Figuring Out Comprehensive Medication Management

AACP Article

The healthcare community has reached consensus, but has a conundrum: ‘We need CMM, but how do we do it?’

By Athena Ponushis

Patients benefit from comprehensive medication management (CMM). Physicians benefit from CMM. Pharmacists no longer have to sell the need for CMM, now they just need to figure out how to implement it and sustain it. That comes from a consistent approach.

“A consistent approach to the patient care process for CMM is essential if we’re going to ensure that what we’re doing is effective, can be scaled and can be sustained,” said Dr. Mary Roth McClurg, professor and executive vice dean at the at the University of North Carolina at Chapel Hill Eshelman School of Pharmacy and the principal investigator of a rigorous study to assess the implementation and effectiveness of CMM in primary care practices.

Advancing the role of pharmacists in primary care, and advancing CMM to further the safe and effective use of medications, starts with a common language, clear intentions and consistent delivery. Schools of pharmacy are eager to put CMM into practice, and that enthusiasm was evident at the Concordia Medication Management Accelerator (CMMA) live pitch event at Concordia University Wisconsin (CUW) in November, where speeding up implementation took on a “Shark Tank” vibe.

Accelerating CMM

A personal donation of $250,000 to the CUW School of Pharmacy from Mr. Erv Dohmen was allocated for the school to do something to advance pharmacy practice in Wisconsin. Dr. Andy Traynor, chair and associate professor of pharmacy practice at Concordia, said such a broad directive got administrators thinking, “What creative things are going on around us? Where are areas of need? Where are opportunities that align with how we feel we are preparing our students to serve their communities?”

This train of thought led Concordia to the Alliance for Integrated Medication Management (AIMM), a national nonprofit known for its work with health systems, primary care clinics and community pharmacists to drive change in the delivery of care. Collaborating with AIMM and connecting with Concordia’s Batterman School of Business, Traynor said he and his colleagues started thinking, “What if we took AIMM-style coaching and processes, and the entrepreneurial experience of our business school, to our students and our local healthcare practices? We could really move the needle on advancing CMM.”

CMMA was born. Fifty-five attendees from 27 different organizations across the state came to the launch. The urgency and deep-down reason for CMM was reemphasized: better care, better outcomes, lower costs. Teams were assembled. Two tracks were laid out: the service accelerator, for established organizations looking to advance or adopt CMM within their practice, and the start-up accelerator, for businesses or innovators who had an idea that would provide a CMM service.

Teams looked to their communities and organizations to identify populations of focus and needs. Using a process known as the Business Model Canvas, teams spent five months outlining their ideas and testing them where their ideas were weak, so they could hone their work and give a solid, final pitch. They were coached over the phone, in person and online.

Then came the “Shark Tank” moment: the live pitch. Team members gave 10-minute pitches in front of four expert, CMM-savvy judges, competing for more than $60,000 in awards. Pitches were passionate, pharmacists were supported and the commitment to CMM was clear, showcasing a need to continue the charge.

“Schools need to strive for further innovation at that interface of community engagement, practice and science, and I think we also need to go into that realizing that we can’t do it on our own,” Traynor said. “There are great experts and perspectives outside our schools of pharmacy who we can collaborate with to work on these things. The work of our practice community, not just our faculty, needs to be a focus.”

A consistent approach to the patient care process for CMM is essential if we’re going to ensure that what we’re doing is effective, can be scaled and can be sustained.

Dr. Mary Roth McClurg

Early Successes

The Marshfield Clinic in North Central Wisconsin had the winning pitch for the service accelerator track, with an idea for pharmacists to provide CMM to high-risk, chronic disease patients for commercial insurers and self-funded employer groups within the clinic’s health plan. The clinic was looking for a return on investment greater than 3:1 in the provision of care to justify the continuation and expansion of that service.

Within the first six months of implementing their CMM service, pharmacists at the Marshfield Clinic have cared for 83 patients, identifying and resolving 140 drug therapy problems. “They were shooting for a 3:1 return on investment and they’ve found a 10:1 projected return on investment,” Traynor said.

The second-place finisher was the Monroe Clinic, a center that serves a number of rural counties in Southern Wisconsin. Chronic disease patients there were waiting four to six weeks to see their primary care physicians and too often ending up in the emergency department, so the team pitched that pharmacists see patients for chronic disease management and provide CMM, opening up the schedule for primary care providers to see patients with more acute issues.

