Opportunities and responsibilities for pharmacists to improve their effectiveness in addressing medication adherence through culturally sensitive collaborations with community health workers

ObjectivesDespite progress in addressing health disparities among vulnerable populations, minority populations are at risk for chronic health conditions associated with multiple determinants of health, which affects their health status and access to care. We offer a potential solution, which creates an unconventional medical team between a pharmacist and a community health worker (CHW). We explore weaknesses and challenges in our medication use system in the context of adherence as a drug therapy problem, the role of culture in shaping medication use, and finally offer a unique paradigm for a collaborative interprofessional team consisting of CHWs and pharmacists.SummaryMedication adherence is far from optimal, especially in minority ethnic populations. Members of an ethnic group may acquire beliefs about illness consistent with their culture’s shared customs. These findings intimate that ethnocultural minority groups may have their own remedies for illness that shape their decision to use medications as prescribed. An interprofessional team in which CHWs and pharmacists collaborate offers an opportunity to improve the effectiveness of pharmacists to address adherence-related problems, especially among minority populations in which culturally determined beliefs can shape medication use decisions.This approach holds promise because CHWs are usually embedded within the community in which their patients live, having experienced the same life experiences. These shared experiences may lead CHWs to uncover medication use practices that pharmacists are not able to discover on their own because the relationship with their patients is often not authentic, which, for many minority patients, can only be established through shared experiences.ConclusionThis paper argues that creating teams of CHWs and pharmacists will help address challenges in achieving health equity and health disparities among vulnerable populations in the medication use system.     

Pharmacists’ knowledge and attitudes toward medication therapy management service and the associated challenges and barriers for its implementation

BackgroundThe literature demonstrated a positive impact of medication therapy management (MTM) services provided by the pharmacists to improve the overall health outcomes. Nevertheless, limited data is available with regard to MTM service implementation by community pharmacists and its associated factors in Jordan.ObjectiveTo evaluate community pharmacists’ knowledge, attitude and practice of MTM service and to explore the challenges and barriers for its implementation.MethodsThe present cross-sectional study utilized a validated online survey which was filled by community pharmacists in different areas across Jordan. In addition to the socio-demographic variables, the study questionnaire evaluated pharmacists’ knowledge and attitudes towards MTM service, extent of MTM implementation and its associated challenges and barriers.ResultsA total of 250 pharmacists completed the survey. The study pharmacists showed moderate knowledge level (median of the total knowledge score = 6 (4–7) out of 10) and positive attitude (median of the attitude score was 23 (19–26) out of 30) towards MTM services. The participating pharmacists recognized performing or obtaining necessary assessments of patient’s health status as the most frequently provided MTM service (84.8%), while the least one was documenting the care delivered and communicating essential information to other healthcare providers (62%). Furthermore, collecting patient-related information was the most commonly recognized challenge to MTM service provision (36.8%), followed by referring the patient to a physician or consultant (36%) and collaboration with them (35.6%). The most reported barrier was negative physician attitudes (40.4%), followed by the lack of training on MTM provision (38.4%), and lack of adequate support staff (37.2%).ConclusionEfforts are needed to enhance collaboration between pharmacists and other health care professional, to develop documentation systems that would preserve and facilitate access to patient information, and to implement appropriate training programs which aim to overcome the challenges and barriers for MTM implementation.     

HIV medication therapy management services in community pharmacies

ObjectivesTo present a rationale and a proposed structure to support pharmacist-delivered medication therapy management (MTM) for human immunodeficiency virus (HIV ) diseaseand to outline challenges to implementing and sustaining the service.Data sourcesProfessional literature.SummaryHistorically, the effect of pharmacy services for HIV-infected persons has been demonstrated in inpatient and clinic-based settings. Developing similar programs adapted for community pharmacists could be a model of care to improve patient adherence to antiretroviral therapy and retention in care. Initiation of antiretroviral therapy and regular monitoring of CD4+ cell count, HIV RNA viral load, adverse drug events, and adherence form the backbone of successful medical management of HIV infection. Support for these services can be provided to HIV-infected patients through pharmacist-managed HIV MTM programs in community pharmacy settings in collaboration with primary providers and other health care professionals.ConclusionCommunity pharmacists can help meet the growing need for HIV care through provision of MTM services. Although resources have been developed, including the general MTM framework, challenges of adequate training, education, and support of community pharmacists need to be addressed in order for HIV MTM to be a successful model.     

