Community Pharmacy Implements Bedside MTM Service

JANUARY 26, 2015
Without a doubt, our health care system is undergoing a dynamic change. Health care professionals are all working toward the provision of a cost-effective and transformative care plan that involves the entire health care team collaborating for the benefit of the patient. Ideally, in this scenario, the patient is taking an active role in the outcome of his or her own treatment regimen.
My pharmacy department has begun to address a small portion of this enormous process. We are a medium-sized community hospital with our own outpatient clinic/community pharmacy located on campus. The pharmacy acts as an independent pharmacy serving discharge patients and employees, as well as an outpatient pharmacy resource for all physicians on campus and the community at large. 
A little more than 3 months ago, our outpatient pharmacy arranged its staffing in such a manner that would provide a pharmacist time to enter the hospital for 4 hours every morning. After 18 months of planning and presenting our idea, we were invited to participate as a member of the patient care team, with regards to discharge planning and patient medication education. The implementation of this program is described in detail here, and an initial 5-week evaluation of the program is described here.
When we were initially implementing the program, a colleague of mine warned me that goals and boundaries need to be identified and put into place. She was testifying, from her own experience, that it would be very easy in a situation like this to become overwhelmed with many little tasks and be carried away from our primary goal.
With that thought in mind, we have been continually refining and redefining our primary goal for this process.  Currently, we have settled on 2 specific and valuable functions:
  1. Participate in the 60-minute rounding of all the patients in the 2 units we are working with, specifically isolating patients with new medications that will be difficult to fill upon discharge.  Proactively obtain a prescription for discharge and asses any prior authorization needs with the patients insurance company so the medication will be ready for dispensing when the patient is ready for discharge.
  2. Perform at least 2 bedside medication therapy management (MTM) sessions each day with patients. The intent of the MTM is to asses and address the patient’s ability to adhere to their medication regimen at home and provide them with the necessary adherence tools. Depending upon the patient's alertness and willingness, we will also assess and educate the patient with regards to his or her current medication regimen. We will then follow up with 3- and 21-day phone calls in order to answer questions and troubleshoot any prescription difficulties the patient may be experiencing.
Secondarily, we are available as a discharge medication resource for the medical and nursing staff. Subjectively, we have found that by being available on the unit for 2 to 3 hours as a discharge medication resource, we are creating a new level of awareness among the hospital medical and nursing staff that a pharmacist is an important part of the patient care team.
Currently, we spend 1 hour each morning reviewing the 60 to 70 charts in an effort to identify the medications that are difficult to fill upon discharge. We have narrowed this list down to less than 15 medications, with 2 or 3 comprising the bulk of the work.

This past week, we have been working with our information technology department to build a report that we can run each morning. This report will give us this specific information so we do not need to review the charts to obtain it. Ideally, this will provide enough time so we will be able to visit 1 more patient for a bedside MTM in the morning before rounds.
Initially, the nurse case managers were confused as to why we were attending rounds; however, over the 3 months that we have been participating, we have become an important member of the patient care team.  Regularly the pharmacist in attendance is addressed directly with questions regarding all aspects of a patient’s prescription regimen.
Rounds participation requires an attentive nature and a willingness to participate. Patients are discussed in a rapid-fire process and there isn’t anyone who stops and looks over at the pharmacist to ask them if they have anything they would like to add to the discussion. The pharmacist needs to not only be prepared, but also be ready to open their mouths and voice their concern when the time presents. In order to make a difference, the pharmacist needs to speak up, state his or her concern, and offer a resolution. 

In less than 2 seconds, the team has finished discussing 1 patient and is on to the next one, so if the pharmacist has not spoken up when necessary, then the opportunity will have been lost.
Bedside MTM
Initially, the pharmacist would show up at rounds and ask the nurse case managers if they had any candidates for bedside MTMs. This was a less-than-perfect scenario, and quite often, we were fortunate if we received 1 recommendation for the day. We have been addressing this situation with various groups in the hospital and have come up with a reasonable solution. 
Every morning, the pharmacist involved in the hospital visit for the day stops by the case management office on the way into the hospital and pick up e separate reports.
·         Expected discharges for the day.
·         Patents at moderate or high risk for readmission.
·         Patients currently in the hospital who were readmitted within 30 days.
While in the nurse case manager office, the pharmacist may take a moment to say "good morning" to the nurses and inquire about any specific patients who may benefit from a bedside MTM visit. As always, direct recommendations from nurse case managers are preferable because they have already evaluated the patient and determined the need.
Fortunately, the nurse case manager who puts together the "expected discharges for the day" list also highlights patients who may benefit from a pharmacist education visit. We then take the 3 lists and compare them. Usually, 4 or 5 patients cross the border and are on all 3 lists. The pharmacist will then take those 4 or 5 patients to rounds and, as they are discussed, ascertain which 1, 2, or 3 would benefit from a bedside MTM visit the most. 
After rounds, the pharmacist now has 90 minutes to complete at least 2 bedside MTM visits and perform the electronic health record charting for the day. While charting the bedside visit, the pharmacist will also document any significant clinical coordination efforts started or completed while in rounds. 
The Future
First and foremost, we need to demonstrate value from our service if our bedside MTM visits are to continue. We have been faithfully charting our efforts with the defined conclusion so that, when we have enough data, the performance and excellence department at our hospital will evaluate our specific impact on readmission rates.

Subjectively, the program is a fantastic success. The medical and nursing staff enjoy our participation in rounds and appreciate our efforts at discharge medication coordination. 
The patients, for the most part, are receptive to a pharmacist visiting with them for 20 minutes. As patients lie in hospital beds, they are not always in the best condition to discuss their medications; however, we have found that they are more than willing to talk about adherence.

We always have a reasonable discussion about their medication process, which includes how they handle their medications from the point of reordering refills, setting them up at their home, taking their doses, and managing the entire process. This discussion allows us to identify any barriers to adherence they might face, which then leads to a discussion about adherence tools.
Historically, our pharmacy has been staffed based upon units of service provided, and bedside MTM visits and attendance at rounds currently falls outside of that staffing metric. Currently, our staffing model is covered under a small budget surplus; however, if the program does not show value, I am sure that it won't last. 
As a means for making our program permanent, we have begun discussions with the 1 accountable care organization (ACO) and medical group that are active in our community hospital. In the not-too-distant future, we may be provided funding through the ACO for a full-time positon for our outpatient pharmacy. This position would rotate into the hospital for 1 week every 3 weeks, providing 3 separate pharmacists with the opportunity to provide full-time bedside MTMs while also maintaining their skills as community pharmacists.

Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at
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