visit. The PMR includes patient information (e.g., allergies, medication-related problems, demographic information) and a comprehensive list of all meds (Rx, OTC, herbals, dietary supplements) along with doses, reason for use, instructions for use, start/stop date, and prescriber, in patient-friendly language. Patients should be encouraged to keep this list updated and share it with all other health care providers, and pharmacists may do so as well, to promote continuity of care. on next page
(PL Detail-Document #300801: Page 8 of 9) Targeted medication review (TMR): A follow-up intervention to address specific or potential medication-related problems, assess medication use, monitor whether unresolved issues need attention, determine if new drug therapy problems have arisen, and assess if the patient has experienced a transition in care. These are also referred to as targeted MTRs. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.
(PL Detail-Document #300801: Page 9 of 9) Project Leader in preparation of this PL Detail- Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor Cite this document as follows: PL Detail-Document, Medication Therapy Management. Pharmacist s Letter/Prescriber s Letter. August 2014. Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA 95219 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249 Copyright 2014 by Therapeutic Research Center Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to www.pharmacistsletter.com, www.prescribersletter.com, or
Worksheet for Med Review (PL Detail-Document #300801) Most medication-related problems can be grouped into just a few general categories. Consider using a worksheet such as the one below to help you prevent, identify, and resolve medicationrelated problems for your patients. This can be a helpful tool for comprehensive medication reviews (CMRs). Problem Example Situations Your Notes/Suggested Interventions Patient is taking an Duplicate therapy No indication for drug unnecessary Drug is being used to treat a medication preventable side effect A needed medication has not been prescribed A medication is ineffective A medication is causing a side effect or toxicity Patient is not taking a medication appropriately Preventive therapy is needed A current condition is untreated or undertreated Additional drug therapy is needed for the best effect Dose is too low Frequency of dosing is inadequate Drug is not used for adequate duration A drug interaction reduces the drug s effect Drug is inappropriate or not the best option for the patient Incorrect storage of drug leads to reduced potency Additional monitoring is needed to determine appropriateness of dose Nonadherence Dose is too high Dosing interval is too short A drug interaction increases the drug s effect Drug is inappropriate for patient or a safer option is available Allergic reaction Dose change made too quickly Additional monitoring is needed to determine appropriateness of dose Patient taking drug incorrectly Patient is unable to or does not understand how to properly take a med or use a device (e.g., inhaler, insulin pen, etc) Patient cannot afford med Patient prefers not to take med Patient forgets to take med Med regimen is too complex www.pharmacistsletter.com ~