What are the best practices for pharmacy Medication Therapy Management (MTM)?

Best Practices for Pharmacy Medication Therapy Management (MTM)

Comprehensive medication therapy management (MTM) programs should include systematic medication reconciliation, thorough assessment of patient adherence, and structured medication review to optimize patient outcomes and reduce medication-related problems. 1

Core Components of Effective MTM Programs

1. Medication Reconciliation and Review

• Verify all current medications using at least two patient identifiers (name, date of birth) at both prescription entry and dispensing 2
• Review the most recent provider notes to validate treatment plans, including diagnosis, allergies, correct drug, dose and directions 2
• Assess for potential drug interactions, duplicate therapies, and toxicity risks at each patient encounter 2
• Document all clinical encounters in the patient's electronic medical record 2, 1
• Conduct medication reviews at least annually, more frequently for high-risk patients or after care transitions 1

2. Patient Adherence Assessment

• Establish a structured plan for assessing adherence at each clinical encounter 2
• Document confirmation that patient received the prescription, start date, and understanding of administration instructions 2
• Evaluate adherence through direct questioning (e.g., "Have you missed any doses in the past 3 days?") 1
• Identify barriers to adherence including financial concerns, side effects, and regimen complexity 1
• Consider appropriate adherence tools such as pill organizers, electronic reminders, and medication calendars 2, 1

3. Patient Education and Communication

• Provide written educational materials in the patient's preferred language 1
• Explain proper administration techniques, potential side effects, and drug-drug/drug-food interactions 1
• Tailor communications to specific medications and patient comorbidities 2
• Establish clear emergency and non-emergency contact points for medication questions 1
• Explain clinical parameters that patients should monitor and symptoms warranting contact with healthcare team 1

4. Safety Protocols

• Screen for high-risk medications (anticholinergics, NSAIDs, sulfonylureas) that may worsen existing conditions 2, 1
• Monitor drug toxicity, laboratory tests, and medication changes 2
• Notify prescribers promptly when compliance issues are identified 2
• Verify that follow-up visits are scheduled after initiation of new therapies 2
• Do not refill medications without verification from prescriber and patient/caregiver 2

Implementation Strategies

For Polypharmacy Management

• Conduct systematic assessment of diseases, treatments, and potential interactions 2
• Evaluate risk-benefit of each medication, especially in older adults 2
• Implement a sequenced approach to medication simplification, making one change at a time with 2-3 weeks between changes 1
• Target medications with unfavorable risk-benefit profiles for potential deprescribing 1
• Use validated tools (Beers Criteria, STOPP/START) to identify potentially inappropriate medications 1

For Special Populations

• For dialysis patients: Perform medication reconciliation at least monthly, with particular attention to altered pharmacokinetics 2
• For older adults: Assess for anticholinergic burden, fall risk medications, and inappropriate medications based on kidney function 2, 1
• For patients with multiple chronic conditions: Involve patients in expressing their personal values and treatment priorities 2

Outcomes and Monitoring

• MTM interventions improve medication appropriateness and adherence 3
• Structured MTM programs involving pharmacists have shown reduced hospitalization rates and costs, particularly for patients with diabetes and heart failure 3, 2
• Monitor clinical parameters (blood pressure, blood glucose), medication adherence, and patient satisfaction 1
• Document all MTM interventions and patient understanding in medical records 1

Common Pitfalls to Avoid

• Relying solely on patient self-reporting for adherence assessment 1
• Assuming medication lists from electronic health records are accurate 1
• Using judgmental attitudes when discussing adherence issues 1
• Adding new medications without discontinuing others, increasing regimen complexity 1
• Neglecting patient preferences in medication management decisions 2, 1

By implementing these evidence-based MTM practices, pharmacists can significantly improve medication use, reduce adverse events, and enhance patient outcomes while potentially lowering healthcare utilization and costs.