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)

Describe the experience and expertise of the MTMCCC Contracts, pilots, and projects Managed care Long term care Staff credentials

Discuss the MTMCCC approach and process with long term care facilities

Identify successes of MTMCCC’s services to health plans

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UF MTM Communication and Care Center

Our Self-Funded business model includes:

Multiple call center locations Gainesville (Established 2010) Lake Nona (Established 2012)

Flexible staffing

Adaptability

Continuous quality monitoring & performance improvement

Academic and research resources

Expertise and Experience Conducted over 12,000 Comprehensive Medication Reviews & 35,000

Quarterly Reviews Conducted over 300,000 live adherence calls in 2013 Projected over 600,000 live adherence calls for 2014 3

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Current Clients -MTM Since Mar. 2010, Auto-Renewal

-Adherence Improvement Services Since Aug 2012 -MTM for MEDsAD Population, 3-Year Pilot Study Since 2011-Extended for 1 additional year to 2015

-Adherence Services Since August 2013-MTM and HEDIS Measure Improvement - August 2014-MTM for UF Health Non-Tuberculosis Mycobacterial ClinicPartnership with UF Clinic - Sept. 2013-Quasi Endowment Funds Pilot Project (February-July 2014)Patient-Centric, Telephonic MTM Services Post-Discharge to Reduce Hospital ReadmissionsAdherence Improvement Services - May 2014

-Coordination of care with case management team and providers-MTM and HEDIS Measure Improvement – November 2014

Our Average Patient

65 years old

Low health literacy

Limited resources and travel

Poor care

Medical conditions: 10

Prescription medications: 15

Over-the-counter (OTC) and/or herbal medications: 5

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Our Team

Patient

Care

Clinical MTM

Pharmacists

UF Faculty

Clinical Associates

Student Pharmacis

ts

Pharmacy Residents

Technology Team

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Our Staff Expertise Pharmacists:

Managed care experience MTM certificate program Board certified ambulatory care pharmacy (BCACP) Board certified psychiatric pharmacy (BCPP) Consultant pharmacy licensure (CPh) Certified geriatric pharmacists (CGP) Pain and palliative care experience Community pharmacy experience

Licensed practical nurse (LPN)

Registered/certified pharmacy technicians (RPhT/CPhT)

Licensed community health worker collaboration (LCHW)

Case management collaboration 7

What Services Are We Providing?

MTM Services Comprehensive Medication Reviews Quarterly reviews

Adherence Services

Prescriber Outreach Services Focusing on care coordination & quality

improvement (QI)

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What is Medication Therapy Management (MTM)?

A patient-specific & individualized service Typically for higher risk population

Goal: To optimize therapeutic outcomes to improve overall patient health

Assesses all aspects of a patient’s medication-related care

In collaboration with other health care providers

Establish continuity of care

No “gold standard” practice model 9

Framework of MTM

Established by collaboration of 11 national pharmacy organizations

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 Referral5. Documentation with Follow-up

American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in Pharmacy Practice (Version 2.0). 2008. Available online at: www.accp.com/docs/positions/misc/coreelements.pdf 10

Medication Therapy Review

AKA: COMPREHENSIVE MEDICATION REVIEW (CMR) Live & Interactive In person or via tele-health

Review of all: Prescription medications Over-the-counter products Vitamins, herbals, homeopathic Anything and everything else

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Medication Therapy Review

Assess medication related problems and opportunities: Drug-drug interactions Drug-disease interactions Non-adherence issues Gaps in therapy:

Medications missing indications Indications missing medications

Duplications of therapy Adverse reactions

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Medication Therapy Review

Inappropriate dosing: Too low/too high Opioid overutilization

Inappropriate medications in the elderly (Beer’s criteria)

Immunizations

Alternative therapies Less costly medications Combination therapy

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Personalized Medication List

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Medication Action Plan

Patient action item documentation

Promotes medication and disease self management

Collaborative effort between patient and pharmacist

Written reminders

Written in patient-friendly language (4th grade reading level)

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Medication Action Plan

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Intervention and Referral

Prescriber Interventions: Potential medication related problems Medication related opportunities Patient reported concerns and issues

Referral sources: Social and economic assistance Crisis intervention Dietary needs Other providers: behavioral health, dental,

physical therapy, etc

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Intervention Example

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Documentation and Follow-Up

Record of services for: Continuity of care Follow and monitoring of outcomes Billing and reimbursement

Documentation systems: UF MTM platform

Components: Record actions and outcomes

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Our General Practice Model

Clinical Associate

outreach to patient

CMR completed

with patient via phone

Documentation Follow-Up

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Long-Term Care (LTC) Process

LTC member determined “interviewable” by obtaining MDS 3.0 scores C0500 B0700 B0800 Scores can be obtained via phone or fax.

