Medication Therapy
Management (MTM) Clinic
Christopher R. Lopez, PharmD, CDE
Clinical Pharmacy Specialist: Population Health
Accountable Care Organization (ACO) Support Team
Dartmouth-Hitchcock
October 14, 2014
Why Initiate an MTM Clinic?
“Pharmaceuticals are the most common
medical intervention and their potential for
both help and harm is enormous. Ensuring
that the American People get the most benefit
from advances in pharmacology is a critical
component of improving the National
Healthcare System.”
The Institute of Medicine (IOM)
Facts and Figures
• 75% of healthcare dollars are spent on chronic conditions
($1.3 trillion annually).
• Total financial impact of medication non-adherence is
estimated at $240 billion annually.
• Almost 50% of the population is on at least one chronic
prescription medication; Over 10% of the population uses
5 or more chronic prescription medications.
Identify Appropriate Patients
• Run workbench reports specific to:
• Insurance Coverage
• Number of medications
• To catch the most complex patients
• Problem list
• To identify patients with specific chronic disease
states
• Age
Once Patients Are Identified…
• Allow PCP to review patients to ensure that
they are appropriate for referral.
• Exclude inappropriate patients:
• Acute condition that would make an additional
patient encounter less than ideal.
• Acute mental health exacerbation
• Ongoing chemotherapy treatments
• Patient in assisted living or skilled nursing facility
• Patient with dementia
Also Provide Guidelines for
Provider Referral
• Patients meeting one or more of the following conditions
are more apt to benefit from a consult:
1) Patient on 10 or more chronic medications.
2) Patient not meeting disease state parameters (e.g.
A1c not at goal, most recent BP not at goal, etc.).
3) Patient on more than 2 chronic narcotics.
4) Elderly patients deemed to be a fall risk.
5) Patient unable to afford medications, and prohibitive cost is
negatively impacting care and compliance.
6) Patient at high risk for ADR/drug-drug interactions.
The Logistics
• Must have the following in place:
• Process for scheduling patient into pharmacist clinic.
• Pharmacist must have appropriate EMR access.
• Exam room/ office to see patient and/or family
members.
• Place for patient to check in. MAKE SURE ENTIRE
FACILITY IS MADE AWARE OF THE SERVICE.
• Procedure for documentation and making
recommendations to appropriate provider.
Billing/ Reimbursement
• Bill 3rd party (e.g. Medicare Part D)?
• Charge patient out-of-pocket?
• Justify pharmacist salary using cost
savings/cost avoidance models, as well as
ability to assist with clinical quality metrics?
The MTM Appointment
• Chart is reviewed prior to appointment
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Medication regimen/ Drug interaction screening
Recent labs/ lab value trends
Vitals
Most recent encounter notes
Allergies/documented ADR’s
• The actual appointment
• 45 Minutes
• Patient/ medication-focused
• Patients are encouraged to bring in all medications to
appointment. All meds are reviewed.
AT is a 72-y/o male…
• With a past medical history significant for
hypertension, diabetes, hyperlipidemia,
depression, GERD, fibromyalgia, and insomnia
who was referred for a MTM consult due to the
existence of more than ten chronic
medications.
• Note: He is currently on 17 chronic medications.
Recommendations:
Streamline Med Regimen
• Patient is currently on several medications for
hypertension, yet none of them are at max daily dose. If
losartan dose were to be increased to 100 mg daily,
perhaps amlodipine could be discontinued, resulting in
one less medication and subsequent copay for this
patient.
• Pt is currently on two medications for lipids.
Recommend increase atorvastatin dose and discontinue
fenofibrate.
Recommendation:
Re-evaluate Therapy
• Pt complains of fibromyalgia pain and
subsequent insomnia secondary to this pain.
Pt is currently on sertraline and mirtazapine for
depression, which he says is well controlled.
Perhaps both of these could be discontinued
and replaced with venlafaxine, which is an
SNRI.
• Pt also taking zolpidem for insomnia.
Recommendation: Therapeutic
Substitution for Better Outcome
• Pt states that he only uses esomeprazole as needed.
This med (Nexium) just achieved OTC status, so it is
very likely that his insurance will stop covering it. Since
he is taking it to relieve GERD symptoms, and not daily
as a maintenance medication, it should most likely be
replaced by an H2 blocker like ranitidine. PPI's typically
don't work well to alleviate symptoms of existing
heartburn. H2's work much better.
Recommendation:
Disease-state Management
• Pt is currently testing his blood glucose fasting
in the AM and 30 min after meals. Pt was
instructed to test post-prandially 2 hours after
meals instead of 30 min. Pt verbalized
understanding.
Recommendation:
Potential for Serious ADR
• Increased risk of seizures is listed in the
manufacturer's package labeling as a
possibility when tramadol and sertraline are coadministered. Serotonin syndrome is also a
potential risk with this combination.
Recommend replace tramadol with a different
agent.
Medication Reconciliation
Discrepancies
• None (miraculously)
MTM Consult Data
• Approximately per every 20 MTM consults…
• 5 Critical drug-drug interactions were identified
• 5 Necessary subspecialty referrals were facilitated
• 6 Recommendations to avoid potentially serious adverse
drug reactions (ADR’s) were identified
• 8 Incidents of improper prescribing were identified
• 97 Medication reconciliation discrepancies were identified
• 2 Problem list discrepancies were identified
• 71 “other” uncategorized recommendations were made
Thank you!
Christopher R. Lopez, PharmD, CDE
Christopher.r.lopez@hitchcock.org