Integrating home-based medication therapy management (MTM) services in a health system

Comprehensive Medication Management Services with a Holistic Point of View, a Scoping Review

Implementing Comprehensive Medication Management (CMM) services uncovered the importance of the totality of the patient's perspective in this process. The holistic approach takes into account the physical, mental and emotional well-being of individuals, as well as their socioeconomic circumstances. The aim of this study was to characterize the scientific evidence associated with CMM services that included this holistic approach. A scoping review was conducted based on Arksey and O'Malley's method. Searches were performed in Google Scholar for papers published between 2010 and 2020 in English, Spanish and Portuguese. Study design, health contexts, sample of patients, results obtained, barriers and facilitators, and the integration of a holistic approach were determined. Two hundred and eighteen papers were evaluated, most of which focused on the implementation of this service through prospective observational studies. A minority of studies reported on a holistic approach, a smaller number examined the effect of social determinants of health, the patient's medication experiences and the pharmacotherapy outcomes from the patient's perspective. Despite the progress achieved, most of the referents do not yet reflect a broader view of the patient's life situation and its relationship to pharmacotherapy and the ways in which the pharmacist implements holistic elements to solve or prevent drug-related problems.

Identifying medication-related problems in pharmacist-run home visits

BACKGROUND

Home visits (HVs) may be warranted for many reasons (e.g., uncontrolled disease states, suspected psychosocial issues, frequent hospitalizations, poor health literacy). Patients who frequently visit the emergency department (ED) are high-risk individuals, oftentimes exhibiting health-related barriers and medication-related problems (MRPs).

OBJECTIVES

This study seeks to answer whether HVs for frequent ED users conducted by a pharmacist with pharmacy students will detect more MRPs compared to office visits (OVs) and enhance patient perception of HV services.

METHODS

Patients who visited the ED at least twice over a 12-month period were included in a retrospective chart review. Eligible patients were randomized into an HV group or OV group. Patients in the HV group were visited by a pharmacist and pharmacy students to identify and resolve MRPs, whereas patients in the OV arm brought their medications into the office for review. Patients in the HV group completed a pre- and postvisit survey about their experiences.

RESULTS

Eighteen patients participated in the study: 10 patients were randomized to the OV arm and 8 patients were randomized to the HV arm. A total of 39 MRPs were identified in 8 HVs versus 33 MRPs in 10 OVs (mean 5 ± 0.926 vs. 3.3 ± 1.89, P = 0.034). Overall, nonadherence was the most common MRP and medication reconciliation was the most common intervention. All 8 HV patients completed the pre- and post-HV surveys. Post-HV survey results indicated that patients agreed that student pharmacists were professional team members and that their HV was needed. The patients agreed to recommend a pharmacist-run HV.

CONCLUSION

Patient homes serve as alternative and convenient spaces for pharmacists to help manage their medications, specifically to identify MRPs and provide meaningful recommendations.

Implementing Pharmacist-Led Patient Home Visits

Introduction Patients with chronic diseases such as hypertension and diabetes often experience difficulties managing complex medication regimens. A promising method for identifying and addressing medication-related problems is pharmacist provision of patient home visits. Pharmacist home visits could alleviate the burden on both patients and providers for the purposes of maintenance medication and goal-achievement assessment. Methods A pharmacist home visit program was developed utilizing social workers to identify patients who would most benefit from a pharmacist home visit. The two pharmacists met with these patients in their homes to evaluate their current medication regimens, adherence, medical condition status, and potential drug-related problems (DRPs). Upon conclusion of the home visit, the pharmacists provided a summary of findings and proposed solutions for identified drug related problems to the patient's primary care provider. Results Fourteen patients participated in pharmacist-provided home visits. During these home visits, 98 unique DRPs were identified. Drug-related problems were grouped into four categories: adherence (n=26, 27%), effectiveness (n=25, 26%), indication (n=24, 24%), and safety (n=23, 23%). Between the initial visit and the final visit, there was a resolution of 25 (26%) drug related problems. Conclusion This project demonstrated a novel referral pathway for identifying patients to participate in pharmacist-led home visits. By providing patient home visits, pharmacists were able to identify and resolve some drug-related problems, but many problems remain unresolved due, in large part, to lack of provider engagement.

