Medication Therapy Management

Medication Therapy Management  is a collaborative effort of a qualified pharmacist, his patient or his caregiver and an assortment of other licensed health-professionals to promote safe and effective use of medications and help the concerned patient reap all the benefits of his medication. In other words, MTM is a healthcare service provided by a healthcare provider, such as a pharmacist, to help patients achieve the targeted outcomes from medication therapy.

This partnership wards off hazards associated with medication use, thus maximizing the cost-effectiveness of medication therapy. Medication Therapy Management(MTM) services, mainly obtained through individual pharmacies, private insurances, and federally funded programs, are conducted between the patient or caregiver and the pharmacist, preferably in face-to-face interaction. This interaction paves the way for a congenial relationship between the patient and the pharmacist, giving the later visual and tangible cues to his patient's health problems, such as adverse reactions to medications, lethargy, alopecia, extrapyramidal symptoms, jaundice, and disorientation. The pharmacist's observations can help detect medication-related problems early, thus dodging emergency room visits, hospitalizations, and medication mishaps.

Medication Therapy Management includes a spate of services- analytical, consultative, educational and monitoring. These are provided by pharmacists who help consumers make the best use of medications through improving consumer understanding of medication therapy, increasing consumer adherence to medications, controlling costs, and preventing drug complications, conflicts, and interactions. This side of pharmacy mainly dwells upon cognitive services and removes the pharmacist from a solely distributive function.

MTM was first proposed by the ex-president of the American Public Health Association (APHA), Ronald Jordan. According to the Medicare Modernization Act of 2003 (MMA 2003), coined by the Congress, each Medicare Part D plan sponsor should offer a Medication Therapy Management program to targeted beneficiaries beginning in 2006. Targeted beneficiaries include members, with multiple chronic conditions, who consume multiple Part D drugs. They are, most likely, subject to annual costs for covered Part D drugs that exceed a predetermined level. Other patients can avail of MTM too. Infact, many plans have deployed MTM programs to prevent medication-related complications and associated health care costs by reaching out to their full population of members. MTM may also apply to populations outside of Medicare, including patients aged less than 65.

a)Based on all the relevant clinical information available to the pharmacist, he thoroughly assesses his patient's health, including his known allergies, laboratory measurements, and his current and past medical conditions and diseases.

b) He also takes into account his patient’s cultural issues, preferences, education level, language barriers, and other characteristics of his communication abilities, which may jeopardize outcomes,

c) The pharmacist, then, interviews his patient or his caregiver to identify symptoms that are triggered by adverse events caused by any of the current medications.

d) He, next, closely examines the prescriptions and over-the-counter medications, consumed or used by the patient in order to detect, solve, and prevent medication-related problems. He also takes into consideration:

I) The clinical appropriateness of each medication taken by the patient

II) The appropriateness of the dose and dosing regimen of each medication, including consideration of indications, contraindications, potential adverse effects, and potential problems with concomitant medications

III) Therapeutic duplication or other unnecessary medications

IV) Adherence to medication therapy (persistence and compliance)

V) Untreated diseases or conditions

VI) Medication cost considerations

VII) Timely monitoring and feedback of results

e) The pharmacist, then, provides his patient with thorough education and training on the appropriate use of medications and monitoring devices, the importance of medication adherence, and understanding treatment goals. He is helped and urged to take his medications properly, regularly and on time.

f) He, next, frames a medication treatment plan.

h) Based on the treatment plan, the pharmacist selects, initiates and modifies or administers a medication treatment

i) He closely monitors and evaluates his patient's response to medication, in terms of its safety and effectiveness. He also records all the services that he has delivered to the patient, so far. He feeds the other healthcare providers with relevant and important information about his patient.

j) Based on the factual and medical evidence gathered, the pharmacist doles out a Patient Medication Record.

k) He, finally, performs a Comprehensive Medication Review.

Thus, Medication Therapy Management includes a spate of services- analytical, consultative, educational and monitoring. These are mainly provided by trained and licensed pharmacists who help consumers make the best use of medications through improving consumer understanding and awareness of medication therapy, increasing consumer adherence to medications, controlling costs, and preventing drug complications, conflicts, and interactions. This side of pharmacy mainly dwells upon cognitive services and removes the pharmacist from a solely distributive function.

