University of Florida College of Pharmacy Medication Therapy Management Communication and Care Center A Patient Care Business: Communications That Make a Difference

Objectives Introduce the University of Florida Medication Therapy Management Communication and Care Center (MTMCCC) Introduce the University of Florida Medication Therapy Management Communication and Care Center (MTMCCC) Describe the experience and expertise of the MTMCCC Describe the experience and expertise of the MTMCCC Contracts, pilots, and projects Contracts, pilots, and projects Managed care Managed care Long term care Long term care Staff credentials Staff credentials Discuss the MTMCCC approach and process with long term care facilities Discuss the MTMCCC approach and process with long term care facilities Identify successes of MTMCCC’s services to health plans Identify successes of MTMCCC’s services to health plans 2

UF MTM Communication and Care Center Our Self-Funded business model includes: Multiple call center locations Multiple call center locations Gainesville (Established 2010) Gainesville (Established 2010) Lake Nona (Established 2012) Lake Nona (Established 2012) Flexible staffing Flexible staffing Adaptability Adaptability Continuous quality monitoring & performance improvement Continuous quality monitoring & performance improvement Academic and research resources Academic and research resources Expertise and Experience Expertise and Experience Conducted over 12,000 Comprehensive Medication Reviews & 35,000 Quarterly Reviews Conducted over 12,000 Comprehensive Medication Reviews & 35,000 Quarterly Reviews Conducted over 300,000 live adherence calls in 2013 Conducted over 300,000 live adherence calls in 2013 Projected over 600,000 live adherence calls for 2014 Projected over 600,000 live adherence calls for

Current Clients -MTM Since Mar. 2010, Auto-Renewal -Adherence Improvement Services Since Aug MTM for MEDsAD Population, 3-Year Pilot Study Since Extended for 1 additional year to Adherence Services Since August MTM and HEDIS Measure Improvement - August MTM for UF Health Non-Tuberculosis Mycobacterial Clinic Partnership with UF Clinic - Sept Quasi Endowment Funds Pilot Project (February-July 2014) Patient-Centric, Telephonic MTM Services Post-Discharge to Reduce Hospital Readmissions Adherence Improvement Services - May Coordination of care with case management team and providers -MTM and HEDIS Measure Improvement – November

Our Average Patient 65 years old 65 years old Low health literacy Low health literacy Limited resources and travel Limited resources and travel Poor care Poor care Medical conditions: 10 Medical conditions: 10 Prescription medications: 15 Prescription medications: 15 Over-the-counter (OTC) and/or herbal medications: 5 Over-the-counter (OTC) and/or herbal medications: 5 5

Our Team Patient Care Clinical MTM Pharmacists UF Faculty Clinical Associates Student Pharmacists Pharmacy Residents Technology Team 6

Our Staff Expertise Pharmacists: Pharmacists: Managed care experience Managed care experience MTM certificate program MTM certificate program Board certified ambulatory care pharmacy (BCACP) Board certified ambulatory care pharmacy (BCACP) Board certified psychiatric pharmacy (BCPP) Board certified psychiatric pharmacy (BCPP) Consultant pharmacy licensure (CPh) Consultant pharmacy licensure (CPh) Certified geriatric pharmacists (CGP) Certified geriatric pharmacists (CGP) Pain and palliative care experience Pain and palliative care experience Community pharmacy experience Community pharmacy experience Licensed practical nurse (LPN) Licensed practical nurse (LPN) Registered/certified pharmacy technicians (RPhT/CPhT) Registered/certified pharmacy technicians (RPhT/CPhT) Licensed community health worker collaboration (LCHW) Licensed community health worker collaboration (LCHW) Case management collaboration Case management collaboration 7

What Services Are We Providing? MTM Services MTM Services Comprehensive Medication Reviews Comprehensive Medication Reviews Quarterly reviews Quarterly reviews Adherence Services Adherence Services Prescriber Outreach Services Prescriber Outreach Services Focusing on care coordination & quality improvement (QI) Focusing on care coordination & quality improvement (QI) 8

What is Medication Therapy Management (MTM)? A patient-specific & individualized service A patient-specific & individualized service Typically for higher risk population Typically for higher risk population Goal: To optimize therapeutic outcomes to improve overall patient health Goal: To optimize therapeutic outcomes to improve overall patient health Assesses all aspects of a patient’s medication-related care Assesses all aspects of a patient’s medication-related care In collaboration with other health care providers In collaboration with other health care providers Establish continuity of care Establish continuity of care No “gold standard” practice model No “gold standard” practice model 9

Framework of MTM Established by collaboration of 11 national pharmacy organizations Established by collaboration of 11 national pharmacy organizations The Five (5) Core Elements: The Five (5) Core Elements: 1.Medication Therapy Review (MTR/CMR) 2.Personal Medication Record (PMR) 3.Medication-related Action Plan (MAP) 4.Intervention and/or Referral 5.Documentation with Follow-up American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in Pharmacy Practice (Version 2.0) Available online at: 10

