Learning Objectives

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2. Learning Objectives Discuss the current landscape of medication therapy management services in pharmacy practice Describe a medication therapy service model for use in pharmacy practice Discuss strategies for pharmacists to collaborate as patients are transitioned between care settings

3. Medication Therapy Management Services: Pharmacy Consensus Definition Three inseparable elements: Primary Definition: services that optimize therapeutic outcomes for individual patients… Professional Service Components: MTM encompasses a broad range of activities and responsibilities within a pharmacist’s scope of practice… Program Requirements: MTM Programs shall include (core criteria for an MTM program)…

4. MTM Activities Performing patient health assessments and comprehensive medication review Formulating a medication treatment plan Selecting, initiating, modifying, or administering medication therapy Monitoring and evaluating the patient’s response to therapy

5. MTM Activities – continued Documenting the care delivered and communicating information to other providers Providing verbal education and training Providing information designed to enhance patient adherence with therapeutic regimens Coordinating and integrating MTM services within the broader health care-management services being provided to the patient

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7. Medicare Part D Only a subset of all patients who may benefit from MTM services Legislation requires that Part D plans must have an MTM program that may be provided by a pharmacist Currently targeted beneficiaries must have: - Multiple chronic conditions - Multiple medications High drug costs (>$4,000 in 2009) CMS call letter for Part D Plans - 2010 Changes that may expand patients who are eligible Potential increased opportunities for pharmacists These are mandates for MTMS under Medicare Part D as defined by the law. MTMS could potentially be provided by other health care professionals. Pharmacists are the only professionals who are specifically named as a possible provider of MTM Services in the bill. Congress has limited Medicare eligible patients to those with chronic, high-cost diseases such as diabetes, hypertension, hyperlipidemia, congestive heart failure, and chronic lung diseases. Eligibility of patients is still unclear considering some patients may have multiple chronic conditions and take multiple generics drugs that place the patient below the spend criteria. This is an issue that APhA has raised concerning patient eligibility for MTMS. Another issue is the definition of the term ‘multiple’ chronic conditions. APhA believes that ‘multiple’ is 2 or more. Medicare Advantage plans may have a greater interest in more robust MTM – at risk for health and prescriptions These are mandates for MTMS under Medicare Part D as defined by the law. MTMS could potentially be provided by other health care professionals. Pharmacists are the only professionals who are specifically named as a possible provider of MTM Services in the bill. Congress has limited Medicare eligible patients to those with chronic, high-cost diseases such as diabetes, hypertension, hyperlipidemia, congestive heart failure, and chronic lung diseases. Eligibility of patients is still unclear considering some patients may have multiple chronic conditions and take multiple generics drugs that place the patient below the spend criteria. This is an issue that APhA has raised concerning patient eligibility for MTMS. Another issue is the definition of the term ‘multiple’ chronic conditions. APhA believes that ‘multiple’ is 2 or more. Medicare Advantage plans may have a greater interest in more robust MTM – at risk for health and prescriptions

8. Scope of MTM Delivery in Pharmacy Practice Public Sector: Medicare Part D (PDP & MA-PDs) Humana, MemberHealth (CCRX/Mirixa), Outcomes Managed-care based services Public Sector: State-based Medicaid Programs Public Sector: Community Health Centers, VA, IHS Private Sector: Self-insured employer groups  or managed care/health plans Asheville project/APhA Foundation projects Outcomes Pharmaceutical Health Care Kaiser– Clinics Hospitals – medication reconciliation

9. 2009 APhA MTM Digest An environmental scan of the current state of MTM Valuable information on the value of MTM and the impact of these services on health care 2nd Annual publication to track the environmental landscape of MTM in pharmacy practice An environmental scan of the current state of MTM Valuable information on the value of MTM and the impact of these services on health care 2nd Annual publication to track the environmental landscape of MTM in pharmacy practice

10. Who is receiving these services in the pharmacy health care sector? Broad delivery of services across all patient care areas Medication-related problems occur in all care settings and cause significant impact on patient care and outcomes Not limited to ambulatory care or community pharmacyWho is receiving these services in the pharmacy health care sector? Broad delivery of services across all patient care areas Medication-related problems occur in all care settings and cause significant impact on patient care and outcomes Not limited to ambulatory care or community pharmacy

11. Why are Providers Offering MTM Services Key factors affecting decision to implement MTM services: Patient health needs Responsibility as a health care provider Recognized a need to improve health care quality Contribution to health care team Key components of value to providers’ organizations resulting from MTM services Increased quality of care/outcomes, patient satisfaction, and professional satisfaction. Providers considered revenue to be of less value. Changed most important to key, and for the second bullet condensed the bullets into a statement. Providers considered revenue to be of less value. Changed most important to key, and for the second bullet condensed the bullets into a statement.