Mapping the route to medication therapy management documentation and billing standardization and interoperabilility within the health care system: Meeting proceedings

ObjectiveTo convene a diverse group of stakeholders to discuss medication therapy management (MTM) documentation and billing standardization and its interoperability within the health care system.MethodsMore than 70 stakeholders from pharmacy, health information systems, insurers/payers, quality, and standard-setting organizations met on October 7–8, 2008, in Bethesda, MD. The American Pharmacists Association (APhA) organized the invitational conference to facilitate discussion on strategic directions for meeting current market need for MTM documentation and billing interoperability and future market needs for MTM integration into electronic health records (EHRs). APhA recently adopted policy that specifically addresses technology barriers and encourages the use and development of standardized systems for the documentation and billing of MTM services. Day 1 of the conference featured six foundational presentations on health information technology (HIT) trends, perspectives on MTM from the profession and the Centers for Medicare & Medicaid Services, health care quality and medication-related outcome measures, integrating MTM workflow in EHRs, and the current state of MTM operalization in practice. After hearing presentations on day 1 and having the opportunity to pose questions to each speaker, conference participants were divided into three breakout groups on day 2. Each group met three times for 60 minutes each and discussed five questions from the perspective of a patient, provider, or payer. Three facilitators met with each of the groups and led discussion from one perspective (i.e., patient, provider, payer). Participants then reconvened as a complete group to participate in a discussion on next steps.SummaryHIT is expected to assist in delivering safe, effective, efficient, coordinated care as health professionals strive to improve the quality of care and outcomes for individual patients. The pharmacy profession is actively contributing to quality patient care through MTM services focused on identifying and preventing medication-related problems, improving medication use, and optimizing individual therapeutic outcomes. As MTM programs continue to expand within the health care system, one important limiting factor is the lack of standardization for documentation and billing of MTM services. This lack of interoperability between technology systems, software, and system platforms is presenting as a barrier to MTM service delivery for patients. APhA convened this invitational conference to identify strategic directions to address MTM documentation and billing standardization and interoperability.ConclusionParticipants viewed the meeting as highly successful in bringing together a unique, wide-ranging set of stakeholders, including the government, regulators, standards organizations, other health professions, technology firms, professional organizations, and practitioners, to share perspectives. They strongly encouraged the Association to continue this unique stakeholder dialogue. Participants provided a number of next-step suggestions for APhA to consider because of the event. Participants noted the pharmacy profession's success in building information technology systems for product transactions with systematic, organized, methodical thinking and the need to apply this success to patient services. A unique opportunity exists for the profession to influence and lead the HIT community in creating a workable health technology solution for MTM services. Reaching consensus on minimum data sets for each functional area—clinical, billing, quality improvement—would be a very important short-term gain. Further, participants said it was imperative for pharmacists and the pharmacy community at large to become actively engaged in HIT standards development efforts.     

Generating demand for pharmacist-provided medication therapy management: Identifying patient-preferred marketing strategies

ObjectiveTo identify effective strategies for marketing pharmacist-provided medication therapy management (MTM) services to patients in a self-insured employer setting.DesignQualitative study.SettingUniversity of Pittsburgh during March through May 2008.Participants26 university employees taking at least one chronic medication.InterventionThree focus group sessions were conducted using a semistructured topic guide to facilitate the discussion.Main outcome measuresEmployees’ perceived medication-related needs, perceived benefits of pharmacist-provided MTM, potential barriers for employee participation in MTM, and effective strategies for marketing MTM.ResultsParticipants reported concerns with timing of doses, medication costs, access, and ensuring adherence. Participants generally felt positively toward pharmacists; however, the level of reported patient contact with pharmacists varied among participants. Some participants questioned pharmacists’ education and qualifications for this enhanced role in patient care. Perceived benefits of MTM noted by participants included the opportunity to obtain personalized information about their medications and the potential for improved communication among their health providers. Barriers to patient participation were out-of-pocket costs and lack of time for MTM visits. Participants suggested use of alternative words to describe MTM and marketing approaches that involve personal contact.ConclusionPharmacists should emphasize parts of MTM that patients feel are most beneficial (i.e., provision of a personal medication record) and use patient-friendly language to describe MTM when marketing their practice. Patients will need greater exposure to the concept of MTM and the pharmacists’ role in order to correctly describe and assign value to this type of pharmacist patient care practice.     

