- Email: [email protected]
Integrating home-based medication therapy management (MTM) services in a health system
SCIENCE AND PRACTICE Journal of the American Pharmacists Association 56 (2016) 178e183
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
EXPERIENCE
Integrating home-based medication therapy management (MTM) services in a health system Shannon Reidt*, Haley Holtan, Jennifer Stender, Toni Salvatore, Bruce Thompson a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 18 January 2016
Objectives: To describe the integration of home-based Medication Therapy Management (MTM) into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. Setting: Minnesota from September 2012 to December 2013. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. Practice innovation: Home-based MTM was promoted throughout the clinics within the health system. Physicians, advanced practice providers, nurses, and pharmacists could refer patients to receive MTM in their homes. A home visit had the components of a clinic-based visit and was documented in the electronic health record (EHR); however, providing the service in the home allowed for a more direct assessment of environmental factors affecting medication use. Evaluation: Number of home MTM referrals, reason for referral and type of referring provider, number and type of medication-related problems (MRPs). Results: In the first 15 months, 74 home visits were provided to 53 patients. Sixty-six percent of the patients were referred from the Internal Medicine Clinic. Referrals were also received from the senior care, coordinated care, and psychiatry clinics. Approximately 50% of referrals were made by physicians. More referrals (23%) were made by pharmacists compared with advanced practice providers, who made 21% of referrals. The top 3 reasons for referral were: nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse. Patients had a median of 3 MRPs with the most common (40%) MRP related to compliance. Conclusion: Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service. © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Home-based health care has been shown to benefit patients with a broad range of needs. Post-stroke rehabilitation delivered by home-health physical therapists has improved activities of daily living and gait speed.1 Home-based nursing programs have demonstrated improvements in patients' clinical outcomes such as fatigue, activities of daily living, and
Disclosure: This project was supported by the Metropolitan Area Agency on Aging Title IIID Health Promotion Program. * Correspondence: Shannon Reidt, PharmD, MPH, BCPS, 308 Harvard St. SE, WDH 7-103, Minneapolis, MN 55415. E-mail address: [email protected] (S. Reidt).
quality of life in patients with stage two or three chronic obstructive pulmonary disease.2 These programs have also improved patient self-efficacy in chronic-condition self-management, including asthma, chronic obstructive pulmonary disease, diabetes, coronary artery disease, hypertension, and congestive heart failure.2,3 Home-based nursing has demonstrated improvements in clinical outcomes such as blood pressure, weight, and blood glucose levels.3 Delivery of care in the home is beneficial for those with limited access to clinics and those with poor or questionable self-management of their disease state(s) and medication regimens.4 Home-based care also provides invaluable information to clinicians about a patient's living environment.4
http://dx.doi.org/10.1016/j.japh.2016.01.003 1544-3191/© 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE Home-based MTM in a health system
Key Points Background: Many other health professions, including medicine, nursing, and therapy, have a history of providing home-based care; however, few descriptions of home-based MTM exist in the literature. Home-based MTM programs have been described that target patients recently discharged from the hospital where the pharmacist providing care is associated with a health system or a home care agency. Findings: Patients with a history of nonadherence, transportation barriers getting to a pharmacy or clinic, or with home health care nurses may be good candidates for home-based MTM. Care coordination and documentation of services in the health-system EHR are essential to successful integration of home-based MTM.
