Barriers and facilitators to implementing pharmacist-provided comprehensive medication management in primary care transformation.

PURPOSE: How to effectively integrate pharmacists into team-based models of care to maximize the benefit they bring to patients and care teams, especially during times of primary care transformation (PCT), remains unknown. The objective of this study was to identify barriers and facilitators when integrating pharmacist-provided comprehensive medication management (CMM) services into a health system's team-based PCT using the Consolidated Framework for Implementation Research (CFIR). METHODS: Semistructured qualitative interviews were carried out with 22 care team members regarding their perceptions of the implementation of CMM in the PCT. Transcripts were coded to identify CMM implementation barriers and facilitators, and resulting codes were mapped to corresponding CFIR domains and constructs. RESULTS: Fifteen codes emerged that were labeled as either a barrier or a facilitator to implementing CMM in the PCT. Facilitators were the perception of CMM as an invaluable resource, precharting, tailored appointment lengths, insurance coverage, increased pharmacy presence, enhanced team-based care, location of CMM, and identification of CMM advocates. Barriers included limited clinic leadership involvement, a need for additional resources, CMM pharmacists not always feeling part of the core team, understanding of and training around CMM's role in the PCT, changing mindsets to utilize resources such as CMM more frequently, underutilization of CMM, and CMM scheduling. CONCLUSION: Clinical pharmacists providing CMM represent a valuable interdisciplinary care team member who can help improve healthcare quality and access to primary care. Identifying and addressing implementation barriers and facilitators early during PCT rollout is critical to the success of team-based services such as CMM and becoming a learning health system.

A Pharmacist-Driven Education and Intervention Program that Improves Outcomes for Hypertensive Patients.

Purpose: Uncontrolled hypertension is serious and may lead to severe cardiovascular events and death. To better educate and empower patients to meet their blood pressure (BP) management goals, a large, integrated academic healthcare system implemented the Blood Pressure Goals Achievement Program (BPGAP), a longitudinal intervention embedding community pharmacists within healthcare teams. This study evaluated BPGAP on its ability to promote patient BP management goals. Methods: A pre-/post-intervention analysis was conducted whereby BP measurements were evaluated longitudinally within acuity groups determined by k-means clustering. Generalized linear mixed models evaluated trends in BP by time period, and proportions of patients meeting BP management goals (<140/90 mmHg) were assessed in relation to BPGAP enrollment date. Results: There were 5,125 patients who were clustered into Uncontrolled, Borderline, and Controlled blood pressure groups; 2,108 patients had BP measurements across 4 time periods before and after BPGAP enrollment. Groups differed by patient age, sex, and other demographics (p<0.0001). Patients in the Uncontrolled and Borderline BP clusters demonstrated significant BP decreases after BPGAP enrollment, continuing at least to 1-year post-intervention; Controlled cluster patients maintained BPs throughout the study period. The proportion of patients with controlled BPs increased from 56% immediately pre-BPGAP to 74% in the 3- to 6-months following enrollment. Conclusion: BPGAP is effective at helping patients achieve their BP management goals. Pharmacists may play a key role in hypertension control through measuring BPs and including updates and recommendations in the electronic health record, educating patients, and engaging in communication with healthcare teams.

Characterizing the reach of comprehensive medication management in a population health primary care model.

INTRODUCTION: As care teams adopt team-based models of care, it is important to examine the reach of interdisciplinary services, such as pharmacists providing comprehensive medication management (CMM). This study examined the reach of pharmacist-delivered CMM in the first 10 months of a population health-focused primary care transformation (PCT). METHODS: Using electronic health record data, descriptive statistics (counts and percentages, as well as means and standard deviations) were quantified to summarize the patients who received CMM in two PCT pilot clinics pre- and post-PCT. RESULTS: Patients who had at least one CMM visit increased from 554 during the pre-PCT window to 880 during the post-PCT window. However, when adjusted for the increased pharmacist full-time equivalents (FTE) included as part of the PCT, 462 and 330 patients/FTE were seen in the pre- vs post-PCT periods, respectively. When calculating the percentage of patients who received CMM, this increased from 2.3% of all primary care patients seen in the two pilot clinics before the PCT began to 4.4% after the PCT was implemented. Most patient demographics remained largely the same between the pre- and post-PCT periods. However, CMM patients seen in the post-PCT period had more medication therapy problems across all medication therapy problem categories compared to patients in the pre-PCT period. Additionally, patients receiving CMM had significantly more conditions and medications and higher hospitalizations and emergency department use compared to the general clinic population. CONCLUSIONS: Reach is an important implementation outcome to determine the representativeness of individuals participating in a given service. This study illustrates that pharmacists providing CMM see complex patients with a high propensity for medication therapy problems. However, opportunities exist to improve the reach of CMM and, in turn, enhance team-based care.

Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System.

BACKGROUND: Medication therapy management (MTM) was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries. Even though the term "MTM" was first used in 2003, pharmacists have provided similar services since the term "pharmaceutical care" was introduced in 1990. Fairview Health Services, a large integrated health care system, implemented a standardized pharmaceutical care service system in 1998, naming it a pharmaceutical care-based MTM practice in 2006. OBJECTIVE: To present the clinical, economic, and humanistic outcomes of 10 years of delivering MTM services to patients in a health care delivery system. METHODS: Data from MTM services provided to 9,068 patients and documented in electronic therapeutic records were retrospectively analyzed over the 10-year period from September 1998 to September 2008 in 1 health system with 48 primary care clinics. Patients eligible for MTM services were aged 21 years or older and either paid for MTM out of pocket or met their health care payer's criteria for MTM reimbursement; the criteria varied for Medicaid, Medicare, and commercially insured enrollees. All MTM was delivered face to face. Health data extracted from the electronic therapeutic record by the present study's investigators included patient demographics, medication list, medical conditions, drug therapy problems identified and addressed, change in clinical status, and pharmacist-estimated cost savings. The clinical status assessment was a comparison of the first and most recent MTM visit to measure whether the patient achieved the goals of therapy for each medical condition (e.g., the blood pressure of a patient with diabetes and hypertension will be less than 130/80 millimeters mercury [mmHg] in 1 month; the patient with allergic rhinitis will be relieved of his complaints of nasal congestion, runny nose, and eye itching within 5 days). Goals were set according to evidence-based literature and patient-specific targets determined cooperatively by pharmacists, patients, and physicians. Cost-savings calculations represented MTM pharmacists' estimates of medical services (e.g., office visits, laboratory services, urgent care visits, emergency room visits) and lost work time avoided by the intervention. All short-term (3-month) estimated health care savings that resulted from addressing drug therapy problems were analyzed. The expenses of these avoided services were calculated using the health system's contracted rates for services provided in the last quarter of 2008. The return on investment (ROI) was calculated by dividing the pharmacist-estimated savings by the cost of MTM services in 2008 (number of MTM encounters times the average cost of an MTM visit). The humanistic impact of MTM services was assessed using the results from the second patient satisfaction survey administered in 2008 (new patients seen from January through December 2008) for the health system's MTM program. RESULTS: A total of 9,068 patient records were in the documentation system as of September 30, 2008. During the 10-year period, there were 33,706 documented encounters (mean 3.7 encounters per patient). Of 38,631 drug therapy problems identified and addressed by MTM pharmacists, the most frequent were a need for additional drug therapy (n = 10,870, 28.1%) and subtherapeutic dosage (n = 10,100, 26.1%). In the clinical status assessment of the 12,851 medical conditions in 4,849 patients who were not at goal when they enrolled in the program, 7,068 conditions (55.0%) improved, 2,956 (23.0%) were unchanged, and 2,827 (22.0%) worsened during the course of MTM services. Pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter) and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 per $1 in MTM administrative costs. In the patient satisfaction survey, 95.3% of respondents agreed or strongly agreed that their overall health and well-being had improved because of MTM. CONCLUSION: Pharmacist estimates of the impact of an MTM program in a large integrated health care system suggest that the program was associated with improved clinical outcomes and cost savings. Patient satisfaction with the program was high. DISCLOSURES: There was no external funding for this manuscript. The 3 authors are employees of Fairview Pharmacy Services. Ramalho de Oliveira had primary responsibility for the concept and design, writing, and revision of the manuscript, with the assistance of Brummel and Miller. Ramalho de Oliveira performed the data collection, and all 3 authors shared equally in data interpretation.