A Patient Medication Record (PMR) is a portable inventory or record of all prescription and over-the-counter (OTC) medications, certain dietary supplements and natural (herbal) products that a patient has been consuming and availing of. A typical PMR includes the name of the concerned patient or identifier, dose(s) and strengths of medicines, how they were taken, when they were prescribed, their intended use, directions for use and anyother important discretionary information.

 The PMR comes in handy, when a patient is looking at medication self-management. It should be taken to all doctor, dentist, and pharmacist visits as well as hospitalizations, so that all the healthcare providers of a particular patient knows what he is taking and can, thus, enhance the continuity of his care. A patient has to produce the PMR to all his health care providers, at all appointments, to ensure that each practitioner is well acquainted with his current medication regimen.

To maintain the uniformity and continuity of information, the PMR should be updated, every time the patient receives a new medication or has a current medication discontinued or has a change in instruction or begins using a new nonprescription medication and dietary supplement, or has any other relevant changes to his medication regimen.  Ideally, the pharmacist should be an equal partaker in this process. Flexible for local variations, PMR can be generated electronically or manually.

A Comprehensive Medication Review (CMR) in Medication Therapy Management shines light on the following:

• Why each medicine is being taken and whether any medicines are potentially unnecessary

• Whether each medicine is effective and efficient

• Whether each medicine could be causing side effects, aggravating the health conditions of patients, or interacting with other medicines

• Whether a medicine regimen can be mellowed down--fewer pills, perhaps, or a more convenient dosing schedule

• Whether a medicine regimen can be made more affordable or cost-effective

• Whether the patient perfectly understands what the medicines are for, and how to take them to make the best out them

Medication Therapy Management services, mainly obtained through individual pharmacies, private insurances, and federally funded programs, are conducted between the patient or caregiver and the pharmacist, preferably in face-to-face interaction. This interaction paves the way for a congenial relationship between the patient and the pharmacist, giving the later visual and tangible cues to his patient's health problems, such as adverse reactions to medications, lethargy, alopecia, extrapyramidal symptoms, jaundice, and disorientation. The pharmacist's observations can help detect medication-related problems early, thus dodging emergency room visits, hospitalizations, and medication mishaps.

Since a patient or a care-giver stays in direct touch with his pharmacist, the human-touch is always there, which allows the former to open up fearlessly and spontaneously to the later. Candid communication makes it easier for trained and qualified pharmacists to extract more accurate medication-related information from patients.

Active involvement of patients is at the heart of pharmacist-issued MTMs. It empowers them to understand their own care and medication better.

This has, not only, improved the quality of patient care and outcomes considerably(disease/symptom improvement/resolution, improved adherence, saved lives), but, has also, enhanced patience safety, combating medical-related adverse events.

Evidence shows that pharmacist-issued MTMs have led to the prescription of more appropriate medications. There has been a significant decrease in the use of high risk medications.

It has also resulted in the potential reduction of unscheduled physician visits, emergency room visits, hospital days, and overall costs. This means patients, availing of pharmacist-issued MTM services, can save more and therefore, enjoy better and more productive lives than the others.

Medication Therapy Management services, mainly obtained through individual pharmacies, private insurances, and federally funded programs, are conducted between the patient or caregiver and the pharmacist, preferably in face-to-face interaction. This interaction paves the way for a congenial relationship between the patient and the pharmacist, giving the later visual and tangible cues to his patient's health problems, such as adverse reactions to medications, lethargy, alopecia, extrapyramidal symptoms, jaundice, and disorientation. The pharmacist's observations can help detect medication-related problems early, thus dodging emergency room visits, hospitalizations, and medication mishaps. Once providers of MTM services acquaint themselves with the specific plan requirements and are supplied with qualifying patients, they will need to contact patients for a Medication Therapy Management counseling session. When the session is fixed, the pharmaceutical and counseling sessions go hand in hand. A private area, in the pharmacy, thus, becomes indispensable to protect the privacy and concentrate more on the patient. Since a patient or a care-giver stays in direct touch with his pharmacist, the human-touch is always there, which allows the former to open up fearlessly and spontaneously to the later. Candid communication makes it easier for trained and qualified pharmacists to extract more accurate medication-related information from patients. Medication Therapy Management empowers them to understand their own care and medication better because active involvement is at the heart of these services

This has, not only, improved the quality of patient care and outcomes considerably(disease/symptom improvement/resolution, improved adherence, saved lives), but, has also, enhanced patience safety, combating medical-related adverse events.