Health care providers such as physicians, nurses, and physical therapists have a history of providing care in patients' homes; however, home-based pharmacist services are much less established. Some home-based pharmacist services have focused on patients who take specific medications, such as warfarin, or have specific conditions, such as heart failure.4-6 Other services have targeted patients who have recently been discharged from hospital.7-9 Benefits of pharmacists' interventions in these patients include improvement of patients' self-management of medications,9 decreased emergency room visits, and decreased hospitalizations.8 In one study, patients who received home-based MTM after hospital discharge were 40% less likely to have an emergency room visit or hospitalization than those receiving usual care.8 Similarly, pharmacists have rated 70% of their home-based interventions as having a “dramatic” or “substantial” improvement on the patients' abilities to manage their medications.9 The benefits of pharmacist-provided MTM have been well documented.10-13 Pharmacists have provided MTM to patients in clinics and pharmacies; however, these environments may have barriers. For example, MTM may be difficult to provide in busy community pharmacies.14 The health system involved in this article observed that some patients had transportation barriers preventing them from getting to a clinic or pharmacy and others did not feel comfortable bringing medications to these locations for an MTM visit. Some patients with caregivers who should participate in an MTM encounter were unable to attend appointments at a clinic or pharmacy. The health system hypothesized that providing MTM in a patient's home may overcome these barriers and identified a need for improved care coordination between primary care providers (PCPs) and home health care care nurses and increased support for nonadherent patients. The health system looked to home-based MTM to meet these needs. Although providing home-based pharmacy services is not a new idea, the present
article adds to the literature by describing how a health system with well established MTM services may implement homebased MTM. Although other home-based pharmacy services have targeted specific populations, this practice is innovative by targeting a wider ambulatory patient population. Objectives The objective of this article is to describe the integration of home-based MTM into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. Practice description Hennepin County Medical Center (HCMC) has been providing MTM services since 2006. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. Services provided include comprehensive medication review, targeted disease state management, therapeutic drug monitoring, patient education, and adherence support. Primary care clinics are patient-centered medical homes, and pharmacists are able to use protocols to modify patients' medication regimens. Annually, pharmacists conduct approximately 10,000 MTM encounters and receive reimbursement primarily from Minnesota Medicaid. However, all insurers are billed for services. All MTM pharmacists undergo a credentialing and privileging process through the HCMC Office of the Medical Director, and appointment is renewed every 2 years. They are additionally credentialed as MTM Providers through insurance plans as able. The department is supported by a full-time MTM support analyst, a former community pharmacy technician, who assists with patient billing, scheduling, data reporting, and quality assurance initiatives. Practice innovation HCMC began providing home-based MTM in 2012. One pharmacist was designated as the home visit pharmacist and devoted 0.2 full-time equivalent to home-based MTM. Because the pharmacist had previous experience providing homebased MTM, no training related to home-based care was provided. The health system does provide personal safety training classes that would have been required otherwise because the pharmacist conducts visits alone. Components of a homebased MTM visit were designed to be similar to a clinic-based MTM visit to promote consistency across the health system. During the home visit, the pharmacist evaluates all medications and over-the-counter (OTC) products for indication, effectiveness, safety, and convenience and compliance. Because the visit occurs in the home, the patient's caregiver can easily participate in conversations related to medication use, and the pharmacist can observe the environment in which medications are taken and stored. The patient and pharmacist devise a plan for medications that is documented in the electronic health record (EHR). Updated medication lists are shared with non-HCMC providers, such as community pharmacies and home health care nurses, by fax. If more information needs
179
SCIENCE AND PRACTICE S. Reidt et al. / Journal of the American Pharmacists Association 56 (2016) 178e183
to be shared, the pharmacist calls pharmacies and home health care nurses instead of faxing a visit note. For example, the pharmacist often calls community pharmacies to discontinue prescriptions that have been changed or discontinued by prescribers. When registering with the health system, each patient signs a patient authorization and consent form which allows health system providers to share information with those outside of the health system. The pharmacist informs the patient of any information that will be shared with health care providers. The pharmacist obtains additional consent if records from an outside institution are needed. The pharmacist communicates recommendations to modify medications to HCMC providers through the EHR. Wireless access to the EHR while in a patient's home has been cost-prohibitive; as a result, the pharmacist reviews the patient's chart before the home visit. Because organizing medications occurs during the home visit, the pharmacist travels with pillboxes, markers, rubber bands, and other organization tools. The pharmacist brings a blood pressure cuff to all visits. If the medication list is updated during the home visit, an updated list is mailed to the patient after the visit. Because Medicare Part D plans are not billed, a Medication Action Plan is not given to the patient at the completion of the visit. Instead, instructions for the patient discussed during the visit are written down and left in the patient's home.
