Long-Term Care Pharmacists Can Provide Medication Therapy Management Services

Pharmacy TimesDecember 2023
Volume 89
Issue 12

Comprehensive medication reviews and drug interaction assessments are examples of clinical interventions

Beginning in 2013, Medicare Part D plans were required to offer comprehensive medication reviews (CMRs) to beneficiaries in longterm care (LTC) settings.1,2 Pharmacists have the opportunity to review patients’ prescription and OTC medications to identify and resolve any medication-related problems. Consultant pharmacists practicing in the LTC setting play an important role in providing medication therapy management (MTM) services (FIGURE3-5).

Close up view of doctor touching patient hand, showing empty and kindness- Image credit: Bongkarn | stock.adobe.com

Image credit: Bongkarn | stock.adobe.com


Consultant pharmacists practicing in LTC settings should provide the following 5 core elements through their MTM services3:

  • Medication therapy review
  • Personal medication record
  • Medication-related action plan
  • Intervention and/or referral
  • Documentation and follow-up

One systematic review of 26 studies evaluated the impact of pharmacists in LTC.3 Medication review was the most common intervention performed by pharmacists, which was evaluated in 24 studies (92%).3 Results from 7 of 11 studies reporting on the total number of medications per patient found a statistically significant reduction in pharmacotherapy with pharmacist interventions.3

Fourteen studies (54%) evaluated medication and health care costs and 4 of these studies found that pharmacist interventions led to a statistically significant reduction in costs.3 The systematic review found that pharmacists play an important role in LTC through clinical interventions, especially medication reviews.3

Another study evaluated CMRs completed by consultant pharmacists in LTC facilities.4 Pharmacists used a software program to create a cover letter, medication action plan, and personal medication list for patients. Only 3% of residents refused to participate in a CMR, and there were a total of 5392 CMRs (96% of residents) completed by consultant pharmacists during the study.4 The average age of the study participants was 79 years.4 Pharmacists provided 7527 drug therapy clinical interventions, and the most common ones included polypharmacy reduction, dosage adjustment, monitoring, and indication documentation.4 Approximately 50% of the recommendations resulted in pharmacotherapy changes, including reductions in potentially inappropriate medications (PIMs).4 Pharmacists reported a positive experience providing MTM services to residents.

The American Geriatrics Society (AGS) Beers Criteria discuss PIMs that should be avoided in adults 65 years or older.5 Pharmacists can assess patients’ drug therapy regimens in LTC settings to identify and resolve any PIMs. This is also a vital time to assess for polypharmacy and determine whether certain prescription or OTC medications can be discontinued. Pharmacists can keep an eye out for some of the classic PIMs, such as anticholinergic medications such as diphenhydramine (Benadryl; J&J).5 Anticholinergic medications can increase the risk of adverse drug events such as dizziness, dry mouth, confusion, and constipation.

The AGS Beers Criteria were updated in 2023 regarding PIMs.5 One notable update is that the AGS recommends all medications in the sulfonylurea category be avoided as first- and second-line treatment options or add-on therapies for diabetes management.5 Evidence demonstrates that sulfonylureas carry a higher risk of adverse outcomes such as cardiovascular complications, mortality, and hypoglycemia than other treatment options.5 If a sulfonylurea is needed, then it’s best to use a short-acting one such as glipizide (Glucotrol; Pfizer).5 Long-acting sulfonylureas such as glyburide (Glynase; Pfizer) are associated with a higher risk of hypoglycemia.5

Another important update to the Beers Criteria is avoiding initiating aspirin therapy for primary prevention of cardiovascular disease.5 In this situation, the risks of bleeding in older adults outweigh the benefits. Pharmacists can recommend deprescribing aspirin therapy in older adults already receiving treatment for primary prevention. Aspirin therapy should be reserved for secondary prevention for older adults with cardiovascular disease.5

About the Author

Jennifer Gershman, PHARMD, CPH, PACS, is a drug information pharmacist and Pharmacy Times contributor who resides in South Florida.


  1. 2013 Medicare Part D Medication Therapy Management (MTM) Programs. Centers for Medicare & Medicaid Services. September 12, 2013. Accessed October 10, 2013. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2013-MTMFact-Sheet.pdf
  2. Gray C, Cooke CE, Brandt N. Evolution of the Medicare Part D medication therapy management program from inception in 2006 to the present. Am Health Drug Benefits. 2019;12(5):243-251.
  3. Sadowski CA, Charrois TL, Sehn E, Chatterley T, Kim S. The role and impact of the pharmacist in long-term care settings: a systematic review. J Am Pharm Assoc (2003). 2020;60(3):516-524.e2.doi:10.1016/j.japh.2019.11.014
  4. O’Shea TE, Zarowitz BJ, Erwin WG. Comprehensive medication reviews in long-term care facilities: history of process implementation and 2015 results. J Manag Care Spec Pharm. 2017;23(1):22-26. doi:10.18553/jmcp.2017.23.1.22
  5. The 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372 J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
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