Convening a Learning Community To Advance Medication Therapy Management for At-Risk Populations
Convening a Learning Community To Advance Medication Therapy Management for At-Risk Populations
In October 2014, the Agency for Health Care Research and Quality (AHRQ) Health Care Innovations Exchange established three learning communities (LCs) to improve the quality of health care delivery by addressing challenges in high-priority areas that AHRQ identified. The Innovations Exchange defined an LC as a select group of potential adopters and stakeholders who engage in a shared learning process to facilitate adaptation and implementation of innovations featured in the Innovations Exchange.
The LC that focused on Promoting Medication Therapy Management for At-Risk Populations (the MTM LC) consisted of 14 organizations that explored how to build upon the Managing Your Medications (MyRx) Medication Adherence Program, an innovation that consisted of an independently tested bundle of MTM interventions. The original MyRx program offered MTM and health education to seniors with hypertension and diabetes who were living in community housing facilities. In collaboration with Texas Southern University College of Pharmacy and Health Sciences, three affiliated clinics of Spring Branch Community Health Center, a federally qualified health center in Houston, TX, served as pilot sites for adapting the MyRx innovation, which incorporated pharmacists within primary care teams and enrolled patients in a protocol designed to help them achieve control of diabetes mellitus.
To learn about the collaborative work of the MTM LC, the Innovations Exchange interviewed its champions and expert faculty: Joy Alonzo, PharmD, ME, Clinical Assistant Professor at the University of Houston College of Pharmacy; and Aisha Morris Moultry, PharmD, MS, Professor of Pharmacy Practice and Clinical Health Sciences, Texas Southern University, Houston. Dr. Moultry and her colleagues developed the original MyRx program.
Innovations Exchange: What factors are driving interest in innovations aimed at developing more effective medication therapy management services?
Joy Alonzo, PharmD, ME: The key factor is the growing awareness of the need to improve coordination of care. There has been a common misconception that the patient, the primary care clinician, medical specialists, and other providers all understand the patient’s medication regimen. In fact, it’s very difficult to keep track of all of the prescriptions written by providers in different settings, determine the best treatment plan, and explain all of this to the patient. The need for better coordination of care is especially great during transitions of care, such as from a hospital stay to ambulatory care. Pharmacists in the hospital try to prevent problems related to conflicting medication orders, but after a patient is discharged, it may be 30 days until the patient follows up with a primary care physician. In the meantime, the patient has new hospital medications as well as previously prescribed medications at home, and often has little to no idea about the correct regimen.
It’s increasingly clear that we need patient care models that integrate the pharmacist within the health care delivery system. With an MTM program, the health system pharmacist is uniquely positioned to see the big picture, including all of the patient’s health conditions and medications. Community pharmacists just don’t have the necessary resources or the complete information that’s required to address these issues.
How would you describe progress in implementing medication therapy management programs?
Aisha Morris Moultry, PharmD, MS: We’re seeing growing interest in developing MTM programs. Since 2003, when the Medicare Prescription Drug, Improvement, and Modernization Act was enacted, pharmacists have been increasingly recognized as important clinicians who can help reduce health care costs and improve health outcomes. Following enactment of the Affordable Care Act in 2010, we’ve seen even more recognition of the role of pharmacists, along with increasing efforts to implement MTM programs. These developments have led to a push to provide more training that prepares pharmacists to play an active role in patient care, including monitoring the treatment of patients in outpatient settings. In professional pharmacy education, we are working to train our students so they are better prepared to provide MTM services and work collaboratively with other health care professionals.
Alonzo: Given the potential value of MTM services, progress has been surprisingly slow. Nationally, efforts to implement MTM remain limited in size and scope. The main obstacle to wider adoption of MTM is the lack of recognition of the pharmacist as a health care provider who can bill directly and obtain reimbursement for MTM services for a wide variety of patients with various types of insurance (outside of Medicare Part B). Only recently have pharmacy schools started requiring MTM training and certification as part of the curriculum.
Also, there’s the issue of perceived encroachment by pharmacists on other health care professionals. Physicians may resist MTM models because they see the pharmacist as perhaps encroaching on their practice and “policing,” rather than acting as a resource for complex medication regimens and increasing patient adherence to these regimens. In some locations, including in Texas, pharmacists can participate in models of care that include collaborative practice agreements with physicians, so the pharmacist can provide care under the physician’s protocol. This approach may work best in large managed care organizations in which patients receive all of their ambulatory care at a single clinic. In many settings, however, the lack of reimbursement remains a challenge. In general, the pharmacy profession needs to do a better job of publishing reports about MTM programs and building a substantial body of literature to support evidence-based MTM initiatives and the associated improvements in patient outcomes.
How did the MTM LC go about adapting the MyRx innovation and other MTM models for use by clinicians at Spring Branch Community Health Center?
Moultry: In the original MyRx program, we provided MTM services to seniors during home visits and provided educational group sessions and telephone followups. We used a slightly different approach with the adapted MyRx program at Spring Branch, and relied on a combination of clinic visits and telephone-based visits with the program pharmacists and pharmacist interns. As we developed the MTM protocol, we had people on the implementation team who had been involved in MTM at other clinics, and we looked at what people were doing in other settings to support MTM initiatives to ensure utilization of best practices.
Alonzo: In the MTM LC, we did ongoing evaluation work as the protocol developed. We asked the implementation team about the challenges they were facing, and looked for outside experts we could bring in so they could tell us about their experiences in overcoming such challenges.
What were some of the challenges and successes in implementing the innovation?