A prospective,multisite implementation-efficacy trial of a collaborative prescriber-pharmacist model of care for Medication Assisted Treatment for Opioid Dependence: Protocol for the EPIC-MATOD study

BackgroundMedication Assisted Treatment for Opioid Dependence (MATOD) is clinically effective and cost effective, yet a lack of MATOD prescribers in the community limits access to this treatment in Australia. These shortages are often greatest in regional and rural areas.Objective(s)The Enhancing Pharmacist Involvement in Care (EPIC)-MATOD study will evaluate clinical and implementation outcomes among people with opioid dependence receiving MATOD through a collaborative pharmacist-prescriber model of care across multiple sites in a regional location (encompassing a mix of metropolitan and non-metropolitan areas) of Victoria, Australia.Methods and analysisThe EPIC-MATOD study is a prospective, multisite, implementation trial of collaborative MATOD care. Pharmacists and prescribers will be recruited through the local network of opioid pharmacotherapy providers. Patients will be recruited through participating healthcare providers. After induction into the collaborative care model, patients and healthcare professionals will be followed up over 6- (patients) and 12-months (pharmacists and prescribers) in a hybrid implementation-efficacy study, with outcomes mapped to the RE-AIM framework. The primary clinical efficacy endpoint is patient retention in treatment at 26 weeks. The primary implementation outcome is treatment capacity, based on prescriber time required to provide treatment through collaborative care compared with traditional care. Secondary clinical endpoints include attendance for dosing and clinical reviews, substance use, mental and physical health and overall well-being. Implementation costs, acceptability, and provider engagement in collaborative care will be used as secondary implementation outcome indicators. Time and costs associated with collaborative care, and health service utilisation, will also be estimated.Project impactThe study will provide important information on outcomes and acceptability of collaborative care for MATOD, as well as the cost and key considerations in delivering a collaborative model of care in Australia and other countries where similar treatment barriers exist.     

Medication assessment tool to detect care issues from routine data: a pilot study in primary care

Background Medication assessment tools (MATs) may be implemented in routine electronic data sources in order to identify patients with opportunities for optimisation of medication therapy management (MTM) and follow-up by a multi-disciplinary team. Objective (1) To demonstrate the use of a MAT for cardiovascular conditions (MAT_CVC) as a means of profiling potential opportunities for MTM optimisation in primary care and (2) to assess the performance of MAT_CVC in identifying actual opportunities for better care. Setting Members of a pharmacotherapy discussion group, i.e. two single-handed general practitioners (GPs), three GP partners, and community pharmacists (CPs) from each of two community pharmacies, in a rural part of the Netherlands. Methods MAT_CVC comprises 21 medication assessment criteria, each of which is designed to detect a specific care issue and to check whether it is ‘addressed’ by provision of guideline recommended care or ‘open’ in the presence (‘open explained’) or absence (‘open unexplained’) of pre-specified explanations for guideline deviations. (1) Relevant data was extracted from linked GP and CP electronic records and MAT_CVC assessment was conducted to profile the population of CVC patients registered with both, participating CPs and GPs, in terms of ‘open unexplained’ care issues. (2) A purposive sample of patients with ‘open unexplained’ care issues was reviewed by each patient’s GP. Main outcome measures Number and proportion of ‘open unexplained’ care issues per MAT_CVC criterion and per patient. The number of patients with MAT_CVC detected ‘open unexplained’ care issues to be reviewed (NNR) in order to identify one that requires changes in MTM. Results In 1,876 target group patients, MAT_CVC identified 6,915 care issues, of which 2,770 (40.1 %) were ‘open unexplained’. At population level, ten MAT_CVC criteria had particularly high potential for quality improvement. At patient level, 1,277 (68.1 %) target group patients had at least one ‘open unexplained’ care issue. For patients with four or more ‘open unexplained’ care issues, the NNR was 2 (95 % CI 2–2). Conclusion The study demonstrates potential ways of using MAT_CVC as a key component of a collaborative MTM system. Strategies that promote documentation and sharing of explanations for deviating from guideline recommendations may enhance the utility of the approach.     

Evaluation of pharmacists' barriers to the implementation of medication therapy management services

