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Comprehensive Medication Management in Pharmacy Practice

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A recent study calculated the cost of prescription drug related morbidity and mortality to be $528.4B.[1] Given the enormous cost and impact on expenses and lives, many health systems and provider groups are working to assess their current medication therapy management programs and implement changes. One effective method that’s being adopted by many is comprehensive medication management, which engages clinical pharmacists as part of the care team and empowers them to lead the optimization of medication management.

Comprehensive medication management is a pharmacy practice that goes beyond medication review and patient education. It includes monitoring high-risk patients post-discharge to avoid adverse drug events (ADEs), and modifying medication regimens to ensure efficacy and reduce unnecessary prescriptions. This is a shift from the pharmacist doling out pills and counseling patients from behind the pharmacy counter. Many clinical pharmacists delivering these services are residency trained, and as such are skilled in delivering patient care and services. They coordinate care with discharge nurses and physicians, are embedded in PCMHs and primary care clinics, and often have clinic hours during which they see patients by appointment. 

Here are 4 ways that clinical pharmacists practice comprehensive medication management services.


1. Conduct post-discharge medication review, education, and follow up for high risk patients.

Elderly patients with multiple conditions and medications, inpatients with congestive heart failure (CHF), diabetics on high risk medications, patients on blood thinners, and patients who have low health literacy. These are just a few examples of populations that a clinical pharmacist focuses his or her attention on for the first 60-90 days after hospital or emergency room (ER) discharge. By proactively identifying and following these patients, clinical pharmacists ensure that prescribed medications are taken correctly and therapy is appropriate based on the patient’s condition and comorbidities. These actions have been shown to reduce ADEs and readmissions.

As an example, Novant Health, an integrated system in the southeast, analyzed its discharge data to learn that about 20% percent of Medicare beneficiaries were being re-hospitalized within 30 days of discharge (34% within 90 days).

According to the system’s own analysis, 90% of these readmissions were unplanned, and estimated to cost $17.4 billion a year. To address this, Novant Health revised its discharge and follow up processes to better identify high risk inpatients and improve discharge communication and counseling with them, establish guidelines for discharge nurses to refer patients to a pharmacist, and integrate clinical pharmacists into the medication review and follow up of high risk patients after discharge from the hospital and ER. The result was a statistically significant reduction in 30 and 60 day readmissions, as compared to a control group.[2]

2. Develop individual medication therapy plans for each patient.

Similar to how physicians develop individualized, clinical treatment plans, a clinical pharmacist meets with patients to design an appropriate plan for medication therapy. This plan is based on a variety of factors that include the patient’s clinical condition, socio-economic status, age, and health literacy. The goal is to develop an effective plan that patients can understand and adhere to.

Goodrich Pharmacy in Minneapolis/St. Paul, MN is a multi-site, independent pharmacy that offers such services, by contracting with primary care clinics and offering consultation hours with patients. The clinics pay Goodrich Pharmacy a bundled payment to work with their patients, and provide access to their electronic health record (EHR) so that pharmacists can review clinical notes, lab and test results, and other data. Goodrich Pharmacy conducts more than 3,000 pharmacy consultations with patients each year and has a goal of eventually deriving 50% of its revenue from patient visits.[3]

Pharmacists looking to move their practice to one that offers comprehensive medication management can speed their program development by reviewing this guide, developed by the College of Psychiatric and Neurologic Pharmacists. It includes a toolkit for implementing a comprehensive practice model, offering resources such as the Essential Elements of a Patient Care Practice, and a variety of forms and checklists such as an Enrollment Form, Case Review Template, and Checklist for Patient Visit.

3. Deliver follow up and ongoing care as part of a PCMH model.

In a busy primary care clinic, it’s challenging to provide patients with thorough counseling and educational information to drive adherence. Clinical pharmacists augment the team in a PCMH by following patients between visits to ensure medications are properly titrated and outcomes are being achieved.

The pharmacist calls, securely messages, or schedules a telehealth visit with a patient to check in at scheduled intervals or when there has been a medication change. For instance, the pharmacist may contact a diabetic patient to discuss glucose levels after a dosage change or the initiation of a new medication. Or, if the PCMH has a remote patient monitoring system, the pharmacist may contact a CHF patient when there is an alert about a sudden weight gain, in order to discuss adherence to a prescribed diuretic, or the patient’s dietary choices.

The conversation and education are tailored to the patient based on their health literacy and condition, often using motivational interviewing (MI) techniques. The pharmacist is empowered to add, remove, modify dosages as appropriate, based on accepted clinical protocols and collaborative practice agreements with the provider group.

4. Round with physicians visiting nursing homes or conducting home visits.

Because clinical pharmacists who deliver comprehensive medication management services are an integral part of the care team, they often accompany a physician when he or she rounds on patients. CareMore, a Medicare Advantage/Medicaid payor, provider and clinic network that serves 150,000 patients in 9 states, employs clinical pharmacists to oversee medication optimization for patients in their Care to You plan. In addition to reviewing records and optimizing medication plans remotely, pharmacists periodically accompany physicians and nurse practitioners when they see patients in nursing homes and residential care facilities.

[1] Watanabe JH1, McInnis T2, Hirsch JD1, Cost of Prescription Drug-Related Morbidity and Mortality, Annals of Pharmacotherapy, September 2018. Epub 2018 Mar 26. https://www.ncbi.nlm.nih.gov/pubmed/29577766. Last accessed, 1/5/19.

[2] Leveraging Pharmacists to Reduce Costs and Improve Medication Adherence in High-Risk Populations, Healthcare Intelligence Network Special Report, 2017. Available at www.hin.com.

[3] McInnis, T. Capps, K. Get the medications right: a nationwide snapshot of expert practices—Comprehensive medication management in ambulatory/community pharmacy. Health2 Resources, May 2016

Whitepaper: Medication Management Challenges and Opportunities for Payers and Providers


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