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Considerations for Successful Medication Therapy Management Training
Medication therapy management (MTM) is defined as a distinct service or group of services that optimize therapeutic outcomes for individual patients.1,2 Pharmacists across all patient care practice sites perform MTM, and although the service(s) may be different in each setting, pharmacists are all working to improve patient care and outcomes through the MTM they provide.
A distinct set of services, including targeted interventions and comprehensive medication review, are provided through the Medicare Part D prescription benefit, as outlined in the Medicare Modernization Act.3 These services are often facilitated through specific platforms, including OutcomesMTM and Mirixa. Community pharmacists across the United States are providing comprehensive medication reviews and targeted interventions through these platforms.
All licensed pharmacists in the community setting are accustomed to providing certain types of MTM.2,4 We identify medication-related problems, educate patients on medication use and disease states, and recommend and administer immunizations on a daily basis. Often, however, these services are not well-documented, are linked with medication dispensing, and pharmacists are not compensated. Therefore, when implementing MTM facilitated through different platforms, providing training for pharmacists is important.
What It Takes to Be a Successful MTM Provider
Comprehensive medication reviews require pharmacists to collect a medical and medication history, assess the appropriateness of each medication based on the patient’s current disease states and the other medications the patient is taking, and to identify missing medications according to evidence-based medicine. Pharmacists must also select and deliver education the patient may need.
After collecting and assessing this patient-related data, the pharmacist and patient create a medication action plan, which includes the most pertinent changes the pharmacist, patient, and/or other healthcare provider may need to make. Finally, the pharmacist must communicate the plan to the patient and other healthcare providers and follow up as needed.
A successful MTM provider must have a working knowledge of the current guidelines for major disease states in the United States, including hypertension, diabetes, hyperlipidemia, and chronic lung disease. Pharmacists must also be abreast of medications considered high risk in elderly patients. Identification of medication-related problems, including drug interactions, inappropriate doses, therapy duplication, and missing medications, is also needed for a successful MTM. This knowledge is essential to community pharmacy practice, and is assessed in an ongoing fashion by each individual pharmacist, and kept up-to-date through continuing education and professional development activities.
Pharmacists must also be able to identify medication-related problems that are related to other patient-specific factors, including patient misconceptions and beliefs. Nonadherence to medications may be associated with patients’ lack of knowledge regarding how, why, or when to use their medication, medication administration issues, forgetfulness, adverse reactions, or misconceptions that may lead patients not to use a medication properly.
Other skills essential to providing quality MTM include motivational interviewing, a method of collaborating with patients that addresses ambivalence about change, and, of course, proficiency operating the platform through which MTM is facilitated and documented.5,6
Facets of MTM Training
Ideally, MTM training includes classroom-style teaching, hands-on training, and follow-up training after service implementation.
Classroom training should consist of the best practices for providing comprehensive medication reviews and targeted interventions, requirements for proper documentation, and operation of the relevant platform(s). In addition, training should include pearls about how to best assess adherence and identify the true causes of nonadherence to medications that are unique to the programs implemented. For example, MTM provided through certain platforms allows pharmacists to identify patients’ nonadherence by accessing prescription insurance claims data to evaluate prescription fill timing, within and outside his or her own pharmacy.
Hands-on training should provide experience operating the platform and documenting MTM, with mock patients or examples. Follow-up training is something that I have experience with and believe to be essential. Pharmacists are accustomed to providing the patient care portion of these services in free form; it is the provision of the specific tasks laid out and required by each platform, and the documentation, that often limits pharmacists’ confidence performing MTM. Thus, follow-up training should be available to answer any questions, assess the pharmacist’s confidence, and eliminate any deficits.
The final component to MTM training is common to all patient care services; it is retraining and evaluation of pharmacists’ performance to assure the quality of the services being provided. Continuous quality improvement is imperative to provide valuable interventions that improve patient outcomes and optimize medication use; it is also an essential standard for community pharmacy practice accreditation.7
The core lesson I have learned by training approximately 40 pharmacists across 15 community pharmacies is not surprising: pharmacists already know how to perform the patient care included in MTM services. They need training to reinforce the patient care process, quality documentation, and communication strategies to impact change with patients.
- American Pharmacists Association; National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008;48:341-353.
- Bluml BM. Definition of medication therapy management: development of profession wide consensus. J Am Pharm Assoc (2003). 2005;45:566-572.
- Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Public law 108-173. 108th Congress. www.gpo.gov/fdsys/pkg/PLAW-108publ173/pdf/PLAW-108publ173.pdf. Accessed October 26, 2015.
- Council on Credentialing in Pharmacy; Albanese NP; Rouse MJ. Scope of contemporary pharmacy practice: roles, responsibilities, and functions of pharmacists and pharmacy technicians. J Am Pharm Assoc (2003). 2010;50:e35-e69.
- Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: Guilford Publications, Inc; 2002.
- Scales R, Miller J, Burden R. Why wrestle when you can dance? Optimizing outcomes with motivational interviewing. J Am Pharm Assoc (2003). 2003;43(Suppl 1):S46-S47.
- Center for Pharmacy Practice Accreditation. Community pharmacy practice standards. March 1, 2013. www.pharmacypracticeaccredit.org/system/rich/rich_files/rich_files/101/orig inal/cppa-community-pharmacy-practice-standards-with-interpretive-narrative-20-26-20glossary-20final-20062515.pdf. Published March 1, 2013. Accessed October 26, 2015.
What are the characteristics of a high-performing pharmacy?
A: The old metrics, including number of prescriptions dispensed and pharmacy department profitability, still apply and speak to the fact that the dispensing component should never go away. However, the following should now be factored into what defines a high-performing pharmacy: immunizations, delivery, med sync or other adherence-type program, medication therapy management, health screenings, point-of-care testing, disease management (ie, diabetes education), compounding, and pharmacogenomics (laboratory testing). At the end of the day, it will probably be the payer who decides what core characteristics are important to be in their network of “high-performing” pharmacies.
—John O. Beckner, RPh, Editorial Board member of Inside Patient Care, and Senior Director of Strategic Initiatives, National Community Pharmacists Association, Alexandria, VA.
A: Even though community pharmacies are being pushed toward clinical services, prescription dispensing is still the primary source of our revenue. The number of prescriptions dispensed is still very important for a pharmacy, but today those numbers mean something a bit different from in the past. With third-party payers pushing 90-days’ supply, expansion of Direct and Indirect Remuneration fees, and growing preferred network-driven reimbursement variability, high numbers of “prescriptions dispensed” don't always translate into high pharmacy profitability like they have in the past.
A pharmacy’s “quality and performance” are being measured by many different groups on individual scales that are most meaningful to those measuring them. For someone who is evaluating a pharmacy for sale, prescription volume is still the metric used to define performance; when looking at pharmacies’ performance with respect to clinical services and quality, other metrics are used. One health plan may use one set of quality metrics, whereas a pharmacy benefit manager might use a different set for the same pharmacy.
Today, many groups are trying to define exactly what a “high-performing retail pharmacy” really is. When we look at pharmacies, we look beyond quality measure metrics, such as proportion of days covered. We consider the suite of clinical services they offer. Do they have an adherence program? Do they offer immunizations? Do they work with local providers on transitions of care? Do they complete their assigned comprehensive medication reviews? Do they offer home delivery? I think by taking a broader approach in determining the quality of a pharmacy, we can better define who is a “high performer,” and who can use this information to create more patient care opportunities for their pharmacy practices.
—Tripp Logan, PharmD, Editorial Board member of Inside Patient Care, and Vice President, Logan & Seiler, Inc, Charleston, MO.
A: We are still fighting the issue that the number dispensed and reimbursement per script is what is being tracked by pharmacies and what decisions are based on. Although we continue to see additional clinical-based reimbursement, many are tying this to product versus creating a new revenue stream category: clinical services.
Pharmacies can look at clinical metrics that were started by the Centers for Medicare & Medicaid Services with the 5-star rating program. However, plans are moving to look at commercial, Medicaid, and exchange patients, and how the pharmacies are performing across line of business as well. We are seeing contracts that include pharmacies (or pharmacy organizations) having to reach specific quality metric goals to then decrease Direct and Indirect Remuneration rates, be included in a QBN (quality-based network), and P4P (pay for performance) inclusion. Pharmacies can look to adherence and HRM (high-risk meds) performance rates, and then gaps in care (eg, patients with diabetes on appropriate statin medications) and immunizations.
—Elliott M. Sogol, PhD, RPh, FAPhA, Editorial Board member of Inside Patient Care, and Vice President of Professional Relations, Pharmacy Quality Solutions, Inc, Springfield, VA.