conditions, a medication list, a narrative of patient symptoms and concerns, laboratory values and vital signs, conditionspecific assessment and plan, including recommended medication changes and patient education needed, assessment of medication adherence, a succinct list of medication-related problems (MRPs), and time spent with the patient. In addition to these elements, home-based MTM notes include a brief narrative of the patient's living situation. For example, the pharmacist documents if the patient lived alone or in an unkempt environment. A “home visit” encounter type is created in the EHR so that when providers and schedulers look at a patient's appointments, they would recognize when a homebased MTM visit is scheduled as opposed to a clinic MTM visit. This prevents patients from having clinic appointments scheduled right before or right after a home visit. When home-based MTM was established, the goal was to use a home visit as a bridge to the clinic. After a home visit, a patient would receive follow-up MTM in the clinic. To promote this continuity of care, communication among the home visit pharmacist and the rest of the care team was essential. Home visit notes were shared with a patient's PCP, clinic pharmacist, and any other specialty providers via the EHR. Additionally, the home visit pharmacist communicated with community-based providers such as community pharmacies and home health care nurses.
Recruitment and scheduling
Billing for services
Initially, hospital discharge patients at high risk of readmission were targeted, and home visits were scheduled at the point of hospital discharge. The objective of targeting these patients was to schedule a home visit within 1 week of hospital discharge. This method was unsuccessful because scheduling a home visit was logistically difficult when many other post-discharge appointments were being scheduled. Feedback from Nurse Clinical Coordinators indicated that the discharge process was already overwhelmed by numerous readmission-reduction initiatives, and scheduling home visits was easily overlooked. As a result, the focus was changed to patients in ambulatory care clinics. Providers, including physicians, advanced practice providers (i.e., nurse practitioners and physician assistants), registered nurses, and pharmacists were educated about home-based MTM. Pharmacy leaders attended department meetings across the health system to give presentations describing what home-based MTM was, what patients were candidates, and how to place referrals. Providers were encouraged to refer a patient for home-based MTM for the following reasons: transportation barriers getting to the clinic, patient unwillingness to bring medications to the clinic, and concerns that environmental factors were affecting medication use. Providers ordered a referral in the EHR, which alerted the MTM support analyst to contact the patient to schedule a 60minute new patient appointment. No geographic restrictions were placed on who could receive home-based MTM.
Charges for services are entered in the EHR and processed by the billing department. In Minnesota, Medicaid and one commercial insurance plan cover MTM delivered in the homes of those patients who take 3 or more prescription medications to treat or prevent one or more chronic conditions.15 Reimbursement rates for home-based MTM are the same for MTM delivered elsewhere (i.e., clinic or pharmacy) and are based on the number of medications and conditions reviewed and the number of MRPs identified. Facility fees are not used for homebased MTM. The health system bills all insurers for MTM visits whether they are provided in clinics or in the patient's home. If coverage for MTM is not provided by the insurance, patients may incur a bill. The health system has negotiated contracts with insurers to cover clinic-based and home-based MTM as MTM services have expanded. In addition to revenue from insurance payments, the health system had a contract with the Metropolitan Area Agency for Aging that supported the cost of home visit for patients 60 years of age and older. The health system reimburses the pharmacist for mileage expenses incurred travelling to patients' homes.
Documentation of services and care coordination A documentation template was created for home-based MTM that mirrored the template used for MTM provided in the clinic. Clinic-based MTM notes include a list of medical 180
Evaluation Home-based MTM was evaluated by the number of referrals, the reason for referral, type of referring provider and the number and type of MRPs. Continuity of care was measured by whether or not patients received clinic-based MTM within 120 days after a home-based MTM visit and whether they received follow-up care from their PCP within 120 days after a home-based MTM visit to address problems identified during the home visit. The PCP was not necessarily the referring provider but was defined as the provider (physician, advanced practice provider) designated in the EHR.