ObjectivesTo assess pharmacists' actual and perceived barriers to implementing medication therapy management (MTM) services in the outpatient setting and to assess demographic and other factors associated with identified barriers.DesignCross-sectional study.SettingUnited States in 2007.Participants970 pharmacists practicing in an outpatient setting.InterventionE-mail invitation to participate in an Internet-based survey.Main outcome measuresBarriers to implementing MTM, practice characteristic influences on barriers, and personal characteristic influences on barriers.Results776 of the 970 respondents (80.0%) were providing MTM or direct patient care services. Of respondents, 35% were compensated and 45% were not compensated for providing MTM services they provided to patients. The most common barriers identified for pharmacists providing MTM services with or without compensation were related to compensation. The most common barriers identified for those interested in providing MTM services were lack of additional staffing (89.6%) and poor access to medical information (84.0%). Pharmacists providing MTM with compensation were significantly less likely to agree with barriers relating to management, documentation, and compensation compared with those providing MTM without compensation. Those providing MTM with compensation were less likely to agree with most barriers compared with pharmacists who were interested in providing MTM services. Pharmacists practicing in a noncommunity setting were less likely to agree with barriers related to interprofessional relationships and documentation.ConclusionThese results show that the most important barriers to implementing MTM services in the outpatient setting identified by pharmacist survey respondents were related to interprofessional relationships, documentation, and compensation. Despite the resources available to pharmacists, barriers continue to hinder the expansion of MTM and direct patient care services.     

Perceptions of patients on Medicare Part D medication therapy management services

ObjectivesTo determine patients’ perceptions and expectations about medication therapy management (MTM) services pertaining to the core elements of an MTM service in the community pharmacy setting, and to develop educational strategies and outreach programs aimed at increasing patients’ knowledge of MTM services and the expanded role of pharmacists in the community pharmacy setting.DesignMulticenter, cross-sectional, anonymous study.SettingFour regional community chain pharmacies in Maryland and Delaware in January and February 2006.Patients81 patients who were 18 years of age or older and able to complete the survey.InterventionSurvey containing 14 questions administered within pharmacies, two of which had patient care centers that were providing clinical services.Main outcome measurePatients’ perceptions and expectations regarding MTM services.Results49 of 81 patients (60%) had never heard of MTM services. A total of 65 patients (80%) had never had or received a medication therapy review, 63 (78%) never had or received a personal medication record, and 70 (86%) never had or received a medication action plan. Some 56% of participants (n = 45) thought that pharmacist provision of medication therapy reviews, personal medication records, medication action plans, recommendations about medications, and referral to other health care providers was very important. At least 70% of participants (n = 57) thought that having one-on-one consultation sessions with pharmacists to improve communication and relationships with their pharmacists and to improve their medication use and overall health was very important. More than 50% of participants indicated that they would like to receive brochures or talk to their pharmacist to learn more about MTM services.ConclusionPatients have very limited knowledge of the core elements of an MTM service in the community pharmacy setting. Patients reported that pharmacist provision of MTM services was important, but they were concerned about privacy and pharmacists’ time. Patients are also supportive of and believe that MTM services can improve communication and relationship with their pharmacist and improve medication use. Patients appear to prefer receiving brochures and talking to pharmacists to learn more about MTM services. This survey identified a key opportunity for pharmacists to inform patients about MTM services.     

Virtual medication therapy management: The cornerstone to a pharmacy renaissance

ObjectivesTo introduce an innovative clinical service that can be used to reduce medication errors and improve quality of care in the rural environment, in order to assist in eliminating or alleviating disparities in health based on geographical location.SummaryVirtual medication therapy management (MTM) will be a tool to assist underserved populations, specifically residents of rural communities. It will use videoconferencing software to provide MTM services to populations that lack access to care. For virtual MTM to be effective, specific measures must be implemented to comply with the Health Insurance Portability and Accountability Act, and state regulations must be established to standardize the practice.ConclusionThe virtual MTM model is a feasible and promising model for advancing MTM services. With commitment and cooperation from various health care fields, virtual MTM could be the cornerstone of a health care renaissance.     

Pharmacists improve diabetes outcomes: a randomized controlled trial

BackgroundThere is a growing shortage of primary care physicians. Pharmacists can fill the gap, and interdisciplinary teams are being evaluated as part of health care reform.ObjectiveThis study aimed to determine whether adding a pharmacist to an interprofessional health team will improve diabetes outcomes.MethodsIn this 2-phase pilot study, Medicaid-eligible patients with diabetes were randomized to receive standard of care (control arm) or standard of care plus the care of a pharmacist (intervention arm) for 12 months (phase 1). The primary outcome was change in glycated hemoglobin (A1C) from baseline. Secondary outcomes included identifying and correcting medication therapy problems (MTPs) for comorbid conditions, adherence to preventive care visits, health care utilization, self-rated health, and satisfaction surveys. After phase 1, patients in the control arm who did not achieve an A1C of < 8% were eligible to enroll into phase 2 where they received treatment with a pharmacist for 6 months.ResultsOf the 239 patients enrolled, 122 completed phase 1. At 12 months, intervention patients’ mean A1C was 1.85 percentage point (pp) below baseline versus 0.94 pp for control (between-group difference 0.91 pp; P = 0.0218). Most control patients (79%) who completed phase 1 and enrolled into phase 2 improved their A1C by more than 1 pp (P < 0.01). The pharmacists completed 806 patient visits and identified 2638 MTPs. Intervention patients were more adherent to preventive care visits with nutrition (P = 0.043), ophthalmology (P = 0.002), and dentistry (P = 0.007). For intervention patients, 78% rated their experience with the pharmacist as excellent whereas, for control patients, 37% rated their experience with their provider as excellent.ConclusionPharmacist comanagement of patients with diabetes can significantly improve glucose control and patient satisfaction. Creative payment models were used to include pharmacists in the interprofessional patient care team.     

