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 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 co-administered. 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