SCIENCE AND PRACTICE Home-based MTM in a health system
Data were collected from the EHR and entered in a Microsoft Excel spreadsheet. Descriptive statistics were used for age, sex, race, referral type and referral reason, and follow-up time with pharmacists and PCPs. Approval was granted by the Institutional Review Board (IRB) of the health system and the University of Minnesota. Results From September 2012 to December 2013, 74 home-based MTM visits were provided to 53 patients. Fifty-five percent of patients were 65 years of age or older, and approximately one-half were black (55%) and female (57%). Patients took a median of 12 prescription and over-the-counter (OTC) medications and had 7 chronic conditions (Table 1). Most patients received 1 home visit; however, 8 patients received more than 1 home visit (range 3 to 9). Patients who were unable or unwilling to see a pharmacist in clinic to follow up on medication changes or adherence counseling received more than 1 home visit. A majority of home visits occurred within a 10-mile radius from the hospital; however, patients living up to 20 miles from the hospital were also seen. The pharmacist spent approximately 10 minutes reviewing the patient's chart before the home visit, and the visit lasted from 30 to 60 minutes. The pharmacist spent approximately 15 minutes documenting each visit. Sixty-six percent of the patients were referred from the Downtown Internal Medicine Clinic, and approximately 50% of referrals were made by physicians. The most common referrals were for patients with nonadherence or transportation barriers preventing them from receiving MTM in the clinic. Additionally, patients who had home health care nurses were often referred, so the pharmacist could reconcile the medications being set up in pillboxes with those on the health system medication list. Nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse accounted for 51% of all referrals. Referrals for patients Table 1 Patient demographics (n ¼ 53) Patient characteristics Age (y) 18e50 51e64 65 Sex Male Female Race Black White American Indian Asian Other Insurance type Medicaid Medicare Commercial Uninsured No. of medications (Rx and OTC) per patient, median (range) No. of medical conditions per patient, median (range) No. of medication-related problems per patient, median (range)
No. of patients (%) 7 (13) 17 (32) 29 (55) 23 (43) 30 (57) 29 20 2 1 1
(55) (38) (4) (2) (2)
4 29 19 1 12
(8) (55) (36) (2) (4e49)
7 (3e17) 3 (0e6)
Table 2 Home medication therapy management (MTM) patient referrals Home MTM referral Clinic Internal medicine Senior care Coordinated care Psychology Provider type Physician Advanced practice provider (nurse practitioner, physician assistant) Pharmacist Registered nurse Patient self-referral Referral reason Nonadherence Transportation barriers Medication reconciliation with public health nurse Will not bring medications into clinic Medication review with caregiver History of no-show clinic appointments Medication reconciliation Hospital discharge follow-up Medication organization Polypharmacy
No. of referrals (%) 33 12 7 1
(62) (23) (13) (2)
27 (51) 11 (21) 12 (23) 1 (2) 2 (4) 9 (17) 9 (17) 9 (17) 7 6 4 4 2 2 1
(13) (11) (8) (8) (4) (4) (1)
with caregivers who could not attend clinic appointments and patients who did not want to bring medications to the clinic were also common (Table 2). Regarding continuity of care, 54% of patients saw their PCP within 30 days of the home visit to address problems identified during the home visit, and 92% followed up with their PCP within 120 days. Within 30 days of the home-based MTM visit, 11% of patients followed up with a clinic pharmacist, and 17% followed up within 120 days (Table 3). MRPs were identified at each home visit and were classified according to type: indication, effectiveness, safety, and compliance.16 A median of 3 MRPs were identified at each home visit. The most common problems identified (40%) were associated with compliance (Table 4). Compliance-related problems were classified for patients who did not understand how to use their medications or preferred not to take their medications. Patients were often using medications, such as inhalers and insulin pens, incorrectly. Compliance-related problems also classified those
Table 3 Continuity of care after home MTM visit (n ¼ 53) Measure
No. of patients (%)
Days elapsed between MTM visit and clinic visit 1e14 0 15e30 6 (11) 31e60 4 (8) 61e120 5 (9) No clinic MTM 34 (64) Days elapsed between home MTM visit and PCP follow-up 1e14 14 (26) 15e30 15 (28) 31e60 10 (19) 61e120 10 (19) No follow-up 4 (8) Abbreviations used: MTM, medication therapy management; PCP, primary care provider.