Medication-related problems during transfer from hospital to home care: baseline data from Switzerland

Background The shift from inpatient to ambulatory care has resulted in an increase in home care patients. Little is known regarding medication safety associated with patient transfer from hospital to home care. Objective To evaluate medication-related problems in patients transferring from hospital to home care in Switzerland. Setting A non-for-profit home care organization in the city of Lucerne/Switzerland. Methods We conducted a prospective observational study, including patients aged ≥ 64 years and receiving ≥ 4 medications at hospital discharge. Two structured questionnaires assessing the transfer process were completed by home care nurses. Prescription quality was assessed using a PCNE Type 2b Medication Review. Main outcome measures The quality of the transfer process was measured comparing agreed-upon with reported parameters. Prescription quality was analyzed assessing the unambiguity of the prescription. Potentially inappropriate medications (Priscus^® list), contraindications, duplications and interactions, and clinical pharmacist-identified potential medication-related problems were collected. Results Study patients (n = 100) received 8.6 ± 3.5 regularly administered medications. Only 5/100 patients had a complete set of written discharge information. At the time of the first visit, 13/100 patients had no written medication information available. Discharge medication prescriptions were clear to nurses in 62% of patients. In 20 patients, the required medications were unavailable, resulting in 19 medication errors. Assessment by a clinical pharmacist revealed only 33/100 patients had a clear discharge prescription. Of a total of 984 prescribed drugs, 16% were considered to be ambiguous, 22 (2.2%) were potentially inappropriate. 7/984 drugs were contraindicated, 8 were duplicates. Conclusion In addition to the known risk factors in patients transferring from hospital to home care (age, polymedication, multiple providers), 3 major problems impacted upon medication safety: fragmented communication, unreliable medication availability and a poor prescription quality. Clinical pharmacists are an important option to improve medication safety ass.

Pharmacist medication therapy management in home health care: Investigation of a sustainable practice model

OBJECTIVES

The objective of this study was to quantify the financial impact of a pharmacist-driven pilot medication therapy management (MTM) program within a visiting nurse service (VNS) and identify types of medication-related problems affecting the home health care population.

METHODS

Patients were contacted to schedule a home visit with the primary investigator. At the appointment, a comprehensive medication review (CMR) was completed, and data collected included primary reason for VNS care, comorbid diagnoses, number of prescription and nonprescription medications at time of visit, and type of pharmacist-identified medication therapy intervention(s). The VNS is a nonprofit independent home health care agency serving patients of all ages and health conditions. Patients admitted with primary insurance coverage through Blue Cross Blue Shield (BCBSRI) Blue Chip for Medicare and 65 years of age and older were eligible for inclusion. Intervention categories were aligned to coordinate with current billable OutcomesMTM claim categories. Dollar allocation for each intervention severity level was assigned according to the predetermined Medicare cost savings predicted value from BCBSRI. Interventions were assigned cost-saving value by the severity level to estimate savings.

RESULTS

Twenty-five patients received CMRs. Patients averaged 5.92 chronic health conditions, 8.48 Part D drugs, and 3.88 over-the-counter medications. Two hundred eighteen medication-related problems were identified spanning 13 intervention categories. Intervention severity level was assigned to the medication-related problems, with calculated cost savings from pharmacist interventions totaling $124,352.

CONCLUSION

This pilot study demonstrated the positive economic impact of a pharmacist-run MTM program at VNS for patients with multiple chronic conditions and medication-related problems. Potential societal benefits include that community members admitted to VNS will continue to have access to a pharmacist as a standard of care with the continuation of this MTM program.