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Smaller hospitals can do well with medication management programs
Here's one good example
Pharmacy directors of small hospitals might think that offering medication therapy management (MTM) services is a little out of their reach. But at least one 25-bed hospital has proven that this is a short-sighted view.
New Ulm Medical Center, an Allina facility, in New Ulm, MN, successfully has launched a pilot MTM program that uses part of the time of one pharmacist.
"We have grants from the state for the pilot stage," says Sarah Leslie, PharmD, pharmacy coordinator at New Ulm Medical Center.
"This is a billable service, but it's complicated to set up the billing," Leslie adds.
Leslie works with four providers and has seven collaborative practice agreements in which she can make medication adjustments in the treatment involving hypertension, diabetes, smoking cessation, asthma, chronic obstructive pulmonary disease (COPD), etc.
The patients she sees typically have multiple issues, including the following:
- Their average age is 70 years;
- Their median number of diagnoses is 10, and the range is 5-40 diagnoses;
- Their median number of medications is 14, including over-the-counter vitamins and analgesics;
- A significant proportion of the patients also have suboptimal blood cholesterol and blood glucose levels.
"These are pretty complicated patients," Leslie says.
The program is too new to have produced outcomes, but it has been a success so far with providers. Some doctors have made referrals even without collaborative practice agreements, and Leslie sees these patients for a poly-pharmacy review.
"So far the program seems to be working," Leslie says. "We haven't allocated additional time for this, so I just hop over there when I have a patient."
Using the case study of a patient who was referred because of multiple statin intolerance, Leslie describes how the program works:
Physicians who have collaborative practice agreements make a full service referral.
"We're an integrated medical center, and our clinic is attached to the hospital," Leslie says. "Say we have a family practitioner who doesn't know what to do about a patient who has tried different statins, and none are working."
The physician orders a consultation with the MTM pharmacist, and Leslie sees the patient on a scheduled clinic day. The referral reason is listed as multiple statin intolerance. The patient arrives with a bag of medications.
Leslie has an hour to spend with the patient to review her medications and problems with the statin drugs.
Review all medications and update med list.
"We go through the patient's medications and I update her medication list," Leslie explains. "There will be things she's no longer taking."
Leslie reviews the patient's medication schedule, talks to her about the drugs she should be taking and how to best take them, and she reminds the patient about why medication adherence is important to improving the patient's health.
Here are her other questions and instructions to MTM patients:
- Do you have any problems with your medications?
- Have you been taking your medications each day and time?
- Do you use a medication reminder device or pill box?
- If you don't have one of these, would you like one?
- Do you take your medicine in the morning or at night?
"Then I do a brief review of systems, looking for adverse reactions to specific types of drugs," Leslie says.
- Do you have muscle aches or cramps (if the patient takes statins)?
- Do you get dizzy when you stand up?
- Do you have problems with constipation (if the patient takes narcotic painkillers)?
- Do you have edema (if the patient takes a diuretic)?
Solve the patient's medication problem.
In the case of the patient with statin intolerance, Leslie discovered that the patient had muscle aches from the drugs.
"Her liver enzyme tests were normal, so I wasn't worried about that and thought we could try another statin," Leslie says. "She had been adherent until she couldn't tolerate the side effects."
The patient's cholesterol would go down, but then she'd quit taking the drugs because of her discomfort from muscle aches.
"She wasn't on the drugs long enough to get the full effect," Leslie says.
"I asked her to describe the muscle aches because a lot of times people think they have muscle aches from a statin, but it's really not the problem," she adds.
For instance, a patient who describes a shin splint pain probably does not have a side effect of the statin drugs.
"Usually, the statin drugs could cause a flu-like ache, and it's usually in the large muscles like biceps and quads, with some weakness, as well," Leslie explains.
In the case of the patient whose cholesterol was not well-controlled, Leslie found that she had tried most available statin drugs with the exception of fluvastatin and lovastatin.
"So I tried her on lovastatin, which was the one that I felt could get her to the goal of having an LDL of less than 100," Leslie explains. "Then I told her to take CoQ10 (Coenzyme Q10), a supplement, as there's some evidence that it helps prevent muscle ache."
Leslie explained that the evidence for CoQ10 was mixed and that there was no evidence from randomized, controlled trials.
"But there's virtually no disadvantage other than you have to pay for it," she adds.
Assess patient's other disease states.
Since the MTM patients invariably have multiple chronic diseases and health problems, Leslie typically spends some time going over their other health issues.
The statin patient also had diabetes, and Leslie assessed whether she had been adherent with those medications, as well as finding out the answers to these questions:
- What is her diet like?
- Had she been exercising?
- If she hadn't been adherent, why not?
Leslie might add sulfonylurea to the patient's medication regimen if diabetes control has become an issue. This drug is within her collaborative practice agreement.
If a patient's diabetes control is very poor, she might start the patient on insulin or refer the patient to a diabetes educator.
Send report to providers.
"Then I send an electronic note to the patient's provider, saying what I did," Leslie says.
If Leslie has a question about taking an action outside her collaborative agreement, then she'll contact the provider with this question, as well.
For instance, a patient might ask to be taken off a particular medication that is outside of the agreement, so Leslie will contact the provider with this question and later get back to the patient with an answer.
Schedule a follow-up appointment.
At the end of the MTM session, Leslie gives patients a letter that summarizes the changes to their medications.
"I type the letter while visiting with them, and it goes home with them," she adds.
The letter states their next appointment and how they need to have their lab tests done before they return. It also lists their medications, times of day to take them, and any other instructions.
For the statin patient, the follow-up appointment would be in 6-8 weeks, unless there are problems that necessitate an earlier visit, Leslie says.
"Or some patients might be asked to call me with their blood sugar numbers in two weeks time," she says. "Some patients know what they're doing and are more independent, while others need closer follow-up."
The follow-up appointment typically lasts a half hour, and Leslie makes certain the patient's lab results are available before the appointment begins.
In the case of the statin patient, the lab results showed that the statin drug change was working. The patient's LDL had dropped 40 points, and she had no intolerable muscle aches, Leslie recalls.
"She's still on the medication and CoQ10," she says.
"If I've done everything I can do for a patient, I'll discharge them from the service and say, 'If in the future you are on new medication or have questions, then you can come back to see me,'" she adds.