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Table 4 Medication-related problems identified Medication-related problem Indication Effectiveness Safety Compliance Total
n (%) 35 (18) 44 (22) 39 (20) 80 (40) 198
instances when patients were using expired or family members' medications. The pharmacist made interventions during the home visit that were typical of clinic-based visits. For example, the pharmacist recommended laboratory monitoring and initiating, discontinuing, or modifying medications. Having access to all medications in the home, the pharmacist was also able to make interventions that may have been difficult to make in a clinic. For example, the pharmacist eliminated duplicate bottles of medications or expired medications and identified a safe and convenient location to store medications. Medication disposal and organization were typical interventions that occurred when patients were using more than 1 pharmacy or continued to receive refills for medications that had been discontinued by a prescriber. Medications were disposed of in the patient's home according to Food and Drug Administratione recommended practices,17 and the pharmacist documented the names of the disposed medications in the EHR. Because 40% of identified MRPs related to compliance, adherence counseling interventions were common. The pharmacist worked with the patient to develop strategies to improve compliance. By observing the patient in his or her home environment, the pharmacist was able to suggest ways that the patient could incorporate taking medications into his or her daily routine. The pharmacist's assessment of compliance often uncovered reasons, besides forgetfulness, for noncompliance, such as not understanding directions, fear of side effects, belief that medications would not work, or poor coordination with caregivers and home health care nurses. When such reasons were uncovered, patients sometimes reported that they would not be willing to have in-depth and candid conversations about compliance in a clinic or pharmacy. Once reasons for noncompliance were identified, the pharmacist and patient agreed on appropriate interventions. Common interventions included patient education tailored to the patient's interests and concerns. Discussion Home-based MTM met the needs of the health system by helping patients with a history of nonadherence and bridging communication gaps between the health system and community-based providers. Home visits offered an opportunity for caregivers, such as personal care attendants, to be involved in the medication assessment, which was important given their valuable insight in identifying and overcoming barriers to compliance. Referral reasons observed in this project may identify patient populations that should be targeted to receive this service. Providers often referred patients with a history of nonadherence that could not be fully understood in the clinic. In the patient's home, the pharmacist could observe environmental factors that might be affecting
182
adherence and could make appropriate interventions. Patient complexity and number and type of MRPs observed in this study are similar to those reported by Reidt et al., who also found compliance-related problems to be the most prevalent. The interventions in this paper are similar to those reported in other studies8,9 that emphasized patient education and care coordination between health systems, home care nurses, and community pharmacies. Patients were referred by providers who were unable to reconcile medications with home care agencies or caregivers. In these cases, medication changes had often been made but were not clearly communicated to the home care agency or caregiver, and providers were uncertain what medications were being set up in a patient's pillbox. Home-based MTM enabled a pharmacist to inspect the pillbox, resolve discrepancies with a home care nurse or caregiver, and collaborate with the nurse or caregiver to develop a care plan to resolve any MRPs. In these cases, the pharmacist was the bridge between the health system and the patient's home support system. There was a low volume of home visits provided during the first 15 months that this service was available, and most patients received only one encounter. The health system expected a low volume of service because home-based MTM was viewed as an option for a select group of patients who were not able to access MTM in the clinic or for whom clinic-based MTM had not resolved all MRPs. Home-based MTM was designed to be a consultative service where the pharmacist would provide a limited number of in-home encounters and then facilitate follow-up with clinic pharmacists. Follow-up with PCPs was much more common than follow-up with clinic pharmacists and this is an area for improvement. The home visit pharmacist often assisted the patient in setting up a PCP appointment, which may explain the high rate of PCP follow-up rate. This same assistance was not provided for follow-up with clinic pharmacists but will be in the future. Promotion of this service primarily relied on word of mouth, which may also explain the low volume of patients served. Because many of the health system clinics are staffed by medical residents who are rotating through clinical sites, communicating information about the service was difficult. Although not formally tracked, very few patients refused a home-based MTM visit. Patients were more likely to agree to the service if the referring provider had discussed the service with the patient before the MTM support analyst called the patient to schedule the visit. Payment for home-based MTM is a limitation to its implementation. Few reimbursement opportunities exist in fee-for-service models, although our health system has successfully included reimbursement for home-based MTM in contract negotiations with insurers and has had grant funding to help cover costs. Currently, the cost of delivering homebased MTM is greater than revenue from insurance payments; however, the health system sees value in this service, because it provides MTM to patients who have a history of nonadherence and may not otherwise access MTM. The health system has made changes to improve the service since its initiation. Coordinating home-based MTM visits with home health care nurse visits has made communication between the pharmacist and nurse more efficient. Reminder calls to patients one day before the home visit has helped to decrease the incidence of patients not being home for the visit.
