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The evolving role of pharmacists: Moving towards medication therapy management to provide enhanced patient care services

Pharmacists’ scope of practice is shifting from a traditional dispensing role toward improving patient health outcomes. A framework called the Blueprint for Pharmacy outlines a future of pharmacy practice in Canada

that is focused on improving drug therapy outcomes of Canadians through patient-centred care.1 For example, various provinces in Canada have introduced new models of funding for medication reviews and medication management. This issue of the Translator highlights various aspects of medication therapy management: n   Understanding pharmacists’ preferences toward providing patient-centred servicesn   Ten years of providing medication therapy management: Pharmacists identify and resolve drug therapy problemsn   A review of remuneration models for pharmacists’ clinical care services: An essential part of integrating medication

therapy management into pharmacy practicen   The Asheville Project: Pharmacists improve diabetes management within a medication therapy management model

Understanding pharmacists’ preferences for providing patient-centred servicesGrindrod KA, Marra CA, Colley L, Tsuyuki RT, Lynd LD. Pharmacists’ preferences for providing patient-centered services: A discrete choice experiment to guide health policy. Ann Pharmacother. 2010;44(10):1554-64.

Issue: Pharmacists wanting to provide patient-centred services in their phar-macy are often faced with several chal-lenges, including a lack of reimbursement, workplace constraints and resistance from patients and physicians. The Blueprint for Pharmacy outlines the need for pharmacy to become more patient-centred; however, pharmacy practice is not as focused on patient health outcomes as it could be.1 A

The Translator is an initiative by the Canadian Pharmacists Association to support the knowledge translation between pharmacy practice research and health policy. Each issue selects a number of pharmacy practice research articles, briefly summarizes them and discusses the health care policy implications. These articles are submitted by researchers who have a strong desire to support evidence-based health care policy and best practices.

Winter 2011, Volume 5, Issue 1

1 The Blueprint for Pharmacy: The Vision for Pharmacy. June 2008. Available: www.pharmacists.ca/content/about_cpha/whats_happening/cpha_in_action/pdf/BlueprintVision.pdf (accessed November 9, 2010).

Most pharmacists did not favour traditional dispensary

services, but rather indicated a preference towards providing

MTM and CDM services.

better understanding of pharmacists’ pref-erences for patient-centred services would be useful to improve the uptake rate of

direct patient care services in community pharmacies.

A solution: A discrete choice experiment was used to survey pharmacists’ own pref-erences toward patient-centred services including medication therapy manage-ment (MTM) and chronic disease man-agement (CDM). Pharmacists chose job satisfaction and personal income as the 2

Understanding pharmacists’ preferences for providing patient-centred services (cont.)

most important attributes for providing patient-centred services. Most pharma-cists did not favour traditional dispensary services — such as dispensing and com-pounding — where the focus was on fill-ing prescriptions. Pharmacists indicated a preference towards providing MTM and CDM services, but did not show inter-est in screening services. Education and training should be provided as a weekly CDM course or monthly paid preceptor-ship rather than an hourly seminar. Pay-ment should occur through a professional

service fee, such as $100/hour paid to the pharmacy.

Implications: Understanding pharmacists’ preferences is an important step in guid-ing health policy that promotes patient-centred employment opportunities that are aligned with pharmacists’ career aspi-rations. This study is one of the first to quantify pharmacists’ preferences toward non-dispensing services. Thus, employ-ers can create positions that are forward-thinking, in line with future pharmacists’

desires and match the type of pharmacists to their preferred job experience. A limita-tion of this study is that due to the topic and voluntary nature of the survey, respon-dents may have been more motivated and biased towards providing patient-centred services. Overall, improving the uptake of patient-centred services must begin with government policy makers, pharmacy organizations and employers recognizing pharmacists’ career preferences and shap-ing future opportunities in the best inter-ests of pharmacists.