In terms of Medication Therapy Management service and its eligible beneficiaries, the most inevitable question that crops up, is whether the plan offers services to all of its enrollees or whether there are specific groups of targeted recipients, such as those having particular diseases or chronic conditions or those taking particular medications or having a minimum threshold level of spending for drugs. Health plans tend to focus on their enrollee population as a whole, while clinical programs tend to focus on individual patients.

Medicare Medication Therapy Management services, according to the Medicare Modernization Act, have to be extended to "targeted beneficiaries"-patients who (I) have multiple chronic diseases, (II) are taking multiple covered part D drugs and (III) are identified as likely to incur annual costs that exceed $4,000.

MTM services have to be dished out to these targeted beneficiaries, according to the plan sponsors, but other patients can avail of these services too. MTM programs also have the potential to reach out to the full population of their members. Infact, these days, Medication Therapy Management services may also apply to populations outside of Medicare, including patients less than 65 years of age.

MTM services can be rendered by any licensed and qualified pharmacists.  However, there are distinct and practical differences between a pharmacist’s way of dispensing and Medication Therapy Management functions since the former depends upon  the volume of prescriptions being filled, whereas the later is more patient oriented, mainly contemplating upon improved health outcomes, avoidance of medication-related problems for an individual patient, or both.

To make MTM services easily accessible to the beneficiaries, the pharmacists partner with both patients and prescribers to sort out medication-related complications. According to guidance of the Centers for Medicare and Medicaid Services (CMS), each eligible patient should be covered for an annual Comprehensive Medication Review (CMR), which will include an interactive and person-to-person consultation. In addition to it, quarterly targeted medication reviews will also be doled out to them. Suitable Medication Therapy Management services will be made available on an ad hoc basis, if medication-related complications are detected.

Pharmacists are also responsible for documenting specific details of the services delivered, including detected drug therapy problems, intervention results, severity ratings, and progress notes. This information is utilized by program sponsors to track down individual patient outcomes, monitor return-on-investment and fulfill CMS reporting requirements.

The Medication Therapy Management service model requires the patient to receive an annual comprehensive medication therapy review, in addition to medication therapy reviews, tailored to the patient’s needs. The pharmacist may monitor the patient’s progress, on a regular basis, in case new or recurring medication-related problems crop up. The total number of reviews required to successfully manage a patient’s therapy will be ultimately determined by the complexity of the individual patient’s medication-related problems.

The coverage for MTM services may be affected by the extent of health plan benefits or other limitations, imposed by the patient’s payer; however, this would not prevent additional services provided by the pharmacist for which the patient pays on a fee-for-service basis.

To perform the most comprehensive assessment of a patient, personal interaction between a healthcare professional and a patient is indispensable. A face-to-face interaction helps the pharmacist identify signs of patient’s health problems, thus enhancing the patient–pharmacist relationship and at the same time, minimizing inappropriate medication use, emergency department visits, and hospitalizations.

MTM services also include alternative methods of interaction with the patient over the phone and it mainly comes into play for those home-bound patients or patients in pharmacy practice settings, in which the pharmacist serves in a consultative role on the healthcare team.

All Medication Therapy Management services, provided via face-to-face interaction or by alternative means, are intended to strengthen the patient–pharmacist relationship.

Documentation is an indispensable part of patient-care, especially pertaining to MTM services because the pharmacist can always fall back upon his documents, whenever he evaluates the progress of his patient. It can also come in handy, during billing. A pharmacist, through his documentation, remains accountable to his patient as well as organization. After documenting all his MTM services in a disciplined manner, a pharmacist arranges a follow-up visit with the patient or his caregiver.