SCIENCE AND PRACTICE Home-based MTM in a health system
Pharmacy students and residents on clinical rotations have been incorporated in the visits, but they do not conduct home visits without direct supervision. There are a number of limitations to evaluation of homebased MTM in this article. Continuity of care was considered only for care that occurred after the home-based MTM visit; therefore, it is uncertain how often patients were seeing their PCPs before the home-based MTM visit. Patients receiving home-based MTM were not compared with those who received clinic-based MTM, so it is uncertain if the types of MRPs experienced by both groups are the same and if homebased MTM contributes to easier identification of some MRPs. Because a broad ambulatory care population was targeted for home-based MTM, disease-specific clinic outcomes (e.g., blood pressure, blood glucose) were not evaluated. Home-based MTM is resource intensive, so demonstrating its value is essential. Future research should evaluate how identification of MRPs may differ between home-based and clinicbased MTM. Other outcomes that may measure the impact of home-based MTM include patient self-efficacy to manage medications, patient satisfaction, and adherence. Finally, it is unclear what patients benefit most from home-based MTM or if telephone-based MTM may serve the needs of health system patients who do not access MTM in a clinic.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Conclusion Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service. The service meets the needs of the health system by addressing nonadherence and bridging the gap between clinicbased and community-based providers. The service is resource intensive, and research is needed to evaluate its impact.
14.
15.
16. 17.
Acknowledgments The authors thank Don Uden, PharmD, FCCP, for review of the manuscript and Candace Mealey for assistance in compiling data. References 1. Asiri FY, Marchetti GF, Ellis JL, et al. Predictors of functional and gait outcomes for persons poststroke undergoing home-based rehabilitation. J Stroke Cerebrovasc Dis. 2014;23(7):1856e1864. 2. Mohammadi F, Jowkar Z, Khankeh HR, Tafti SF. Effect of home-based nursing pulmonary rehabilitation on patients with chronic obstructive
pulmonary disease: a randomised clinical trial. Br J Community Nurs. 2013;18(8):400e403. Cooper J, McCarter KA. The development of a community and homebased chronic care management program for older adults. Public Health Nurs. 2014;31(1):36e43. Lenaghan E, Holland R, Brooks A. Home-based medication review in a high risk elderly population in primary caredthe POLYMED randomised controlled trial. Age Ageing. 2007;36(3):292e297. Stafford L, Peterson GM, Bereznicki LR, et al. Clinical outcomes of a collaborative, home-based postdischarge warfarin management service. Ann Pharmacother. 2011;45(3):325e334. Triller DM, Hamilton RA. Effect of pharmaceutical care services on outcomes for home care patients with heart failure. Am J Health Syst Pharm. 2007;64(21):2244e2249. Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med. 1998;158(10):1067e1072. Reidt SL, Larson TA, Hadsall RS, et al. Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits. Home Healthc Nurse. 2014;32(3):146e152. Pherson EC, Shermock KM, Efird LE, et al. Development and implementation of a postdischarge home-based medication management service. Am J Health Syst Pharm. 2014;71(18):1576e1583. Brummel AR, Soliman AS, Carlson AM, et al. Optimal diabetes care outcomes following face-to-face medication therapy management services. Popul Health Manag. 2013;16(1):28e34. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43(2):173e184. Isetts BJ, Brown LM, Schondelmeyer SW, et al. Quality assessment of a collaborative approach for decreasing drug-related morbidity and achieving therapeutic goals. Arch Intern Med. 2003;163(15):1813e1820. Isetts BJ, Brummel AR, de Oliveira DR, et al. Managing drug-related morbidity and mortality in the patient-centered medical home. Med Care. 2012;50(11):997e1001. Doucette WR, McDonough RP, Klepser D, et al. Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy. Clin Ther. 2005;27:104e111. Minnesota Department of Health and Human Services. MTM provider manual. Available at. Accessed www.dhs.state. mn.us/main/idcplg?IdcService¼GET_DYNAMIC_CONVERSION&; RevisionSelectionMethod¼LatestReleased&dDocName¼dhs16_136889; September 26, 2015. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the clinician's guide. 2nd ed. New York: McGraw-Hill; 2004. Food and Drug Administration. Disposal of unused medicines: what you should know. Available at: www.fda.gov/Drugs/ResourcesForYou/ Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/ SafeDisposalofMedicines. Accessed July 4, 2015.