Issue: The inappropriate use of medica-tions contributes to greater than 1.5 million preventable adverse events annually in the U.S.A. and is estimated to cost $177 bil-lion USD.1 Approximately 3.2% of hospital admissions in the U.S.A. are caused by an adverse drug event and 76% are prevent-able.2 Medication therapy management (MTM) presents a promising solution to reduce drug therapy problems; however, more clinical, economic and humanistic data are needed to confirm the long-term effectiveness of pharmacist-led MTM care.

A solution: Core services of the MTM model include medication therapy review, personal medication record, medication-related action plan, intervention, referral, documentation and follow-up. Pharmacists applied these core services to over 12,000

Background or research methods: A group of 634 pharmacists and senior pharmacy students were recruited from Alberta and British Columbia and 539 submitted complete responses to a vol-untary online survey. The survey included a series of 18 sets of hypothetical scenar-ios, where respondents chose between

2 patient-centred service options or 1 status quo option. Each scenario had a defined list of attributes describing the service, setting, education, fee, income and job satisfaction. Software was used in order to identify statistically significant differences in pharmacists’ humanistic, environmental and financial preferences

toward patient-centred services.

Financial support: Funding was provided by a grant from the Canadian Foundation for Pharmacy and a trainee grant from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research.

Ten years of providing medication therapy management: Pharmacists identify and resolve drug therapy problemsRamalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185-95.

2 © 2011 Canadian Pharmacists Association

Background or research methods: This retrospective study analyzed the MTM program at Fairview Health Services in Minnesota, a large integrated health care centre. Data from 9,068 patients were analyzed over a 10-year period from September 1998 to September 2008. All

MTM sessions were delivered face-to-face and pharmacists subsequently identified drug therapy problems; upon follow-up pharmacists assessed whether the patient achieved the therapy goals for each medi-cal condition. A cost-savings calculation and patient survey were administered to

measure the economic and humanistic impact of the MTM program.

Financial support: No external funding provided.

1 The Blueprint for Pharmacy: The Vision for Pharmacy. June 2008. Available: www.pharmacists.ca/content/about_cpha/whats_happening/cpha_in_action/pdf/BlueprintVision.pdf (accessed November 9, 2010).

1 Medication Therapy Management: MTM Central. American Pharmacists’ Association. 2010. Available: www.pharmacist.com/MTM (accessed July 26, 2010).2 Senst BL, et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health Syst Pharm. 2001;15;58(12):1126-32.

85% of patients had at least one drug therapy problem

and 28% of patients required additional therapy.

medical conditions, resulting in 55% of the conditions improving and 23% remaining unchanged. The economic benefit of the MTM program resulted in a health sys-tem cost savings of approximately $86 per patient encounter. Results from the patient satisfaction survey are also compelling: 95.3% of respondents strongly agreed or agreed that MTM improved their well-being and overall health; and 99.0% of respondents strongly agreed or agreed that the pharmacist helped them understand the goals of therapy and how to take their medication safely.

Implications: Pharmacists can play a vital role in the health care team by providing MTM services. MTM seeks to enhance patient care by improving communication and collaboration among pharmacists and other health care professionals, in addi-tion to empowering patients to optimize their medication use.1 This study demon-strates that pharmacists providing MTM services improved clinical outcomes for the patients, contributing to health care cost savings. Patient satisfaction with the program also rated very high. The MTM program developed in Fairview Health Services supports the idea that pharmacist-led MTM can be applied to many medical conditions and can provide long-term cost saving to the health care system.

Issue: In Canada, an aging population, rise in chronic disease rates and increas-ing array of pharmaceutical therapies put pharmacists’ clinical care skills in grow-ing demand.1 The rationale behind a move towards pharmacist-led chronic disease care and medication therapy management (MTM) is clear; however, remuneration for these services remains uncertain. Minimal consideration for business sustainability and lack of evaluating effect on outcomes remain major barriers to implementing clinical care remuneration models. This may explain why over 43% of community pharmacists provide patient care, but only 22% charge fees for enhanced services.2

A solution: The goal of this review was to assist Canadian pharmacists in creating their own remuneration programs. Forty-nine articles were selected that provided descriptions of existing remuneration models for pharmacist clinical care ser-vices. The majority of remuneration came from government agencies, third-party payors and national or regional programs.