Alonzo: Patient engagement was a big issue. Patients need to see MTM as a valuable service, and understand the value of coming in for their followup visits with the pharmacist. The MTM LC had experts speak during monthly meetings and offer ideas on how to get patients to come in for their first visit and return for followup visits. The key is motivational interviewing, which is a patient-centered communication technique that aims to empower the patient, rather than exerting authority over the patients. Through motivational interviewing, the pharmacist would talk with patients about their treatment adherence and health behaviors, and help the patients see what changes they needed to make.
Moultry: Another key challenge was getting patients to come back to the clinic for followup visits. As a federally qualified health center (FQHC), the clinic primarily serves patients classified as having low socioeconomic status. Typically, these patients may have hourly jobs with minimal flexibility, and therefore their work schedules and limited transportation access sometimes made it difficult to schedule and conduct the clinic visits. Also, it was sometimes hard to reach the patients by phone, and the pharmacists had to be flexible about scheduling the calls, providing the required education and counseling at the times that they were able to speak with the patients.
Alonzo: Staffing was another challenge, especially the need to find bilingual pharmacists who could provide MTM services to a mainly Spanish-speaking patient population. The protocol tried to involve pharmacy students and give them a script to follow during telephone visits. However, because students had limited availability and needed a pharmacy preceptor to monitor their work, they didn’t conduct many of the phone visits.
Furthermore, within an MTM program, it can be highly challenging to adjust treatments for patients with uncontrolled diabetes. Still, among the treated patients, their hemoglobin A1c levels decreased fairly consistently, and self-reported adherence to medication regimens improved.
Moultry: The biggest take-home message is that the LC helped us implement an effective MTM intervention. The pharmacists had a positive impact on the patients enrolled in the MTM protocol, in comparison with the retrospective control group. Clearly, getting the pharmacist involved as part of the health care team in an outpatient setting was beneficial for the patients.
How would you describe the experience of using an LC as a dissemination and implementation strategy?
Moultry: The MTM LC focused on information sharing. It’s always valuable when you can gather with like-minded people who can share ideas. Having AHRQ involved in sponsoring the LC added credibility and helped get people to pay attention and contribute to the effort. When we ran into challenges, we had a network of members and invited experts who shared their own experiences and strategies for making implementation successful.
Alonzo: By working with the LC, we could figure out what was going well and what wasn’t, and we could come up with topics to discuss and find experts who could offer practical approaches. That was valuable for learning about how to address issues such as getting low-cost medications for patients who can’t afford their medications, helping pharmacists and other clinicians improve their cultural competency, or exploring options for obtaining grant funding to support MTM interventions. An LC offers a valuable way to achieve changes in clinical practice that are hard to achieve with traditional continuing education for pharmacists, physicians, and other clinicians.
About Joy Alonzo, PharmD, ME: Dr. Alonzo is Clinical Assistant Professor in the Department of Pharmacy Practice and Translational Research at the University of Houston College of Pharmacy, and Associate Director of Pharmacy Services for Texas Children's Health Plan. She performs comparative effectiveness research, drug utilization review, and evaluation of health care disparities with regard to the Texas Medicaid pediatric population. Dr. Alonzo has extensive clinical experience, direct patient care responsibilities, and teaching responsibilities in advanced interprofessional and collaborative ambulatory care practice settings.
About Aisha Morris Moultry, PharmD, MS: Dr. Moultry is Professor of Pharmacy Practice and Clinical Health Sciences and Associate Dean of Clinical and Administrative Services at Texas Southern University College of Pharmacy and Health Sciences, where she coordinates pharmacy management and endocrine pharmacotherapy courses and is establishing a simulation center for six health profession programs. Dr. Moultry has conducted grant-funded research and published peer-reviewed articles in the areas of women’s health, medication management, pharmacists’ smoking cessation counseling practices, and hospital clinical practices.
Dr. Alonzo and Dr. Moultry both reported that they received payment from the AHRQ Health Care Innovations Exchange for providing consultation services to the learning community.
AHRQ Health Care Innovations Exchange. Culturally tailored pharmacist home visits and educator-led group sessions increase medication adherence and reduce blood pressure for seniors with hypertension and diabetes. Available at: https://innovations.ahrq.gov/profiles/culturally-tailored-pharmacist-home-visits-and-educator-led-group-sessions-increase.
AHRQ Health Care Innovations Exchange. 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. Available at: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide-medication-management-risk-patients-safety-net.
AHRQ Health Care Innovations Exchange. Pharmacists integrated within patient-centered care teams help at-risk patients manage medications, leading to better outcomes and lower costs. Available at: https://innovations.ahrq.gov/profiles/pharmacists-integrated-within-patient-centered-care-teams-help-risk-patients-manage.
AHRQ Health Care Innovations Exchange. Quality tool. The patient-centered medical home: a resource guide for integrating comprehensive medication management to optimize patient outcomes (second edition). Avalable at: https://innovations.ahrq.gov/qualitytools/patient-centered-medical-home-resource-guide-integrating-comprehensive-medication.
- AHRQ Health Care Innovations Exchange. Innovations Exchange Learning Communities. Available at: https://innovations.ahrq.gov/learning-communities.
- AHRQ Health Care Innovations Exchange. Culturally tailored pharmacist home visits and educator-led group sessions increase medication adherence and reduce blood pressure for seniors with hypertension and diabetes. Available at: https://innovations.ahrq.gov/profiles/culturally-tailored-pharmacist-home-visits-and-educator-led-group-sessions-increase.
- AHRQ Health Care Innovations Exchange. Promoting medication therapy management for at-risk populations: an Innovations Exchange Learning Community. Available at: https://innovations.ahrq.gov/learning-communities/medication-therapy-management.