Shannon Reidt, PharmD, MPH, BCPS, University of Minnesota College of Pharmacy, Minneapolis, MN, and Hennepin County Medical Center, Minneapolis, MN Haley Holtan, PharmD, BCPS, BCACP, Hennepin County Medical Center, Minneapolis, MN Jennifer Stender, PharmD, AE-C, Hennepin County Medical Center, Minneapolis, MN Toni Salvatore, Pharmacy student, University of Minnesota College of Pharmacy, Minneapolis, MN Bruce Thompson, RPh, MS, Comprehensive Pharmacy Services, Former Director, Hennepin County Medical Center, Minneapolis, MN
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Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
EXPERIENCE
Integrating home-based medication therapy management (MTM) services in a health system Shannon Reidt*, Haley Holtan, Jennifer Stender, Toni Salvatore, Bruce Thompson a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 18 January 2016
Objectives: To describe the integration of home-based Medication Therapy Management (MTM) into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. Setting: Minnesota from September 2012 to December 2013. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. Practice innovation: Home-based MTM was promoted throughout the clinics within the health system. Physicians, advanced practice providers, nurses, and pharmacists could refer patients to receive MTM in their homes. A home visit had the components of a clinic-based visit and was documented in the electronic health record (EHR); however, providing the service in the home allowed for a more direct assessment of environmental factors affecting medication use. Evaluation: Number of home MTM referrals, reason for referral and type of referring provider, number and type of medication-related problems (MRPs). Results: In the first 15 months, 74 home visits were provided to 53 patients. Sixty-six percent of the patients were referred from the Internal Medicine Clinic. Referrals were also received from the senior care, coordinated care, and psychiatry clinics. Approximately 50% of referrals were made by physicians. More referrals (23%) were made by pharmacists compared with advanced practice providers, who made 21% of referrals. The top 3 reasons for referral were: nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse. Patients had a median of 3 MRPs with the most common (40%) MRP related to compliance. Conclusion: Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service. © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Home-based health care has been shown to benefit patients with a broad range of needs. Post-stroke rehabilitation delivered by home-health physical therapists has improved activities of daily living and gait speed.1 Home-based nursing programs have demonstrated improvements in patients' clinical outcomes such as fatigue, activities of daily living, and
Disclosure: This project was supported by the Metropolitan Area Agency on Aging Title IIID Health Promotion Program. * Correspondence: Shannon Reidt, PharmD, MPH, BCPS, 308 Harvard St. SE, WDH 7-103, Minneapolis, MN 55415. E-mail address: [email protected] (S. Reidt).
quality of life in patients with stage two or three chronic obstructive pulmonary disease.2 These programs have also improved patient self-efficacy in chronic-condition self-management, including asthma, chronic obstructive pulmonary disease, diabetes, coronary artery disease, hypertension, and congestive heart failure.2,3 Home-based nursing has demonstrated improvements in clinical outcomes such as blood pressure, weight, and blood glucose levels.3 Delivery of care in the home is beneficial for those with limited access to clinics and those with poor or questionable self-management of their disease state(s) and medication regimens.4 Home-based care also provides invaluable information to clinicians about a patient's living environment.4
http://dx.doi.org/10.1016/j.japh.2016.01.003 1544-3191/© 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE Home-based MTM in a health system
Key Points Background: Many other health professions, including medicine, nursing, and therapy, have a history of providing home-based care; however, few descriptions of home-based MTM exist in the literature. Home-based MTM programs have been described that target patients recently discharged from the hospital where the pharmacist providing care is associated with a health system or a home care agency. Findings: Patients with a history of nonadherence, transportation barriers getting to a pharmacy or clinic, or with home health care nurses may be good candidates for home-based MTM. Care coordination and documentation of services in the health-system EHR are essential to successful integration of home-based MTM.