Medication Therapy Review AKA: COMPREHENSIVE MEDICATION REVIEW (CMR) AKA: COMPREHENSIVE MEDICATION REVIEW (CMR) Live & Interactive Live & Interactive In person or via tele-health In person or via tele-health Review of all: Review of all: Prescription medications Prescription medications Over-the-counter products Over-the-counter products Vitamins, herbals, homeopathic Vitamins, herbals, homeopathic Anything and everything else Anything and everything else 11

Medication Therapy Review Assess medication related problems and opportunities: Assess medication related problems and opportunities: Drug-drug interactions Drug-drug interactions Drug-disease interactions Drug-disease interactions Non-adherence issues Non-adherence issues Gaps in therapy: Gaps in therapy: Medications missing indications Medications missing indications Indications missing medications Indications missing medications Duplications of therapy Duplications of therapy Adverse reactions Adverse reactions 12

Medication Therapy Review Inappropriate dosing: Inappropriate dosing: Too low/too high Too low/too high Opioid overutilization Opioid overutilization Inappropriate medications in the elderly (Beer’s criteria) Inappropriate medications in the elderly (Beer’s criteria) Immunizations Immunizations Alternative therapies Alternative therapies Less costly medications Less costly medications Combination therapy Combination therapy 13

Personalized Medication List 14

Medication Action Plan Patient action item documentation Patient action item documentation Promotes medication and disease self management Promotes medication and disease self management Collaborative effort between patient and pharmacist Collaborative effort between patient and pharmacist Written reminders Written reminders Written in patient-friendly language (4 th grade reading level) Written in patient-friendly language (4 th grade reading level) 15

Medication Action Plan 16

Intervention and Referral Prescriber Interventions: Prescriber Interventions: Potential medication related problems Potential medication related problems Medication related opportunities Medication related opportunities Patient reported concerns and issues Patient reported concerns and issues Referral sources: Referral sources: Social and economic assistance Social and economic assistance Crisis intervention Crisis intervention Dietary needs Dietary needs Other providers: behavioral health, dental, physical therapy, etc Other providers: behavioral health, dental, physical therapy, etc 17

Intervention Example 18

Documentation and Follow-Up Record of services for: Record of services for: Continuity of care Continuity of care Follow and monitoring of outcomes Follow and monitoring of outcomes Billing and reimbursement Billing and reimbursement Documentation systems: Documentation systems: UF MTM platform UF MTM platform Components: Components: Record actions and outcomes Record actions and outcomes 19

Our General Practice Model Clinical Associate outreach to patient CMR completed with patient via phone DocumentationFollow-Up 20

Long-Term Care (LTC) Process LTC member determined “interviewable” by obtaining MDS 3.0 scores LTC member determined “interviewable” by obtaining MDS 3.0 scores C0500 C0500 B0700 B0700 B0800 B0800 Scores can be obtained via phone or fax. Scores can be obtained via phone or fax. If interviewable  CMR with member If interviewable  CMR with member If NOT interviewable  CMR with POA/Caregiver If NOT interviewable  CMR with POA/Caregiver If POA or caregiver not available, attempt CMR with nursing staff or consultant pharmacist at facility If POA or caregiver not available, attempt CMR with nursing staff or consultant pharmacist at facility 21

Clinical Focus for LTC Disease state management Disease state management Identification of polypharmacy Identification of polypharmacy Prescribing cascade Prescribing cascade Detection of adverse drug reactions; medication overuse/underuse. Detection of adverse drug reactions; medication overuse/underuse. Evaluation of drug interactions Evaluation of drug interactions Identification of high risk medications in the elderly Identification of high risk medications in the elderly Beer’s List medications Beer’s List medications Fall prevention Fall prevention Sedative/ hypnotic initiatives Sedative/ hypnotic initiatives 22

Adherence Services Level 1 Program Enrollment Live Interactive Reminder Calls Level 2 Assessment of Barriers with Patient-Specific Interventions Level 3 Interactive Follow-Up Reviews Level 4 Pharmacist Interventions for High-Level Needs 23

Outreach Projects Patient Safety Measures High Risk Medications Diabetes Treatment Measure HEDIS/Care Measures Cardiovascular Care Diabetes Care Osteoporosis Management RA Management Antidepressant Med Management Other Reducing Hospital Readmissions  Target patient and/or prescriber to improve quality measure performance 24

