Authors from the University of Minnesota College of Pharmacy highlight the role that pharmacists can play in care optimization for seniors with chronic conditions.
The spectrum of treatment strategies available, the importance of diligent patient self-management, frequent presentation of comorbidities, and the number of healthcare providers often engaged in the care of a patient, frequently make diabetes a complex chronic illness to manage. Unfortunately, the result of this complexity is that, despite good intentions, oversight of a patient’s complete medication regimen may be incomplete and create opportunities for suboptimal management. This is illustrated in the following case.
Bob is a 68-year-old patient with diabetes referred for comprehensive medication management (CMM) services offered by one of the authors (KF). Bob’s primary care physician (PCP) made the referral after noting he was not taking his insulin as directed and his glycated hemoglobin (A1C) was now 11.3%. The PCP was particularly concerned that Bob had developed gangrene in 1 foot. From the comprehensive medication review, it was learned that Bob was choosing to ration his insulin in order to save money, so he could afford medications for secondary stroke prevention and depression. During the assessment, Bob also noted that he did not feel the medication prescribed for depression was achieving the desired outcome. While this patient was referred specifically for support in taking his medication as prescribed, the result of a comprehensive evaluation of all of his medication-related needs revealed the following medication-related problems:
• Poor control of diabetes secondary to nonadherence (by choice) with the prescribed insulin regimen
• Lack of control of depression secondary to the wrong (ineffective) drug prescribed
• Risk for stroke secondary to a medication regimen deemed unaffordable by the patient.
As part of developing a care plan to address the 3 medication-related problems, the pharmacist collaborated with the 3 physicians involved in prescribing Bob’s medications to,
1. Transition to a less-expensive medication for stroke prevention
2. Alter treatment for depression to a medication that was less expensive and expected to produce a better clinical outcome
3. Help Bob understand the implications of rationing insulin use.
As a result of these changes, Bob’s A1C improved to 8.5% within 6 months, symptoms of depression improved and reached defined treatment goals, and Bob was able to maintain an antiplatelet regimen that provided appropriate stroke protection.
MEDICATION USE AND THE TRIPLE AIM
The Institute of Medicine has stated, “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.”1 Thus, the influence of medication use on the ability to achieve the Triple Aim2 is enormous. This is evident in the case presented above, where Bob’s medication-related problems related to each component of the Triple Aim:
1. He was not achieving the clinical goals associated with his medical conditions 2. His healthcare experience was negatively influenced by his inability to afford his medications 3. The cost associated with his care was higher than necessary, secondary to preventable complications from his diabetes.
In cases like Bob’s, fragmentation of healthcare often produces a scenario in which no medical provider is monitoring and assuming responsibility for all components of a patient’s medication-related treatment plan. Unfortunately, thousands of patients across the United States encounter these situations every day. The frequency of suboptimal medication use may occur even more often in seniors with diabetes, because medication complexity increases in people with diabetes,3 and adverse drug events are more prevalent with increased age.4
COMPREHENSIVE MEDICATION MANAGEMENT
CMM services are emerging as a solution to this problem. This service involves application of a specific assessment process to ensure that all of a patient’s medication-related needs are met and existing medications are appropriately indicated, their medications are achieving their intended clinical effects, they will not produce adverse effects (given other medications or comorbidities), and the medication-related treatment plan aligns with the lifestyle and needs of the individual patient.5
CMM services are typically provided by pharmacists collaborating with a primary care team. A defined care process is applied with each patient, which begins with an assessment, followed by identification of problems, development of a care plan, and follow-up.5 However, the manner in which the assessment is completed is distinct. When providing CMM services, a pharmacist will systematically assess medication needs in the context of the individual patient, categorizing medication-related problems using a defined framework (TABLE 1)5. To resolve medication-related problems, the pharmacist collaborates with the patient’s medical providers to confirm and implement a revised care plan that addresses all of the patient’s medication-related needs.
Application of this assessment process and problem categorization system reveals some interesting findings regarding the prevalence of what factors are driving sub-optimal outcomes from medication use. While a great deal of attention has recently been placed on ensuring patient adherence to medication regimens, the work of 3 large health systems in Minnesota, that have consistently integrated CMM programs in their primary and specialty care clinics, demonstrates that nonadherence is only the third most common medication-related problem (TABLE 2).6 More frequently, patients are not achieving therapeutic goals because,
1. Patients have not been prescribed a medication indicated for their medical situation
2. Medications are not prescribed at a dose high enough to achieve the desired goal.
CMM: BENEFITS FOR SENIORS WITH DIABETES
Clinical and financial outcomes associated with patients with diabetes receiving CMM have been positive. In one study, patients with diabetes referred for CMM services experienced A1C reductions of 1.3% to 2.7%.7 Furthermore, CMM services have been associated with a positive impact on cardiovascular risk factors, such as blood pressure (BP) and low-density lipoprotein (LDL) cholesterol in patients with diabetes.7 A trial that compared outcomes of patients enrolled in a pharmacist-managed diabetes service compared with those who were referred to this service, but never attended, found that not only were A1C reductions greater in the pharmacist-managed group, but more patients in this group achieved BP- and LDL cholesterol goals, more frequently took aspirin as indicated, and had greater adherence to smoking-cessation measures. These outcomes occurred even though patients enrolled in the pharmacist service had a more complex medical history and medication regimens.8
Seniors represent a group likely to benefit from CMM services because medication regimens often become more complex as one ages. Although seniors comprise only 13% of the US population, they receive 30% of all prescriptions dispensed.9 They also tend to have more prescribers than younger patient groups and also more frequently use multiple pharmacies. Both of these factors put seniors at greater risk of adverse drug reactions.10
Cost savings associated with CMM services have also been reported. One health system analyzed costs associated with patients that experienced over 9000 CMM encounters and projected a 12:1 return on investment from CMM.11 Other studies have also demonstrated cost savings from CMM services or similar programs.12,13
OPPORTUNITIES FOR CMM
Although improved health outcomes and cost savings are associated with CMM, this service remains limited in its presence in healthcare settings. One reason is that typical fee-for-service programs, operated by payers, generally do not recognize services provided by pharmacists as a covered benefit. However, as our healthcare system continues to expand value-based payment principles, it is likely that the integration of CMM services will increase due to the positive impact on quality, cost, and experience metrics that will drive the design of care delivery models in the future.
While the negative aspects of Bob’s healthcare are quite commonly observed in our healthcare system today, the positive experience derived from having CMM included in the spectrum of services provided by his primary care team could become the norm of the future. Bob personally saw the value in these services and expressed gratitude for the positive influence CMM had on his health. Additionally, Bob’s medical providers expressed appreciation for the team-based approach to care that enhanced the care they were providing and produced a more effective treatment regimen. While the complex nature of his medication regimen made Bob an ideal candidate for CMM services, the presence of this service in primary care remains limited. It is our hope that the positive data and patient stories produced by CMM services will quickly influence healthcare service design, making access to these services possible for all patients with complex edication-related needs.
Kylee A. Funk, PharmD, BCPS, is assistant professor in the Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota. As a clinical faculty member, she splits her time among College of Pharmacy activities and her practice site where she provides CMM services.
Todd Sorensen, PharmD, is professor and associate department head in the Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota. He is also executive director of the Alliance for Integrated Medication Management, a nonprofit that supports health care organizations in quality improvement initiatives focused on medication use.
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