Consistent and professional documentation facilitates information sharing among various members of the health care team.  Documents related to MTM services usually disclose the following information:

·         Patient’s history and demographics

·         Known allergies, diseases, or conditions

·         A record of all medications, including prescription, nonprescription, herbal, and other dietary supplement products, given to the patient

·         Assessment and evaluation of medication therapy problems and future plans for resolution

·         Therapeutic monitoring performed

·         Interventions or referrals made

·         Education received

·         Schedule and plan for follow-up appointment

·         Amount of time spent with patient

·         Feedback to providers or patients

Medication Therapy Management in community pharmacy endeavors to enhance care through improved communication and collaboration between the patient and provider, optimizing targeted therapeutic outcomes and medication use. Ideally, a pharmacist metes out MTM services to a patient, whom he is familiar with. The patient usually receives the service in a private or semi-private area of the pharmacy, far from the prying eyes, where his prescription has been filled in. During an MTM session, a pharmacist pays undivided attention to his patient, lending an ear to the medication related problems that he encounters on a regular basis. A patient can either book an appointment with his pharmacist or can even visit him, unpremeditated. A pharmacist can only begin his MTM sessions, once he has spotted complex medication therapy complications via prescription dispensing process.

A typical community pharmacy model consists of an annual comprehensive medication therapy review, doled out by a pharmacist to his patient. The pharmacist can conduct additional MTM sessions with his patient throughout the year, addressing and redressing the concerns and issues, related to his medication. The number of visits that a patient has to pay to his pharmacist entirely depends upon the seriousness of his medication management problems or his health plan or both. A patient is generally entitled to four visits per year but, he can avail of extra visits, if he is compelled by his health condition. During the same year, any significant event such as a hospital or emergency room discharge can mandate an additional comprehensive review.

An MTM, in a community pharmacy setting, typically contains five components including Medication Therapy Review, a Personal Medication Record, a Medication Action Plan, Intervention and Referral Services, Documentation and Follow-up.

A pharmacist conducts a Medication Therapy Review/MTR in close partnership with his patient or caregiver through the medium of several face-to-face interactive sessions. These sessions give the pharmacist an insight into the patient’s health problems, including adverse reactions to medications, lethargy, alopecia and extrapyramidal symptoms. The observations significantly help in the earlier detection of medication related problems, staving off emergency room visits, hospitalizations and any other medical mishaps. An MTR can be targeted or comprehensive, depending upon the patient’s unique medication problems. In a comprehensive MTR, the pharmacist is made thoroughly familiar with the current medications of his patient, including his prescription and non-prescription drugs, herbal products and other dietary supplements. The pharmacist, after gauging the appropriateness of the medication therapy, educates the patient, in collaboration with his caregiver and prescriber, on how to combat diseases through effective medication and disease management.

The patient, at the end of an MTM session, receives a Medication Action Plan that is created in consultation with his pharmacist, physician and other health care providers. The wide use of a MAP, which is essentially a patient-centric document, not only, guarantees improved medication self-management, but also, uniformity in information sharing among members of the health care team.

The pharmacist, besides providing consultative services, is also required to intervene on behalf of the patient, solving his medication related concerns. If the patient’s need is beyond the scope of an MTM service provider, he can even be referred to other health care providers with special qualifications.

Documentation, which is inextricably associated with patient care, helps pharmacists consistently and professionally document and record MTM services in a manner that is central to the evaluation of patient progress, billing purposes and future reference, while facilitating information sharing among various health care professionals. Each MTM session culminates into a follow-up appointment with the patient or his caregiver, in accordance with the specific requirements of patients, thereby improving the continuity of care.

All patients, who take prescription drugs, vastly benefit from the MTM services as they enhance the patients’ understanding of medications and their compliance with drug regimens but priority will be given to those, who have chronic conditions and need immediate attention and help.

Overmedication and consequent adverse drug events have reached epidemic proportions in the US.  It is a daunting, entrenched and often neglected issue in the modern health care. Improper medication can wreak havoc amongst elderly population and continue to escalate their health care problems. Researchers have confirmed that if a patient doggedly sticks around with her medication regimen, she can mellow, if not completely obliterate, the side-effects that contribute to her downward health spiral. There is evidently a distinct co-relation between old age and adverse drug events.

As people get older, they tend to take more medicines for multiple, chronic conditions. Consequently, they are more susceptible to side-effects than younger patients. Research confirms that older adults are mostly vulnerable to diseases such as Alzheimer's Disease, Depression, Arthritis, Osteoporosis, High Blood Pressure, Heart Problems, Cancer, Prostrate Enlargement and hence, are swamped by a large number of prescription drugs that they have to consume on a routine basis. It is, therefore, critical for senior patients to assure that none of their medications are dangerously interacting or duplicating or nullifying one another. This is where Medication Therapy Management comes into play.  In MTM, a licensed pharmacist works in conjunction with the patient’s physician(s), crafting an extensive, clinically appropriate and evidence-based medication therapy program that removes, adds and even, substitutes medications.