Pharmacists at Monroe Clinic have been seeing patients and positive outcomes. One member of its CMMA team, a 2017 graduate of the pharmacy program at CUW, was offered a position to keep doing the CMM work he’s been doing as part of the initiative there.

“That’s really exciting to see,” said Traynor, who believes creating relationships with practice sites will invoke a sense of community and give students positive experiences to further such progressive work.

He encourages schools of pharmacy to “really engage the practice sites, the practice community, tell those stories, share those experiences and strive to involve the students, especially so they can see what I would call the vulnerability of practice advancement, that it doesn’t just happen; it takes effort.” In addition to ensuring consistent delivery in practice, it’s as important that we teach and model the process for students, and engage them in the delivery of CMM and patient care,” said Roth McClurg.

The winner of the start-up accelerator track was MedSync-Rx, a Milwaukee-based group made up of CUW faculty and a student pharmacist, for their idea to create a mobile app to synchronize prescription refills, saving time and money for patients and providers.

All CMMA teams, regardless of where their pitches placed, were invited to participate in the implementation phase. “That’s really where the big value comes in,” Traynor said. “All teams will get that implementation coaching moving forward.”

Teams will share their final results from the 18-month initiative in November 2018.

Implementation as Intended

Studying the implementation of CMM in primary care practices, McClurg, who also serves as the associate director for academic innovation at the Eshelman Institute for Innovation at UNC, has noticed that while everyone focuses on impact and effectiveness, not enough of us are focused on effective implementation. She cautions her fellow researchers: not so fast.

“If you don’t explicitly define what the intervention is and ensure fidelity to delivery of the intervention, then it’s very difficult to assess impact or effectiveness, if you don’t know what you are assessing in the first place,” Roth McClurg said. While there is certainly evidence to support the outcomes and impact of CMM, the evidence itself is inconsistent. Much of this inconsistency can be attributed to variability in implementation of the intervention, said Roth McClurg.

A clear intention and consistent delivery will create a common understanding among patients, pharmacists, physicians and other providers, allowing the service of CMM to grow. That’s why McClurg’s team has been so meticulous, defining the intervention with precision, while making it possible to replicate and scale the service, sustain it and seek payment for it.

“Payers want to know what the intervention is, what it is that they’re buying. Patients are asking what it is they will receive, and we’ve heard from providers that they need to know what it is the pharmacists on the team are doing to optimize medication use,” Roth McClurg said. “So we have spent a lot of time really trying to refine that part of it, and once you have that…then you can assess outcomes because you know what it is that you’re assessing.”

Study findings will be available near the end of the year. Funding was provided by the American College of Clinical Pharmacy (ACCP), the American College of Clinical Pharmacy Research Institute, and the UNC Eshelman Institute for Innovation.

There are great experts and perspectives outside our schools of pharmacy who we can collaborate with…the work of our practice community, not just our faculty, needs to be a focus.

Dr. Andy Traynor

‘The Big Three’ Takeaways

CMM is a patient-centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers. CMM can also be visualized in the image of a triangle, depicting CMM as having three core components to it with the patient at the center of the triangle. Through research conducted over the past year and a half, the study team has worked hard to rigorously evaluate and operationally define the core components of CMM.

The first side of the triangle would be the philosophy of practice, which is a set of professional values held within a discipline to guide the actions of practitioners, instilling trust in the care delivered. For CMM, the philosophy of practice establishes the values that guide the actions of the pharmacist as a member of an interdisciplinary team, forging trust between pharmacist and patient. Through their research, the study team arrived at five core tenets of the philosophy of practice.

The second side would be consistent approach in CMM delivery. One of the greatest developments to come out of the team’s research is the development of a common language for the delivery of CMM, articulated in a document titled, “The Patient Care Process for Delivering Comprehensive Medication Management: Optimizing Medication Use in Patient-Centered, Team-Based Care Settings,” to help ensure a consistent approach to delivering CMM.

“That’s one of the problems in the profession right now, we don’t have a consistent approach to what we do,” Roth McClurg said. “Everybody does something a little differently and we call it different things.”