12. What is limiting the expansion of MTM in pharmacy practice? Neither rated any challenges/barriers as “very significant.” Non-providers of MTM services generally felt the barriers were more significant than providers. Order of barriers in 2008 was similar to that reported in 2007 by non-providers of MTM.What is limiting the expansion of MTM in pharmacy practice? Neither rated any challenges/barriers as “very significant.” Non-providers of MTM services generally felt the barriers were more significant than providers. Order of barriers in 2008 was similar to that reported in 2007 by non-providers of MTM.

13. Who is eligible for these services today? -patients in all types of insurance/managed care programs, people with traditional, HMO and health savings type accounts Who is eligible for these services today? -patients in all types of insurance/managed care programs, people with traditional, HMO and health savings type accounts

15. Sample Outcomes Used to Assess Impact of MTM by Payers Medication Related Costs/Total Costs Medication Costs overall (82%) Safety Issues Drug Interactions (71%) Patient Focused Improved Compliance/Adherence (75%) Quality of Care Issues Treatment changed to align with guidelines (64%)

16. Impact of MTM – Payers Improvements Reported: Inappropriate Medication Use in the Elderly (36%) HEDIS (29%) Patient Quality of Life/Satisfaction Surveys (25%) ROI *: Among 5 respondents, ROI ranged from >1:1 to 6:1 Median ROI was 3.5:1 Median ROI in 2007 was 3.1:1 *very limited number of respondents

18. Sound Medication Therapy Management Programs – v2.0 AMCP: Guide health plan designers in developing sound, effective MTM programs Patient-centered approach Interdisciplinary approach Communication Population and patient approach Flexibility in application Evidence-based medicine Promotion of MTM services Version 2.0 – validation process Supported by national pharmacy organizations Framework for MTM Programs – provides guidance for plans on the development and implementation of MTM programs by NCQA Framework for MTM Programs – provides guidance for plans on the development and implementation of MTM programs by NCQA

19. A framework for the consistent delivery of MTM services by pharmacists Result of collaboration of APhA & NACDS Foundation Developed with an advisory panel from diverse care settings Involvement, input and support from 8 other national pharmacy organizations How do we standardize service delivery to meet the expectations of payers, patients, other providers and all other stakeholders? How do we standardize service delivery to meet the expectations of payers, patients, other providers and all other stakeholders?

20. MTM in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 Maintains the 5 MTM Core Elements presented in V1.0 Expands framework of MTM services to all patient care settings where patients can be actively involved in managing their medications Focus on patients’ empowerment to manage their medications Stresses pharmacist collaboration with physicians and other providers Emphasizes following patient during transitions from one care setting to another (hospital to home)

21. Goals of MTM Core Elements Version 2.0 Improve collaboration among pharmacists, physicians, and other health care professionals Enhance communication between patients and their health care team Empower patients to optimize medication use for improved health care outcomes

22. MTM Core Elements Version 2.0 – 5 Core Elements Medication Therapy Review (MTR) Personal Medication Review (PMR) Medication-Related Action Plan (MAP) Intervention and/or referral Documentation and follow-up The PMR contains information to assist the patient in his or her overall medication therapy self-management. This comprehensive list can be completed either by the patient with the assistance of the pharmacist or by the pharmacist. Whether the pharmacist provides the PMR manually or electronically, the information should be written at a literacy level that is appropriate for and easily understood by the patient. The PMR template in Version 2.0 has been reviewed by a health literacy consultant and is designed to be comprehended by individuals utilizing it. The patient MAP includes only items that the patient can act on that are within the pharmacist’s scope of practice or that have been agreed to by relevant members of the health care team. The MAP should not include outstanding action items that still require physician or other health care professional review or approval. The patient receives an individualized MAP for use in medication self-management. The patient can use the MAP as a simple guide to track his or her progress. The MAP reinforces a sense of patient empowerment and encourages the patient’s active participation in his or her medication-adherence behavior and overall MTM. Documentation is as essential element of the MTM service model. Proper documentation of MTM services may serve several purposes: Facilitating communication between the pharmacist and the patient’s other health care professionals Improving patient care and outcomes Enhancing the continuity of patient care among professionals and care settings Ensuring compliance with laws and regulations for the maintenance of patient records Protecting against professional liability Capturing services provided for justification of billing or reimbursement Demonstrating the value of pharmacist-provided MTM services Demonstrating clinical, economic, and humanistic outcomes The PMR contains information to assist the patient in his or her overall medication therapy self-management. This comprehensive list can be completed either by the patient with the assistance of the pharmacist or by the pharmacist. Whether the pharmacist provides the PMR manually or electronically, the information should be written at a literacy level that is appropriate for and easily understood by the patient. The PMR template in Version 2.0 has been reviewed by a health literacy consultant and is designed to be comprehended by individuals utilizing it. The patient MAP includes only items that the patient can act on that are within the pharmacist’s scope of practice or that have been agreed to by relevant members of the health care team. The MAP should not include outstanding action items that still require physician or other health care professional review or approval. The patient receives an individualized MAP for use in medication self-management. The patient can use the MAP as a simple guide to track his or her progress. The MAP reinforces a sense of patient empowerment and encourages the patient’s active participation in his or her medication-adherence behavior and overall MTM. Documentation is as essential element of the MTM service model. Proper documentation of MTM services may serve several purposes: Facilitating communication between the pharmacist and the patient’s other health care professionals Improving patient care and outcomes Enhancing the continuity of patient care among professionals and care settings Ensuring compliance with laws and regulations for the maintenance of patient records Protecting against professional liability Capturing services provided for justification of billing or reimbursement Demonstrating the value of pharmacist-provided MTM services Demonstrating clinical, economic, and humanistic outcomes

