On August 3, 2004, the Centers for Medicare and Medicaid Services proposed a rule to include Medication Therapy Management Services (MTMS) as part of the Medicare Prescription Drug Benefit. This regulation has the ability to change the face of community pharmacy practice by offering compensation for pharmacists to provide MTMS.
The first step toward medication management is understanding and managing the disease state that warrants the medication. It is very important when community pharmacies are creating medication management programs that this significant piece of the puzzle is not overlooked.
The next step is to decide what services can be offered for certain disease states and medication management. This article will discuss 3 disease state/medication management programs that have been successful in a community pharmacy setting and the measures needed to implement them: hypertension, hyperlipidemia, and diabetes.
Monitoring hypertension involves assessment of blood pressure (BP) on a routine basis as well as education in proper medication utilization. One way to incorporate both of these ideas into a valuable service is the "Blood Pressure Club."This service consists of offering BP readings as well as medication management for a specific fee, dependent on the duration of membership. For instance, a 1-month membership may give patients the opportunity to come in as often as they choose, during normal business hours, for a BP reading and medication management.
The resources needed to start such a program include a confidential area in which to meet with patients, a sphygmomanometer with a stethoscope, charts to record visit information, and appropriate patient education materials. The visits should include measurement of BP and a complete medication history, and any recommended changes in therapy should be provided to the patients'physician for review. This valuable service allows the pharmacist to assist in the management of patients'hypertension, while building a provider relationship with their physicians.
Technology has provided a safe and efficient way to monitor cholesterol and liver function outside of the doctor's office or hospital. A system such as the Cholestech LDX allows the pharmacist to collect a blood sample by a finger stick and to run a complete lipid panel or test alanine aminotransferase (ALT) in just 5 minutes. The results can be provided to the patient and the physician and can be interpreted during the initial visit. The resources needed to start the program include a confidential area to test cholesterol and conduct visits, appropriate Occupational Safety and Health Administration Blood Borne Pathogen training for participating pharmacists, the testing machine and materials needed, charts to record levels and visit information, and appropriate patient education materials.
Monitoring cholesterol levels can identify patients with unknown hyperlipidemia who need referral to a physician. For patients with diagnosed hyperlipidemia, monitoring levels provides an assessment of progress made through lifestyle modifications or medication management. Many patients on medication for cholesterol also will need to have their liver function assessed routinely. A system such as the Cholestech LDX can be used to monitor ALT liver function, and levels can be provided to the patient and the physician in just a few minutes. The cholesterol service is quicker, more convenient, and oftentimes cheaper for patients with limited or no insurance coverage for laboratory work.
It is important to understand that the assessment of cholesterol is only a screening tool that will determine how the patient visit should be completed. The greatest feature of the pharmacy service is not measuring the cholesterol levels, but instead providing education in managing these levels. The pharmacist must interpret the different measurements on the cholesterol panel (total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides) and provide goals for each. Patients must be assessed for cardiac risk based on established risk factors and should be referred to a physician immediately if goals are not met. At each visit, the pharmacist must reinforce the need for lifestyle modification and provide patients with their own personal dietary and fitness goals.
The success of this program depends greatly on establishing open lines of communication with each patient's physician and gaining trust and respect through repeated correspondence. A great benefit of an established relationship with a physician is that, when patients present with a need for referral, the pharmacist will know whom to call.
Diabetes as a disease requires extensive education, complicated medication therapy, routine monitoring, and intensive lifestyle modifications. The needs of patients with diabetes open many doors for community pharmacy services. One of the many possible services is blood glucose meter training. A meter training service requires only a confidential space in which to conduct the patient visit. The pharmacist can educate the patient on everything there is to know about the meter and blood glucose monitoring. This education is often neglected in a doctor's visit due to time constraints. When it is given in the counseling window of the pharmacy, it may be condensed to a 5-minute review.
Meter training service involves how to change settings and all the operations of the meter, how to use the lancet and strips to test appropriately, goals for blood glucose levels, when to test, and education on the importance of recording readings for managing diabetes. This service offers more than is expected in a normal counseling session, and most patients will recognize its value.
This brief description of pharmacy services does not begin to capture all the opportunities available. It is hoped, however, that this article has provided some insight into how some pharmacies have gotten started in providing MTMS.
Dr. Downing is a clinical coordinator for Kerr Health Care Center, Raleigh, NC.
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