Outcomes From UF Projects MEDS-AD Demonstration Project MEDS-AD Demonstration Project MTM services provided to MEDS-AD patients over 4 years MTM services provided to MEDS-AD patients over 4 years MEDS-AD Waiver Medication Therapy Management (MTM) Program Interim Report by FSU College of Medicine/Social Work MEDS-AD Waiver Medication Therapy Management (MTM) Program Interim Report by FSU College of Medicine/Social Work Describes the quantitative/qualitative evaluation and preliminary findings Describes the quantitative/qualitative evaluation and preliminary findings The gold standard of satisfaction lies in the interviews with participants themselves, it became evident to the interviewers “that the commitment on the part of the UF COP staff to patient well-being transcended the limitations of the MEDS-AD Demonstration project while maintaining the integrity of the MTM process” The gold standard of satisfaction lies in the interviews with participants themselves, it became evident to the interviewers “that the commitment on the part of the UF COP staff to patient well-being transcended the limitations of the MEDS-AD Demonstration project while maintaining the integrity of the MTM process” Table 2: Global Evaluation of the MEDS-AD Demonstration Project Very Poor N(%) Poor N(%) Fair N(%) Good N(%) Very Good N(%) How would you rate the overall care that you experienced with the medication program? 0(0) 7(33)14(67) 25

Outcomes From UF Projects MEDS-AD Demonstration Project (continued) MEDS-AD Demonstration Project (continued) UF COP staff also noted as performing tasks often defined as medical social services. UF COP staff also noted as performing tasks often defined as medical social services. Examples of these services included: Examples of these services included: Identifying transportation services from Tampa to Orlando to aid a patient in obtaining services from the only pain specialist who accepted patients with Medicaid. Identifying transportation services from Tampa to Orlando to aid a patient in obtaining services from the only pain specialist who accepted patients with Medicaid. Providing information on Medicaid coverage for non- medication services such as environmental counseling for patients with diagnoses of asthma. Providing information on Medicaid coverage for non- medication services such as environmental counseling for patients with diagnoses of asthma. 26

Pharmacist Recommendations During Year One 27

Transition of Care Pilot Program UF Health MTM Readmission Pilot Program UF Health MTM Readmission Pilot Program Provided patient-centric telephonic follow-up after hospital discharge Provided patient-centric telephonic follow-up after hospital discharge 314 comprehensive medication reviews performed 314 comprehensive medication reviews performed Results: pharmacist interventions Results: pharmacist interventions Total interventions via facsimile = 189 Total interventions via facsimile = 189 Total CMRs with intervention via facsimile = 112 (35.7 % of total CMRs completed) Total CMRs with intervention via facsimile = 112 (35.7 % of total CMRs completed) CMRs with 1 intervention = 65 CMRs with 1 intervention = 65 CMRs with 2 interventions = 27 CMRs with 2 interventions = 27 CMRs with > 2 interventions = 20 CMRs with > 2 interventions = 20 Medication list discrepancies Medication list discrepancies Total number of discrepancies identified = 823 Total number of discrepancies identified = 823 Represented 78.34% of CMRs completed Represented 78.34% of CMRs completed 28

Items Identified During Pilot Program UF Health MTM Readmission Pilot Program (continued) UF Health MTM Readmission Pilot Program (continued) 29

New Medicaid Pilot Project Managed Medicaid Plan: November 2014 Managed Medicaid Plan: November 2014 Targeted 1000 patients based on uncoordinated care criteria & other medication related criteria Targeted 1000 patients based on uncoordinated care criteria & other medication related criteria Initial CMR conducted with patient Initial CMR conducted with patient Targeted medication review (TMR) may also be done with Primary Care Physician or Behavioral Health provider Targeted medication review (TMR) may also be done with Primary Care Physician or Behavioral Health provider Medication Action/Treatment Plan determined then shared with provider(s) & communicated to patient Medication Action/Treatment Plan determined then shared with provider(s) & communicated to patient Ongoing care coordination & medication reviews with a focus on communications between prescribers/providers (integrated into case management activities) Ongoing care coordination & medication reviews with a focus on communications between prescribers/providers (integrated into case management activities) Quarterly assessment of changes in utilization & quality measures Quarterly assessment of changes in utilization & quality measures Will be looking at patient-care and medical cost related outcomes Will be looking at patient-care and medical cost related outcomes 30

Summary of UF’s MTM Program Adaptability Adaptability Flexible staffing Flexible staffing Continues quality monitoring and performance improvement Continues quality monitoring and performance improvement Academic and research resources Academic and research resources Clinical expertise and experience Clinical expertise and experience 31

The UF MTM Promise Proceed with patient permission. Proceed with patient permission. Be prepared for patient. Be prepared for patient. Give patient our undivided attention. Give patient our undivided attention. Never be interrupted. Never be interrupted. Never interrupt the patient. Never interrupt the patient. Give the patient time to think. Give the patient time to think. We will: 32

Questions? Teresa E. Roane, PharmD, BCACP Clinical Assistant Professor Daryl E. Miller, PharmD MTM and Geriatrics PGY-1 Pharmacy Resident