23. “Heart” of the Core Elements Service Model Types Annual Comprehensive Medication Therapy Review (MTR) designed to improve patients’ self-management of medications Targeted Medication Therapy Reviews to address new or ongoing medication-related problems MTRs are conducted between the patient and the pharmacist. They are designed to improve patients’ knowledge of their medications, address problems or concerns that patients may have, and empower patients to self-manage their medications and their health condition(s). Pharmacist-provided MTR and consultation in various settings has resulted in reductions in physician visits, emergency department visits, hospital days, and overall health care costs. Pharmacists have been shown to obtain accurate and efficient medication-related information from patients. MTRs are conducted between the patient and the pharmacist. They are designed to improve patients’ knowledge of their medications, address problems or concerns that patients may have, and empower patients to self-manage their medications and their health condition(s). Pharmacist-provided MTR and consultation in various settings has resulted in reductions in physician visits, emergency department visits, hospital days, and overall health care costs. Pharmacists have been shown to obtain accurate and efficient medication-related information from patients.

24. What What

25. Global Trends Driving MTM Services Increasing focus on the quality of healthcare Escalating healthcare/medical costs including medications Increasing focus on the magnitude and scope of drug-related problems Recognition of pharmacists for medication expertise Healthcare practitioner shortages Changing dispensing model - automation Electronic health record/e-prescribing Pharmacy profession initiatives to change the practice model Joint Commission of Pharmacy Practitioners (JCPP) Project Destiny (APhA, NACDS, NCPA)

26. Transitions of Care Between Care Settings Critical time for care coordination among all providers Medication reconciliation critical to preventing, identifying and resolving medication-related problems Opportunity for pharmacists to improve care for patients MTM Core Elements Service Model offers a framework for care coordination

27. MTM Core Elements & Medication Reconciliation MTM Core Elements Service Model stresses collaboration among providers and importance of transitions of care PMR & MAP can be used as a basis for medication reconciliation Targeted medication review can be utilized to prevent, identify & resolve medication related problems Documentation and follow-up critical Appropriate interventions and/or referral to other providers essential Documentation and follow-up critical to ensure that accurate information is available for other care providers and that medication-related problems are addressed/resolved Appropriate interventions and/or referral to other providers addresses medication-related problems and improves careDocumentation and follow-up critical to ensure that accurate information is available for other care providers and that medication-related problems are addressed/resolved Appropriate interventions and/or referral to other providers addresses medication-related problems and improves care

28. Significant outreach to educate patients and health care providers about the value of MTM services Risk stratification models to determine patients who could benefit most from MTM services A consistent, efficient format for documentation and billing MTM services Outcomes measures to measure the impact of MTM services Developing a consistent process of care to facilitate transitions of care and quality Addressing the challenges to making this happen:Addressing the challenges to making this happen:

29. APhA MTM Resources MTM Definition – 11 national pharmacy organizations APhA-NACDS Model - Core Elements of an MTM Service Lewin Report: MTM Services: A Critical Review APhA-ASCP MTM Certificate Training Program APhA-NACDS CD-ROM MTM Pharmacist Training Program APhA MTM Self-Assessment APhA-NACDS MTM Implementation Manual APhA MTM Central – www.pharmacist.com/mtm

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