Twenty Years of Experience and Counting: Strategies for Growing Medication Therapy Management Services.

DISCLOSURES: No funding supported the writing of this commentary. Brummel has consulted, presented, or was engaged in an advisory board for UCB, Boerhinger Ingelheim, Pfizer, and Lilly. Sorenson has nothing to disclose.

Drug Therapy Problem Severity Following Hospitalization and Association With 30-Day Clinical Outcomes.

BACKGROUND: Improved understanding of how drug therapy problems (DTPs) contribute to rehospitalization is needed. OBJECTIVE: The primary objectives were to assess the association of DTP likelihood of harm (LoH) severity score, as measured by comprehensive medication management (CMM) pharmacist after hospital discharge, with 30-day risk of hospital readmission, observation visit, or emergency department visit, and to determine whether resolution of DTPs reduces 30-day risk. Secondary objectives were to determine if any eventswere associated with DTPs and preventability of events. METHODS: Data were collected for 365 patients who received CMM following hospitalization and had at least 1 DTP identified. Retrospective chart reviews were completed for 80 patients with subsequent events to assess associationg with a DTP and its preventability. RESULTS: For each 1-point increment in maximum LoH score, there was 10% higher risk of the composite end point (hazard ratio [HR]=1.10; 95% CI:0.97-1.26; P=0.13). When DTPs were resolved by the CMM pharmacist, the association was attenuated, with a HR of 1.15 (95% CI:0.96-1.38; P=0.12) when the DTP was unresolved and HR of 1.09 (95% CI:0.96-1.25; P=0.52) when resolved; for hospital readmission alone, the corresponding HRs were 1.23 (95% CI:1.00-1.53; P=0.05) and 1.05 (95% CI:0.87-1.27; P=0.60). Of 80 subsequent events, 44 were associated with a medication; 22 were considered preventable. Conclusion and Relevance: The LoH severity score was associated with risk of 30-day events. The strength of association was attenuated when DTPs were resolved by the CMM pharmacist. However, because of statistical uncertainty, larger studies are needed to confirm these patterns.

Seeing the Forest Through the Trees: Improving Adherence Alone Will Not Optimize Medication Use.

Medication adherence is a problem that has received widespread attention in the medical literature and health policy circles. With the increased emphasis on recognizing and rewarding quality in the U.S. health care system, medication adherence measures are increasingly being adopted to assess quality of medication use. However, when adherence is discussed in the literature or evaluated via quality measures, there is rarely any dialogue surrounding adherence in the context of patient-centered issues such as clinical status, individualized medication needs, or personal expectations and social situation. When nonadherence is identified via a comprehensive assessment of all of a patient's medication-related issues, it typically is recognized as only the third most frequent type of medication-related problem. Issues such as requiring a medication that has not been prescribed or receiving a medication prescribed at a dose too low to achieve the intended clinical goal are more frequently experienced. Furthermore, if a patient is nonadherent to a medication because of adverse effects or if the medication prescribed is not appropriate considering the patient's individual clinical situation, promoting adherence can create unintended harm. Therefore, achieving medication adherence as typically evaluated via existing quality metrics such as proportion of days covered is only valid if the medication is first deemed to be indicated, effective, and safe for the patient. Medications are the most common medical intervention for chronic illnesses. As a result, success in achieving the Triple Aim of health care is highly dependent on optimizing medication use. When quality measures for medication use narrowly focus on measuring adherence, the resulting programs of payers and providers will likely ignore the most frequent types of medication problems that prevent improved health, create unnecessary costs, and could negatively impact patients' experience with the health care system. Strong leadership and advocacy on the part of agencies in the position to influence the quality measurement landscape in the U.S. health care system will be critical to achieve widespread awareness of medication nonadherence in the context of the full scope of medication-related problems in health care. DISCLOSURES: No outside funding supported this research. Brummel provides consulting services to other health systems; has received grants from Sanofi and speaking fees from AMCP, APhA, and ASHP; and is on the faculty at the University of Minnesota and employed by Fairview Pharmacy Services. Ekstrand provides consulting services for Alliance for Integrated Medication Management and has received speaking fees from International Diabetes Center and MN Alliance of Physician Assistants. The authors report no other conflict of interest, potential or otherwise. Study concept and design were contributed primarily by Sorensen, Brummel, and Rehrauer, along with the other authors. Rehrauer, Brummel, and Ekstrand collected the data, which were interpreted by Sorensen, Brummel, Rehrauer, and Ekstrand. Pestka and Sorensen wrote and revised the manuscript, with assistance from the other authors.

