Promoting Medication Therapy Management for At-Risk Populations Learning Community: Two-Year Summary

 

Introduction

The Medication Therapy Management Learning Community (MTM LC) explored inter-professional care in ambulatory care settings, with a particular focus on providers serving at-risk patients who experience socioeconomic complexity and have one or more chronic conditions. Frequently, these populations face challenges in understanding both how to take their medications appropriately and why it is important to be actively engaged in the self-management of their health conditions. The MTM LC addressed this challenge by incorporating pharmacists within the primary care team for medication therapy management and focused education.

The MTM LC built upon the work of the Managing Your Medications (MyRx) Medication Adherence Program, which consists of a bundle of MTM interventions that were independently tested using comparative effectiveness research (CER) methodology, namely: 1) medication reviews, 2) health education to improve health literacy, 3) health counseling using motivational interviewing, and 4) follow-up calls at scheduled intervals. The MTM LC adapted the original MyRx innovation to include protocols for integrating a pharmacist into the primary care team with pharmacist/primary care provider “huddles” to discuss pharmacist recommendations.

In collaboration with Texas Southern University College of Pharmacy and Health Sciences, three affiliated clinics of the Spring Branch Community Health Center (SBCHC) Federally Qualified Health Center (FQHC) in Houston, Texas served as pilot sites for implementing the adapted MyRx innovation. The MTM LC had national representation from fourteen primary care, clinical pharmacy, and academic sites working collaboratively to help pilot and monitor the program. In addition to providing technical assistance and support, MTM LC members learned from the MyRx experience and served as dissemination partners. 

Learning Community Aims

The MTM LC was guided by four primary aims:

  • Aim #1: Pilot test the team-based Medication Therapy Management innovation in three FQHC-affiliated community-based clinics.
  • Aim #2: Improve medication adherence among patients with uncontrolled diabetes treated in ambulatory care settings.
  • Aim #3: Prevent and reduce potential medication-related errors prior to discharge from clinic visits.
  • Aim #4: Leverage the expertise of LC members to enhance lessons learned about the pilot.

Activities and Accomplishments

During the past two years, the MTM LC held virtual monthly membership meetings, core team and leadership meetings, and two in-person meetings in Houston, Texas.  These meetings were designed to review the MyRx pilot program at SBCHC, identify strategies for improving the program, and discuss issues, trends, and challenges that relate to MTM. Some of the topics discussed among the MTM LC include:

  • MTM Motivational Interviewing
  • Cultural Competency
  • Staffing  MTM Initiatives: Use of Pharmacy Students
  • Increasing Access to Medications for At-Risk Populations
  • Funding and Sustaining MTM Initiatives

Guest experts identified from the Innovations Exchange were also invited to present at LC meetings.  The Innovations Exchange profiles that informed the work of the MTM LC included:

Culturally Tailored Pharmacist Home Visits and Educator-Led Group Sessions Increase Medication Adherence and Reduce Blood Pressure for Seniors with Hypertension and Diabetes

Pharmacy Teams Use Telepharmacy To Provide Medication Management to At-Risk Patients in Safety Net Clinics, Leading to Better Outcomes and Lower Utilization and Costs

Pharmacists Integrated Within Patient-Centered Care Teams Help At-Risk Patients Manage Medications, Leading to Better Outcomes and Lower Costs

Clinical Pharmacists Provide Outpatient Medication Management to Patients With Severe Diabetes and Those on Anticoagulants, Leading to Improved Outcomes and Lower Costs

Statewide Consortium Increases Use of Pharmacist-Led Medication Therapy Management in Federally Qualified Health Centers, Improves Management of Hypertension and Diabetes

Prior to the start of the MyRx pilot, the project team recruited and trained two bilingual pharmacists and six pharmacy students. The team also developed a protocol that outlined how the pharmacists would coordinate with the primary care team, as well as how the pharmacists would engage and interact with patients throughout the pilot program. The intervention comprised an initial in-person meeting with a pharmacist, four follow-up phone visits, and an in-person post-intervention visit over the course of a 16-week period. Patients identified for participation in the pilot program satisfied the following criteria:

  • Were 18 years of age or older
  • Had a confirmed diagnosis of diabetes
  • Had a hemoglobin A1c level above 8 percent
  • Did not visit the clinic within 2 months prior to enrollment

Patients were enrolled in the MyRx pilot program on a rolling basis between February and April 2015. The pilot enrolled a total of 57 patients during this period.

Results

The average baseline hemoglobin A1c for enrolled patients was 10.6 percent, and the average length of time living with diabetes mellitus was 9 years. The average baseline diabetes knowledge assessment score was 8.47 (scale of 0 to10) and the average baseline medication adherence score was 28.33 (scale of 0 to 30).

A total of 230 pharmacist actions (i.e., recommendations for lifestyle modifications, drug therapy changes, additional testing, etc.) were made during the initial in-person patient meeting with the pharmacist, or an average of 4 pharmacist actions per patient. Of the 230 pharmacist actions, there were a total of 24 medication change recommendations, all of which were accepted by the patients’ primary care providers.

Among the 38 patients who completed their post-intervention follow-up with a provider, the average hemoglobin A1c was 8.53, representing a 15.2 percent reduction from baseline. Additionally, there was a 13 percent increase in average knowledge score, a 3.1 percent increase in medication adherence score, and a post-intervention satisfaction score of 77.35 (the highest score on the satisfaction instrument was 80).

Overall, these findings show the potential for the MyRx program to achieve improvements in clinical outcomes for at-risk patients through the integration of pharmacists into interdisciplinary health care teams in ambulatory care settings.

Challenges

Although the MyRx pilot program was successful in reducing overall hemoglobin A1c levels in the enrolled patients, the program did encounter challenges with implementation, including the following:

  • Enrolling the original  target number of patients based on the percentage of patients that met the program’s eligibility criteria,
  • Retaining patients throughout the entire 6-month pilot period, and
  • Ensuring that patients completed the established protocol, which designated four follow-up phone calls and a final in-person visit with the pharmacist.

LC member organizations shared common experiences and challenges in implementing medication therapy management programs and similar quality improvement initiatives targeting vulnerable populations.  The LC categorized these challenges into 5 categories:

  • Organizational structure
  • Patient enrollment
  • Patient engagement
  • Data collection and evaluation
  • Program sustainability

The LC also collaborated to develop a case study report entitled Implementation of a Medication Therapy Management Intervention in Ambulatory Care Settings: Experiences and Lessons Learned from the MyRx Pilot.  The document represents the collective work of the MTM LC, conveying the expertise, knowledge, and experiences gained throughout its two years. The document:

  • Provides lessons learned and anecdotal stories from the MyRx pilot to highlight “real-world” experiences in implementing an MTM program in an ambulatory care setting; and
  • Discusses potential solutions that mitigate barriers to implementing MTM programs, based on both the MyRx experience and the collective experiences of LC members.

Next Steps

The MTM LC completed its work in September 2016. However, the LC champions and members are exploring ways to continue the professional relationships that were established. Furthermore, members plan to share the findings from the MyRx pilot and lessons learned in their local communities, conference presentations, and publications.

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