The types of services remunerated included MTM, disease management and

Background or research methods: A literature review of clinical care services provided by pharmacists was performed using a wide variety of online literature search engines. Articles were included if they involved a large group of phar-macists and the source of remuneration

was a third-party payor. Patients paying for services and dispensing fees out-of-pocket were not included in this review. The search was performed by 1 reviewer, sorted by 2 independent reviewers, and disagreements were managed by a third independent reviewer. A panel of several

pharmacy faculties reviewed the articles and presented conclusions.

Financial support: Funding was provided by a grant from the Canadian Foundation for Pharmacy.

A review of remuneration models for pharmacists’ clinical care services: An essential part of integrating medication therapy management into pharmacy practice Chan P, Grindrod K, Bougher D, Pasutto F, Wilgosh C, Eberhart G, Tsuyuki R. A systematic review of remuneration systems for clinical pharmacy care services. Can Pharm J. 2008;141(2):102-12.

© 2011 Canadian Pharmacists Association 3

1 Blueprint for Pharmacy. June 2008. Available: http://www.pharmacists.ca/content/about_cpha/whats_happening/cpha_in_action/pdf/BlueprintVision.pdf (accessed November 9, 2010).2 Conference. Pharmacy Technician Society of Alberta 2009. Available: http://www.pharmacytechnicians.ab.ca/files/pharmacytrends2009aroadmapfortechs.pdf (accessed September 24, 2010).

Minimal consideration for business sustainability and lack of evaluating effect on

outcomes remain major barriers to implementing clinical care

remuneration models.

non-dispensing services. MTM service typically involved medication reviews, with a rate of pay ranging from $27 to $170 per review. Disease management programs usually treated a chronic disease state with payments ranging from $33 to $134 per visit. Non-dispensing services included counselling for over-the-counter products, resolving adverse drug reactions and con-tacting physicians, with payments ranging from $4 to $17 per intervention.

2) Create a plan to identify and address barriers.

3) Evaluate the remuneration system for economic and clinical outcomes.

4) Summarize the outcomes and commu-nicate the results.

5) Launch a marketing campaign to show the benefits of and establish demand for the new services.

Implications: This review can help Cana-dian pharmacists recognize that a clinical care model is feasible, has potential cost savings and financial advantages. The successful uptake of clinical care services requires pharmacists who are innovative, highly trained and willing to embrace change. Thus, pharmacists may need to take a more active role in establishing clinical care by creating a funding model, developing a specialized service and inte-grating the service into their community pharmacy practice. Furthermore, physi-cians, nurses, pharmacists and patients can actively promote direct patient care, support expanding services, and advocate for governments and third-party payors to subsidize clinical care.

The Blueprint for Pharmacy: Making Medication Therapy Management a reality across Canada

Learn more about our fundraising campaign  at www.blueprintforpharmacy.ca or contact Conrad Amenta at camenta@pharmacists.ca 

Take part in the transformation of the profession!

Five key points were identified to help Canadian pharmacists create a clinical care program: 1) Develop a remuneration model that

pays according to the value of the ser-vice provided.

Issue: An estimated 1.8 million Canadians have diabetes, and this number contin-ues to rise.1 Pharmacists provide care for patients with diabetes and can improve patient outcomes such as glycemic control and blood pressure.2 However, research also indicates that such improvements tend to decline 3 months after an intervention has been completed.3 Thus, community pharmacists are ideally placed to reinforce and emphasize the importance of diabetes management through ongoing consulta-tions and follow-ups.