Patient characteristics predicting the frequency of medication therapy management visits for patients with diabetes.

BACKGROUND: Patient characteristics associated with a higher exposure to medication therapy management (MTM) and the relationship between frequency of MTM visits and meeting clinically defined goals of therapy have not been documented. OBJECTIVE: The goal of this study was to evaluate factors predicting frequency of MTM visits for patients with diabetes and the impact of these visits on diabetes clinical outcomes. METHODS: All patients with diabetes participating in a 2007 MTM demonstration project (N = 121) were included in the analysis. A negative binomial regression controlling for age, sex, presence of diabetes complications, taking insulin, Charlson score Index, and hypertension and cholesterol medication regimen composition was used to assess predictors of the number of MTM visits. Optimal diabetes management differences between the 2 groups defined according to median number of MTM visits (low frequency, ≤4; high frequency, >4) was compared by using Wilcoxon Mann-Whitney and χ(2) tests. RESULTS: Having diabetes complications (relative risk = 2.83 [95% CI, 1.3-6.17]; P = 0.0088) and taking insulin (relative risk = 1.43 [95% CI, 1.12-1.83]; P = 0.0038) were associated with a higher number of MTM visits. At baseline, the high-frequency group had a significantly higher proportion of patients with insulin therapy (P < 0.01), higher proportion with diabetes complications (P = 0.07), and higher mean Charlson score (P = 0.08). The rate of optimal diabetes care was significantly lower in the high-frequency group before MTM (P = 0.02) but not statistically different from the low-frequency group during and 1 year after the demonstration project. CONCLUSIONS: Patients with diabetes complications and using regimens that include insulin received more frequent MTM visits. MTM services delivered to a diabetes population with more complex disease or taking insulin have a positive impact on optimal diabetes care.

Optimal diabetes care outcomes following face-to-face medication therapy management services.

Pharmacists play an integral role in influencing resolution of drug-related problems. This study examines the relationship between a pharmacist-led and delivered medication therapy management (MTM) program and achievement of Optimal Diabetes Care benchmarks. Data within Fairview Pharmacy Services were used to identify a group of patients with diabetes who received MTM services during a 2007 demonstration project (n=121) and a control group who were invited to receive MTM services but opted out (n=103). Rates of achieving optimal diabetes clinical management for both groups were compared using the D5 diabetes measure for years 2006, 2007, and 2008. The D5 components are: glycosolated hemoglobin (HbA1c<7%); low-density lipoprotein (<100 mg/dl); blood pressure (<130/80 mmHg); tobacco free; and daily aspirin use. Multivariate difference-in-differences (DID) estimation was used to determine the impact of 1 year of MTM services on each care component. Patients who opted in for MTM had higher Charlson scores, more complex medication regimens, and a higher percentage of diabetes with complications (P<0.05). In 2007, the percentage of diabetes patients optimally managed was significantly higher for MTM patients compared to 2006 values (21.49% vs. 45.45%, P<0.01). Nonlinear DID models showed that MTM patients were more likely to meet the HbA1c criterion in 2007 (odds ratio: 2.48, 95% confidence interval [CI]: 1.04-5.85, P=0.038). Linear DID models for HbA1c showed a mean reduction of 0.54% (95% CI: 0.091%-0.98%, P=0.018) for MTM patients. An MTM program contributed to improved optimal diabetes management in a population of patients with complex diabetes clinical profiles.

Managing drug-related morbidity and mortality in the patient-centered medical home.

