Medication therapy management in interprofessional heath care

Student pharmacist Samuel Akinyele noticed on her chart that Maria's blood sugar was too high. He suspected that her insulin dose was too low. Akinyele reviewed her medications with volunteer pharmacist Faramarz Zarfeshan, RPh, who brought a physician and other team members into a huddle.

Akinyele and other University of Maryland School of Pharmacy students at the Mercy Health Clinic in Gaithersburg, Md. are learning firsthand about the remarkable effectiveness of medication therapy management (MTM), a hot new pharmacy trend in interprofessional heath care.

Meanwhile, patients in the MTM program are getting better all the time, says Mercy's medical director Nancy Ripp Clark. She says MTM provides some underserved patients with medication reviews while it provides experiential rotations for fourth year pharmacy students and pharmacy residents.

In 2009, the School of Pharmacy, ALFA Specialty Pharmacy of Columbia, Md., the Primary Care Coalition of Montgomery County, and the free, not-for-profit Mercy Health Clinic collaborated to provide MTM in an interprofessional model. At Mercy, patients with high risk, multiple medical conditions, and multiple medications are referred to MTM for medication reviews and management.

Results from clinical outcomes data analysis of patient health confirm team members' observations of a resounding success for the model.

The model is also receiving national recognition. Most recently, the American Diabetes Association presented the MTM team with its Promising Practice Award of Excellence.

The team includes three pharmacists, two physicians, two nurses, two pharmacy residents, and three pharmacy students at a time, plus, when needed, language interpreters, nutritionists, and social case workers. In the first 18 months, 130 patients have been seen and more than 1,000 medications reviewed, averaging eight medications per patient.

In Maria's case, the MTM team reached a collective decision to switch the 50-year-old Spanish- speaking patient to a different type of insulin that would better disseminate throughout her bloodstream and better suit her lifestyle. Maria's problem might have lingered without the MTM teamwork approach and was perhaps partly due to her language barrier. She couldn't explain that she is not able to medicate several times a day.

With MTM, pharmacists' time with the patients is invaluable, says Mercy Health Director Clark. "Pharmacists provide in-depth health care and excellent teaching. As pharmacists they have given us insight into certain channels for ordering certain types of medications. They are very up to date on medication interactions and side effects," Clark says.

Each pharmacy student sees five patients every Thursday. They review the patients' medications, take their blood pressure and pulse, and discuss any side effects. "One of my patients today was taking meds from somewhere else, and I reviewed this with Dr. Zarfeshan," says Akinyele.

According to Rosemary Botchway, MS, director for the Center for Medicine Access at the Primary Care Coalition (PCC) of Montgomery County, the program now offers free access to 38 generic drugs. Also pharmaceutical companies, through a program called Medbank, provide free brand name medications to people who cannot afford to buy their medicine. The PCC is a private, non-profit, charitable organization working with public/private partners to provide high-quality, accessible, equitable, efficient, and outcome-driven health care services for low-income, uninsured County residents.

"I am very excited to be part of the team here," says the PCCMC's community pharmacy coordinator, Tanya Dang. She analyzes the clinical outcomes data from patient charts and sends it to the Health Resources and Services Administration (HRSA). "That helps tell our story at the national level." The federal agency set up a national initiative of collaboration with a goal "to provide health care quality and outcomes through integration of evidence-based clinical pharmacy services within interprofessional health care teams," states the HRSA web site.

Each month Dang participates in a conference call with HRSA. "The monthly conference makes me so happy to realize that the patients are definitely getting better," she says. There are 128 HRSA-associated collaboratives nationwide. The MTM model is the only such collaborative in the state.

Clark and Botchway say the MTM teamwork provides a better review of patients' medications because physician visits are typically short. The collaborative plans to expand to a similar clinic, the Proyecto Salud in Wheaton, Md., this fall.

The MTM model serves multiple purposes in education, says Heather Congdon, PharmD, CACP, CDE, assistant dean for the School of Pharmacy's campus at the Universities at Shady Grove, where many of the students rotating at Mercy matriculated. "The education the students received here crosses health care lines. There is no limit to what can be learned in such a collaborative atmosphere." She is also a provider at the MTM clinic and a certified diabetes educator. She provides diabetes education and monitoring for patients in the program who have diabetes.

"I am amazed by the dedication and leadership of the team and our collaborative partners, and thankful for this distinctive rotation opportunity for our Doctor of Pharmacy students who get to witness the power of collaboration and gain experience in real-world patient care to prepare for their practice as pharmacists," says Hoai An Truong, PharmD, MPH, acting director of the School's Experiential Learning Program, assistant professor of pharmaceutical health services research, and an MTM pharmacist.

"It's a health care playground for education," adds Zarfeshan, "both in patient relationships and data gathering. They work as a team and everything is done under the same roof." He says the MTM model has "a huge potential for the pharmacy profession to impact the general health of the American population, while reducing national health care costs. Many patients go to multiple doctors of different practices. Here all of this can be channeled in a central location."

Zarfeshan says that pharmacists "are in a great position to give the patient the right information. We have a vision to make a difference for the health care system."