Informing a collaborative-care model for delivering medication assisted treatment for opioid dependence (MATOD): An analysis of pharmacist,prescriber and patient perceptions

BackgroundDemand for medication assisted treatment for opioid dependence (MATOD) in Australia exceeds capacity, particularly in rural and regional areas. There is increasing recognition that community pharmacists are well-positioned to take on expanded roles in MATOD delivery, however there has been limited Australian research exploring attitudes of pharmacists, prescribers, and patients to collaborative models of care.Objective(s)This study aimed to better understand enablers and barriers to a collaborative model for MATOD, to inform implementation in regions where increases in treatment capacity are urgently needed.MethodsSemi-structured telephone interviews were conducted with pharmacists (n = 11), prescribers (n = 6), and patients (n = 8) recruited from the Frankston-Mornington Peninsula region in Victoria, Australia, where transport and access to services have impacts on health care utilisation. The COM-B model was used to explore perceptions of pharmacists’ capability, opportunity, and motivations for delivering collaborative care.ResultsThere was strong motivation among healthcare professionals to participate in a collaborative model of care, with the main perceived benefits including improvements in accessibility, convenience, and continuity of care, and leverage of pharmacists’ high level of patient engagement. Key barriers identified by both pharmacists and prescribers included a perceived lack of pharmacist skills in some areas (capability) and resources (opportunity) to deliver collaborative care in a community pharmacy setting. Established relationships between all stakeholders (social opportunity) and communication between pharmacists and prescribers were identified as facilitators. Barriers and facilitators aligned with seven key areas: skills, confidence, relationships, patient selection, protocols, communication and resources.ConclusionsFindings informed the development of a collaborative model that was individualised, protocol based, and supported by training and clear processes.Project impactThis study identifies specific barriers and facilitators to a pharmacist-prescriber collaborative model of care for MATOD. The resulting model will be tested in a hybrid implementation-effectiveness trial in the Frankston-Mornington Peninsula region.     

Factors that influence patient acceptance of clinical pharmacy services: A nationwide survey

ObjectiveExamine the factors that influence a patient’s likelihood of participating in clinical pharmacy services so that pharmacists can use this knowledge to effectively expand clinical services.MethodsAn online survey was distributed to U.S. citizens 55 years of age or older through a market research company. The survey assessed pharmacy and medication use, general health, interest in clinical pharmacy services, and general demographics. The specific clinical services examined included medication therapy management (MTM) and a collaborative practice agreement (CPA). Logistic regression and best-worst scaling were used to predict the likelihood of participating and determine the motivating factors to participate in clinical pharmacy services, respectively.ResultsTwo hundred eight (58.45%) respondents reported being likely to participate in MTM services, and 108 (50.6%) reported being likely to participate in the services offered by a pharmacist with a CPA, if offered. The motivations to participate in MTM were driven by pharmacist management of medication interactions and adverse effects (best-worst scores 0.62 and 0.51, respectively). The primary motivator to participate in a CPA was improved physician-pharmacist coordination (best-worst score 0.80). Those with a personal pharmacist were more likely to participate in MTM (odds ratio [OR] 2.43 [95% CI 1.41–4.22], P = 0.002) and a pharmacist CPA (2.08 [1.26–3.44], P = 0.004). Previous experience with MTM increased the likelihood of participating again in MTM (5.98 [95% CI 2.50–14.35], P < 0.001). Patient satisfaction with the pharmacy increased the likelihood of participating in a pharmacist CPA (1.47 [95% CI 1.01–2.13], P = 0.04).ConclusionPatients are interested in clinical pharmacy services for the purposes of medication interaction management, adverse effect management, and improved physician-pharmacist coordination. The factors that influenced the likelihood of participating included having a personal pharmacist, previous experience with MTM, and pharmacy satisfaction. These results suggest a potential impact of the patient-pharmacist relationship on patient participation in clinical services.