BACKGROUND: The appropriate use of medications can influence quality performance measures and costs. Drug-related morbidity and mortality represents a public health challenge due to the ineffective and unsafe consequences of medication use. This article addresses the impact of team-based care that incorporates comprehensive medication therapy management on per capita expenditures, quality performance measures, and resolution of drug therapy problems. METHODS: A team-based medication therapy management system developed over 13 years in an integrated health system in 4 Minnesota innovation clinic sites was assessed in terms of: (1) differences in total median health expenditures compared with noninnovation clinics, (2) improvements on 5 performance benchmarks for patients with diabetes in comparison with statewide results, and (3) resolution of drug therapy problems. RESULTS: Spending growth was 11% less in innovation clinics than that in 38 noninnovation clinics. Median per member per month health care costs measured at 5 intervals over a 15-month period were significantly lower in innovation than in noninnovation sites (P=0.05). Forty percent of patients with diabetes in the innovation clinics achieved all 5 performance benchmark treatment goals in 2009, with a range from 34% to 45%, compared with the statewide result of 17.5% of patients achieving all 5 benchmarks. In addition, over 4000 drug therapy problems were reported to be resolved. CONCLUSIONS: Team-based care helped to achieve quality performance and control spending growth through medication therapy management in a patient-centered medical home innovation.

Medication therapy management: 10 years of experience in a large integrated health care system.

BACKGROUND: Medication therapy management (MTM) was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries. Even though the term "MTM" was first used in 2003, pharmacists have provided similar services since the term "pharmaceutical care" was introduced in 1990. Fairview Health Services, a large integrated health care system, implemented a standardized pharmaceutical care service system in 1998, naming it a pharmaceutical care-based MTM practice in 2006. OBJECTIVE: To present the clinical, economic, and humanistic outcomes of 10 years of delivering MTM services to patients in a health care delivery system. METHODS: Data from MTM services provided to 9,068 patients and documented in electronic therapeutic records were retrospectively analyzed over the 10-year period from September 1998 to September 2008 in 1 health system with 48 primary care clinics. Patients eligible for MTM services were aged 21 years or older and either paid for MTM out of pocket or met their health care payer's criteria for MTM reimbursement; the criteria varied for Medicaid, Medicare, and commercially insured enrollees. All MTM was delivered face to face. Health data extracted from the electronic therapeutic record by the present study's investigators included patient demographics, medication list, medical conditions, drug therapy problems identified and addressed, change in clinical status, and pharmacist-estimated cost savings. The clinical status assessment was a comparison of the first and most recent MTM visit to measure whether the patient achieved the goals of therapy for each medical condition (e.g., the blood pressure of a patient with diabetes and hypertension will be less than 130/80 millimeters mercury [mmHg] in 1 month; the patient with allergic rhinitis will be relieved of his complaints of nasal congestion, runny nose, and eye itching within 5 days). Goals were set according to evidence-based literature and patient-specific targets determined cooperatively by pharmacists, patients, and physicians. Cost-savings calculations represented MTM pharmacists' estimates of medical services (e.g., office visits, laboratory services, urgent care visits, emergency room visits) and lost work time avoided by the intervention. All short-term (3-month) estimated health care savings that resulted from addressing drug therapy problems were analyzed. The expenses of these avoided services were calculated using the health system's contracted rates for services provided in the last quarter of 2008. The return on investment (ROI) was calculated by dividing the pharmacist-estimated savings by the cost of MTM services in 2008 (number of MTM encounters times the average cost of an MTM visit). The humanistic impact of MTM services was assessed using the results from the second patient satisfaction survey administered in 2008 (new patients seen from January through December 2008) for the health system's MTM program. RESULTS: A total of 9,068 patient records were in the documentation system as of September 30, 2008. During the 10-year period, there were 33,706 documented encounters (mean 3.7 encounters per patient). Of 38,631 drug therapy problems identified and addressed by MTM pharmacists, the most frequent were a need for additional drug therapy (n = 10,870, 28.1%) and subtherapeutic dosage (n = 10,100, 26.1%). In the clinical status assessment of the 12,851 medical conditions in 4,849 patients who were not at goal when they enrolled in the program, 7,068 conditions (55.0%) improved, 2,956 (23.0%) were unchanged, and 2,827 (22.0%) worsened during the course of MTM services. Pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter) and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 per $1 in MTM administrative costs. In the patient satisfaction survey, 95.3% of respondents agreed or strongly agreed that their overall health and wellbeing had improved because of MTM. CONCLUSION: Pharmacist estimates of the impact of an MTM program in a large integrated health care system suggest that the program was associated with improved clinical outcomes and cost savings. Patient satisfaction with the program was high.