This document outlines the five essential functions of CMM, and for each essential function, McClurg’s team has explicitly defined the operational definitions that make up that essential function. The team arrived at this document through rigorous research that engaged approximately 40 practice sites across the country.

The third side of the CMM triangle would be practice management. Practitioners must be mindful of the different elements of practice management that are essential as they integrate CMM into the environment, to support the effective, efficient, and sustainable use of the service. McClurg’s team developed a tool to help with this. “It walks you through the different elements of practice management and allows a site to self-assess where they are,” Roth McClurg said. “It doesn’t mean that they’re doing poorly if they’re not at a certain stage, it just gives them some sort of a barometer as to where they are and where they could go as a team.”

McClurg’s team is also assessing fidelity to the intervention, finding the exact degree to which a practice site has implemented and delivered the CMM intervention as intended. “The importance of fidelity is that when you have a well-defined intervention if people don’t implement it as it’s intended, then you might get a wide variety of ways to do something, which likely will yield inconsistent findings,” Roth McClurg said.

The Joint Commission of Pharmacy Practitioners (JCPP) has also been focused on language, approving a revised and expanded definition for medication therapy management services in February to better align with contemporary practice: “Medication Management Services are a spectrum of patient-centered, pharmacist-provided, collaborative services that focus on medication appropriateness, effectiveness, safety and adherence with the goal of improving health outcomes.”

Representatives from 13 national pharmacy organizations, including AACP, developed the definition for consideration by JCPP, examining existing terms and their use in the traditional and evolving delivery of healthcare. The definition uses the broad term medication management services (MMS) to encompass various terms, like CMM or medication therapy management (MTM), used for these services. “The definition is intended to promote better understanding of medication management services and provide consistency in how those services are defined,” said Dr. Lynette R. Bradley-Baker, AACP senior vice president of public affairs and engagement.

Comprehensive Medication Management Triangle - Patient Care Process, Practice Management Systems, Philosophy of Practice

Ongoing Work

McClurg’s team continues to learn a lot about improvement work from their practice sites. The team has taken the sites through a series of plan, do, study, act (PDSA) cycles and they will be sharing those findings later this year. They are also doing a lot of work around the patient experience with CMM and the value it brings, as well as the impact of pharmacist-delivered CMM on physician burnout and well-being.

And they are looking at implementation outcomes. “This study is just as much about effective strategies for implementation, to ensure effective implementation, as it is about does it work. I just want to say that because so many studies focus on, ‘Well, does it work? What’s the impact on cost and utilization?’ and this study will do that, those findings are still pending, but this study is as much if not more about strategies to ensure effective implementation,” Roth McClurg said.

ther findings still pending include the impact on quality metrics like diabetes, hypertension, heart failure and others, as well as the impact on healthcare utilization, largely hospitalizations and ER visits. “Then rolling all of that up into a cost analysis, hoping to generate a few different return-on-investment models for the different types of sites and cohorts that we have in the study,” Roth McClurg said.

Sustaining the Work

Recognizing the need for consistency in the delivery of patient care, the JCPP released the patient care process, applicable to any setting where pharmacists provide patient care and for any patient care service provided by pharmacists. AACP has been working on an initiative for the patient care process to be adopted into curricula and into practice.

“Our accrediting body now has this in the standards, that schools and colleges of pharmacy need to pay attention to the patient care process throughout their curricula. Just putting that in a standard doesn’t tell people what that is or how to do that,” said Roth McClurg, who hopes the dissemination of her team’s common language document will help schools in their efforts to incorporate and assess the process.

Another way by which McClurg hopes to create a community of learning around her work, she and her team are developing a technology platform that will walk a team or a site or a pharmacist through what they call a CMM implementation and improvement system. “You would enter this technology portal and you would have all of the guidance and resources you need to understand what CMM is, and then it would take you through a variety of different assessments to find out where you are and guide you through the implementation and improvement process,” Roth McClurg said.

A series of about 10 steps, some of them more interactive than others, this tool would even give participants the option of having a coach. “We’re really excited about the findings coming out of our work and we’re trying to package it in a way that can benefit the profession and healthcare, and can assist pharmacists and healthcare teams in scaling and sustaining their own services,” Roth McClurg said.

Athena Ponushis is a freelance writer based in Ft. Lauderdale, Fla.