One of the primary goals of Medicare Part D is to contain the cost of prescription drugs for Medicare beneficiaries and significantly improve their accessibility to better health care facilities. But speculations are running wild as to the fact that pharmaceutical use and therefore, the potential risks that it poses, will spiral out of control, if consumers are granted uninhibited access to prescription drugs. New drugs, further added to the complex and sensitive treatment regimens of older patients, baffle them, making it infinitely difficult for them to stick to their medications. Without proper guidance, moral support and family back-ups, it verges on being impossible for older adults to stay committed to their rigorous medication therapies. Senior Americans, no longer in the workforce, usually suffer from poverty, which is one of the typical barriers to adherence to proper medications. Some older adults may have lost social contact over the time. Loneliness and depression can impel them to skip doses, eventually contributing to medication mismanagement.

Senior patients, covered by Medicare, now, have unrestrained access to MTM services; thanks to the new, tougher Medicare rules. Even privately-owned insurance businesses abide by these rules, offering drug coverage to members who annually incur a cost of $3000 for their medications. In Medication Therapy Management, a licensed pharmacist or health care professional, in partnership with the patient’s physician, is required to offer verbal education and training to the patient, enabling him to achieve optimal therapeutic outcomes. Over the recent years, due to adverse drug events, the world has witnessed a dramatic rise in the mortality and morbidity risks amongst older Americans. However, adverse drug reactions, sporadic amongst patients aged over 60, can be kept well under control through disciplined, consistent and timely medication management. MTM successfully helps older adults adhere to their drug-regimens and churn out positive and economical results from their drug therapies. The program routinely keeps a close eye on the side-effects, triggered by particular medications and recommends relevant changes, as and when required.

Communication gap with prescribers spells disaster on patients, who eventually wind up having the wrong medication doses. Cognitive decline or any form of disability can further exacerbate their problems, contributing to adverse drug events and subsequent, hospitalizations, morbidity and even, death. Since ageing and infirm bodies take longer to soundly process their bodies, any drug misappropriation can be lethal. Reports reveal that every year, USA splurges over $200 billion to rectify medication related discrepancies. Patients either fail to take the exact doses, as prescribed by their physicians or are administered medicines in their wrong doses. Some patients are prescribed medicines that dangerously interact with each other and cause untimely deaths. Woes of elderly patients are further aggravated by pharmaceuticals like warfarin that carry a high degree of risk.

Old age and decrepitude, coupled with increased susceptibility to multiple chronic diseases, pave the way for medication related problems elderly people. According to the reports of the US Health and Human Services Department, almost 55% of the elderly population fails to adhere to their rigorous drug regimens and 28% of hospital readmissions amongst people over 65 can be solely attributed to medication related problems.  For patients, suffering from dementia and Alzheimer’s disease, MTM is a welcome relief, as these diseases require rigorous and consistent compliance with medications. Ideally, all Medicare Part D plans should craft MTM programs that seamlessly meet the ends of patients, afflicted by Alzheimer’s disease and dementia but, unfortunately, the eligibility criteria, modes of delivery and enrollment models of most plans miserably fail to cater to the needs of such patients. It’s high time seniors with dementia and Alzheimer’s disease get a fair chance in life through MTM services that aim at cutting down costs via patient-education and low-cost, alternative therapeutic programs.

MTM services can be direct, face-to-face. They can even be delivered via mailed educational materials and telephonic conversations. Consistent and systematic adherence to drug-regimens and cost optimization are the two main desired outcomes of MTM. A clinical pharmacist, before doling out MTM services, will thoroughly review the drug formulary of the concerned patient for potential adverse drug reactions. He will also gauge the medication habits of the patient before he takes the plunge and optimizes his therapeutic outcomes. However, the popularity of MTM service, at the end of the day, boils down to the characteristics of the older patient and how easily he can access it. It’s evident that a patient with complex medication regimen will more likely opt for MTM services. However, he has to be aware of the benefits that he can reap from such a service.