A solution: The Asheville Project was cre-ated through a collaboration of pharma-cists, physicians, employers and the City of Asheville, North Carolina, to assess the effectiveness of community pharmacist–led pharmaceutical care services. Long-term clinical, economic and humanistic out-comes were assessed on the pharmacist-run medication therapy management (MTM) program for patients with diabetes. The intervention consisted of a consultation

ContributorsKalena Truong, BSc(Pharm) (candidate)Marie-Anik Gagné, HBSocSc, MA, PhDPeter Delanghe, BSc(Pharm) (candidate)Philip Emberley, BSc(Pharm), MBA

ReviewersKelly A Grindrod, PharmD, MScDjenane Ramalho de Oliveira, PhDRoss Tsuyuki, PharmD, MSc, FCSHP, FACCDale B. Christensen, RPh, PhDKen Austin, BA

Contact InformationPhilip EmberleyDirector, Pharmacy Innovation Canadian Pharmacists Association 

pemberley@pharmacists.ca(613) 523-7877, ext. 2201-800-917-9489

www.pharmacists.ca/research

The dissemination of this innovative publication is made possible in part through an unrestricted educational grant from Pfizer.

4 © 2011 Canadian Pharmacists Association

The Asheville Project: Pharmacists improve diabetes management within a medication therapy management modelCranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43(2):173-84.

The success of the Asheville Project demonstrates that a patient-centred, employer- payor–driven MTM program can be successfully run and

implemented by pharmacists.

1 Johnson JA, Lewanczuk R. Opportunity knocks: a diabetes strategy for pharmacists in Canada. Can Pharm J. 2009;142(1):84.2 Cioffi ST, Caron MF, Kalus JS, Hill P, Buckley TE. Glycosylated hemoglobin, cardiovascular, and renal outcomes in a pharmacist-managed clinic. Ann Pharmacother. 2004 May;38(5):771-5. 3 Cohn S. Expanding the possibilities: sites in six states demonstrate benefits of the Asheville Model. Pharmacy Times: Beyond Asheville. June 2005. p. 12-15. Available: http://www.pharmacist.com/AM/Template.cfm?Section=Asheville_Project (accessed July 28, 2010).4 APhA Foundation. The Diabetes 10 City Challenge. Available: http://www.diabetestencitychallenge.com/ (accessed: July 28, 2010).5 The Asheville Project. 2010. Available: www.theashevilleproject.net (accessed July 28, 2010).

To receive an e-copy of new issues of the Translator, contact us at research@pharmacists.ca.

with a pharmacist certified in diabetes edu-cation. After discussion with the patient, pharmacists developed a care plan to set and monitor treatment goals, provided training for the blood glucose monitoring device and educated patients about adher-ence to their regimen.

Patients showed significant improve-ments in accepted diabetes and cholesterol indicators, including HbA1C, LDL-C and HDL-C levels, with over 50% of patients recording improvements with each phar-macist visit. After the first follow-up, A1C values decreased by 1.1% and the number of patients reaching an optimal A1C value (<7%) increased by 24.3%. Patients also showed a slight decrease in average LDL-C

concentration of 4.2 mg/dL and increase in HDL-C of 1.1 mg/dL after their first follow-up. The economic outcome of the project demonstrated net cost savings due to a large reduction in insurance claims, resulting in direct medical cost savings of $1,622 to $3,356 USD per patient, per year.

Implications: The Asheville Project dem-onstrates that pharmacists can success-fully implement and run a patient-centred, employer-payor–driven MTM program. This project provides inspiration for a new health care model where employers and public insurers can directly reimburse phar-macists for providing MTM programs.4,5 Today, the Asheville Project has expanded to include MTM services for patients with asthma, hypertension and dyslipidemia.5 Thus, pharmacist-led MTM services pro-duce results — not only improved clinical outcomes for patients and increased satis-faction for pharmacy service providers, but also considerable cost savings to the health care system.

Background or research methods: In the year 1996, the city of Asheville, North Carolina, unveiled an employer-sponsored wellness program to provide pharmaceutical care services such as education and medication therapy management to patients with dia-betes. Employees (and beneficiaries) from the City of Asheville and Mission-St. Joseph

Health System were selected to form a group of 194 patients with diabetes who enrolled in this program at no cost. The City of Asheville group and Mission-St. Joseph Health System group baseline outcomes were measured for 2 years, one serving as a comparison group to the other, then the 2 groups were combined for the intervention to increase sample size.

Long-term clinical and economic data were tracked before and after patient participation in the program. Community pharmacists in retail settings met with patients every 6 months for follow-up appointments.

Financial support: No external funding provided.