Characterization of Actions Taken During the Delivery of Medication Therapy Management: A Time-and-Motion Approach

OBJECTIVES: To characterize actions performed by pharmacists and support staff during provision of medication therapy management (MTM) and to compare actions performed according to practice characteristics. METHODS: A purposeful sample of 7 MTM practices (2 call centers and 5 community practices) was identified and visited by investigators. Pharmacists and support staff were observed during their routine provision of MTM. Investigators characterized "major" (e.g., preparation for a comprehensive medication review) and "minor" (i.e., specific steps in overarching major action) actions with the use of a time-and-motion approach. RESULTS: A total of 32 major and 469 minor actions were observed. Practices were characterized as Later Maturity Level or Early Maturity Level on the basis of their self-reported MTM appointment volume, self-assessment of the extent of integration of chronic care model principles, and payer mix. Later Maturity Level practices were more likely to deliver follow-up medication therapy reviews and comprehensive medication reviews (CMRs) as opposed to targeted medication reviews (TMRs) and to receive physician referrals for MTM. Later Maturity Level practices were also more likely to use paid interns than pharmacy rotation students. CMR activities observed at Later Maturity Level practices lasted a median of 30.8 minutes versus 20.3 minutes for CMR activities at Early Maturity Level practices. Similarly, TMR activities observed at Later Maturity Level practices were longer: a median of 31.0 minutes versus 12.3 minutes. At Later Maturity Level practices, pharmacists spent a greater proportion of time providing patient education, while support staff spent a greater proportion of time on tasks such as capturing demographics and introducing or explaining MTM. CONCLUSION: MTM activities were longer at Later Maturity Level practices, and these practices were more likely to use paid pharmacy interns and to receive physician referrals for MTM. This work provides a foundation for future research

Factors associated with comprehensive medication review completion rates: A national survey of community pharmacists

Background Completion rates for medication therapy management (MTM) services have been lower than desired and the Centers for Medicare and Medicaid Services has added MTM comprehensive medication review (CMR) completion rates as a Part D plan star measure. Over half of plans utilize community pharmacists via contracts with MTM vendors. Objectives The primary objective of this survey study was to identify factors associated with the CMR completion rates of community pharmacies contracted with a national MTM vendor. Methodsl Representatives from 27,560 pharmacy locations contracted with a national MTM vendor were surveyed. The dependent variable of interest was the pharmacies' CMR completion rate. Independent variables included the pharmacy's progressiveness stratum and number of CMRs assigned by the MTM vendor during the time period, as well as self-reported data to characterize MTM facilitators, barriers, delivery strategies, staffing, selected items from a modified Assessment of Chronic Illness Care, and pharmacist/pharmacy demographics. Univariate negative binomial models were fit for each independent variable, and variables significant at p < 0.05 were entered into a multivariable model. Results Representatives from 3836 (13.9%) pharmacy locations responded; of these, 90.9% (n = 3486) responses were useable. The median CMR completion rate was 0.42. Variables remaining significant at p < 0.05 in the multivariable model included: progressiveness strata; pharmacy type; scores on the facilitators scale; responses to two potential barriers items; scores on the patient/caregiver delivery strategies sub-scale; providing MTM at multiple locations; reporting that the MTM vendor sending the survey link is the primary MTM vendor for which the respondent provides MTM; and the number of hours per week that the pharmacy is open. Conclusions Factors at the respondent (e.g., responses to facilitators scale) and pharmacy (e.g., pharmacy type) levels were associated with CMR completion rates. These findings could be used by MTM stakeholders to improve CMR completion rates

Evaluation of a “Meds-to-Beds” program on 30-day hospital readmissions

Background Effective programs for transitional care from hospital to home are needed to improve patient outcomes. Purpose To evaluate readmissions among patients who received a medication discharge program compared with control patients who did not receive the program. Methods This was a retrospective, observational cohort study during a 1-year period in a medium-sized Midwestern health system. The “meds-to-beds” program consisted of a pharmacist and/or technician delivering patient's medications to bedside prior to discharge. When indicated, the pharmacist provided medication counseling, reviewed discharge medications, and provided an updated medication list to patients. The intervention cohort was defined as all hospitalized patients eligible for and opting into the “meds-to-beds” program. The control cohort was defined as hospitalized patients eligible for the program who did not opt-in to receive it. Data were collected through both a retrospective chart review and an administrative claims data warehouse. The primary outcome was defined as any 30-day readmissions. Secondary outcomes were defined as any preventable 30-day readmissions using the Agency for Healthcare Research and Quality's potentially avoidable hospitalization for ambulatory care sensitive conditions classification. Multivariable logistic regression models examined the odds of 30-day readmissions between the intervention and control groups. Results Data were collected for 500 intervention and 1591 control patients. Both groups were similar with respect to age, gender, race, co-morbid conditions, and previous health care utilization. In the multivariable model, all-cause readmissions within 30 days were not significantly different between the intervention and control groups (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.42-1.07, P = .09). The most common preventable readmissions were for pneumonia (43.2%), heart failure (18.9%), and dehydration (16.2%). In the multivariable model, patients in the intervention group were less likely to be readmitted for a preventable cause within 30-days than patients in the control group (OR = 0.49; 95% CI: 0.28-0.89, P = .02). Conclusion This “meds-to-beds” program was not associated with a significant reduction in 30-day all-cause readmissions but was associated with a reduction in 30-day preventable hospital readmissions

Variation in Medication Therapy Management Delivery: Implications for Health Care Policy

BACKGROUND: Medication therapy management (MTM) program evaluations have revealed mixed outcomes, with some studies finding favorable outcomes and others finding no differences between patients who received MTM versus those who did not. One possible reason for outcomes variability is differences in delivery of MTM programs. The Chronic Care Model (CCM) provides a framework for how health care organizations can improve care for the chronically ill through 6 elements: organization of health care, delivery system design, clinical information systems, decision support, self-management, and linkages to community resources. OBJECTIVE: To apply the CCM to understand variation in MTM delivery and formulate policy recommendations. METHODS: This study used a mixed-methods descriptive analysis of MTM delivery. Investigators conducted visits to a purposeful sample of MTM practices to observe MTM and interview participants. The pharmacists and staff of these practices completed a modified Assessment of Chronic Illness Care (ACIC). Pairs of investigators analyzed interview transcripts to identify themes. Demographics and ACIC scores were summarized using descriptive statistics. After analysis, investigators discussed overarching themes and policy implications organized by CCM elements. RESULTS: Seven practices participated, and 87 participants were interviewed. Based on ACIC scores, MTM patient volume, and payer mix, practices were categorized as Early Maturity Level or Later Maturity Level. From the model, organization of health care themes included whether MTM was the practice’s core competence, belief/confidence in the MTM process, lack of formal rewards, and the influence of organizational goals and external environment. Delivery system design themes pertained to the extent that MTM processes were formalized. Clinical information systems themes were the extent to which systems were influenced by payers, efficiency strategies, and the accuracy and availability of information. In considering clinical decision support themes, alert design limitations and variation in user approaches to alerts based on experience were noted. We observed strong support for patient self-management; when present, barriers were attributed to the patient, MTM provider, or payer. Referral to community resources was minimal. Numerous policy implications were identified. CONCLUSIONS: Our research identified numerous ways by which MTM delivery varies, particularly by MTM practice maturity level. These findings provide evidence for several policy changes that could be considered to optimize MTM delivery, encourage alignment with the CCM, and promote practice maturation