If interviewable CMR with member

If NOT interviewable CMR with POA/Caregiver If POA or caregiver not available, attempt CMR

with nursing staff or consultant pharmacist at facility

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Clinical Focus for LTC

Disease state management

Identification of polypharmacy Prescribing cascade Detection of adverse drug reactions; medication

overuse/underuse.

Evaluation of drug interactions

Identification of high risk medications in the elderly Beer’s List medications Fall prevention

Sedative/ hypnotic initiatives

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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

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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

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Outcomes From UF Projects

MEDS-AD Demonstration Project 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 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” 

Table 2: Global Evaluation of the MEDS-AD Demonstration Project

  VeryPoorN(%)

PoorN(%)

FairN(%)

GoodN(%)

VeryGoodN(%)

How would you rate the overall care that you experienced with the medication program?

0(0) 0(0) 0(0) 7(33) 14(67)

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Outcomes From UF Projects

MEDS-AD Demonstration Project (continued)UF COP staff also noted as performing tasks

often defined as medical social services.  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. 

Providing information on Medicaid coverage for non-medication services such as environmental counseling for patients with diagnoses of asthma.

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Pharmacist Recommendations During Year One

Cost-Effec-tive Option

Excessive Pill Burden

Gap in Therapy

Medication Related Problem

MISC Potential Overuse

Potential Underuse

Interven-tions

8 16 22 36 7 11 39

Resolutions 5 3 4 17 1 6 14

2.57.5

12.517.522.527.532.537.542.5

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Transition of Care Pilot Program

UF Health MTM Readmission Pilot Program Provided patient-centric telephonic follow-up after

hospital discharge 314 comprehensive medication reviews performed Results: pharmacist interventions

Total interventions via facsimile = 189 Total CMRs with intervention via facsimile = 112 (35.7 %

of total CMRs completed) CMRs with 1 intervention = 65 CMRs with 2 interventions = 27 CMRs with > 2 interventions = 20

Medication list discrepancies Total number of discrepancies identified = 823 Represented 78.34% of CMRs completed 28

Items Identified During Pilot Program

UF Health MTM Readmission Pilot Program (continued)

Potential Gap in Therapy

49%

Drug- Drug Interaction

16%

Drug-Age In-teraction

3%

Drug-Disease Interaction

2%

Duplication of Therapy

3%

Excessive Med-ication Dosage

or Use3%

Excessive use of SABA2%

Lack of Efficacy1%

Adverse Event 4%

Non-Adherence7%

Dosing Dis-

crepency4%

Suboptimal Pain Regimen2%

Refill Request2%

Reduction in Pill Burden 2%

Asthma/COPD: Lack of Rescue 3%

Asthma/COPD: Lack of Controller

3%

Diabetes: Lack of ACEI/ARB

16%

Diabetes: Lack of Statin11%

Heart Failure: Lack of ACEI/ARB

4%

Heart Failure: Lack of Beta Blocker

2%Heart Failure:

Suboptimal Beta Blocker12%

Osteoporosis: Lack of An-tiresorptive

4%

Long Term Steroid Use: Lack of An-

tiresorptive10%

ACS/CAD: Lack of Beta Blocker

3%

ACS/CAD: Lack of Fast Acting Nitrate

19%

ACS/CAD: Lack of Statin

1%

A.Fib: No Antico-agulation

2%

Other Indication9%

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New Medicaid Pilot Project

Managed Medicaid Plan: November 2014 Targeted 1000 patients based on uncoordinated care criteria & other

medication related criteria Initial CMR conducted with patient

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

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

Will be looking at patient-care and medical cost related outcomes 30

Summary of UF’s MTM Program

Adaptability

Flexible staffing

Continues quality monitoring and performance improvement

Academic and research resources

Clinical expertise and experience

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The UF MTM Promise

Proceed with patient permission.

Be prepared for patient.

Give patient our undivided attention.

Never be interrupted.

Never interrupt the patient.

Give the patient time to think.

We will:

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Questions?

Teresa E. Roane, PharmD, BCACPClinical Assistant Professortroane@cop.ufl.edu

Daryl E. Miller, PharmDMTM and Geriatrics PGY-1 Pharmacy Residentdmiller@cop.ufl.edu