Health care providers such as physicians, nurses, and physical therapists have a history of providing care in patients' homes; however, home-based pharmacist services are much less established. Some home-based pharmacist services have focused on patients who take specific medications, such as warfarin, or have specific conditions, such as heart failure.4-6 Other services have targeted patients who have recently been discharged from hospital.7-9 Benefits of pharmacists' interventions in these patients include improvement of patients' self-management of medications,9 decreased emergency room visits, and decreased hospitalizations.8 In one study, patients who received home-based MTM after hospital discharge were 40% less likely to have an emergency room visit or hospitalization than those receiving usual care.8 Similarly, pharmacists have rated 70% of their home-based interventions as having a “dramatic” or “substantial” improvement on the patients' abilities to manage their medications.9 The benefits of pharmacist-provided MTM have been well documented.10-13 Pharmacists have provided MTM to patients in clinics and pharmacies; however, these environments may have barriers. For example, MTM may be difficult to provide in busy community pharmacies.14 The health system involved in this article observed that some patients had transportation barriers preventing them from getting to a clinic or pharmacy and others did not feel comfortable bringing medications to these locations for an MTM visit. Some patients with caregivers who should participate in an MTM encounter were unable to attend appointments at a clinic or pharmacy. The health system hypothesized that providing MTM in a patient's home may overcome these barriers and identified a need for improved care coordination between primary care providers (PCPs) and home health care care nurses and increased support for nonadherent patients. The health system looked to home-based MTM to meet these needs. Although providing home-based pharmacy services is not a new idea, the present
article adds to the literature by describing how a health system with well established MTM services may implement homebased MTM. Although other home-based pharmacy services have targeted specific populations, this practice is innovative by targeting a wider ambulatory patient population. Objectives The objective of this article is to describe the integration of home-based MTM into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. Practice description Hennepin County Medical Center (HCMC) has been providing MTM services since 2006. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. Services provided include comprehensive medication review, targeted disease state management, therapeutic drug monitoring, patient education, and adherence support. Primary care clinics are patient-centered medical homes, and pharmacists are able to use protocols to modify patients' medication regimens. Annually, pharmacists conduct approximately 10,000 MTM encounters and receive reimbursement primarily from Minnesota Medicaid. However, all insurers are billed for services. All MTM pharmacists undergo a credentialing and privileging process through the HCMC Office of the Medical Director, and appointment is renewed every 2 years. They are additionally credentialed as MTM Providers through insurance plans as able. The department is supported by a full-time MTM support analyst, a former community pharmacy technician, who assists with patient billing, scheduling, data reporting, and quality assurance initiatives. Practice innovation HCMC began providing home-based MTM in 2012. One pharmacist was designated as the home visit pharmacist and devoted 0.2 full-time equivalent to home-based MTM. Because the pharmacist had previous experience providing homebased MTM, no training related to home-based care was provided. The health system does provide personal safety training classes that would have been required otherwise because the pharmacist conducts visits alone. Components of a homebased MTM visit were designed to be similar to a clinic-based MTM visit to promote consistency across the health system. During the home visit, the pharmacist evaluates all medications and over-the-counter (OTC) products for indication, effectiveness, safety, and convenience and compliance. Because the visit occurs in the home, the patient's caregiver can easily participate in conversations related to medication use, and the pharmacist can observe the environment in which medications are taken and stored. The patient and pharmacist devise a plan for medications that is documented in the electronic health record (EHR). Updated medication lists are shared with non-HCMC providers, such as community pharmacies and home health care nurses, by fax. If more information needs
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to be shared, the pharmacist calls pharmacies and home health care nurses instead of faxing a visit note. For example, the pharmacist often calls community pharmacies to discontinue prescriptions that have been changed or discontinued by prescribers. When registering with the health system, each patient signs a patient authorization and consent form which allows health system providers to share information with those outside of the health system. The pharmacist informs the patient of any information that will be shared with health care providers. The pharmacist obtains additional consent if records from an outside institution are needed. The pharmacist communicates recommendations to modify medications to HCMC providers through the EHR. Wireless access to the EHR while in a patient's home has been cost-prohibitive; as a result, the pharmacist reviews the patient's chart before the home visit. Because organizing medications occurs during the home visit, the pharmacist travels with pillboxes, markers, rubber bands, and other organization tools. The pharmacist brings a blood pressure cuff to all visits. If the medication list is updated during the home visit, an updated list is mailed to the patient after the visit. Because Medicare Part D plans are not billed, a Medication Action Plan is not given to the patient at the completion of the visit. Instead, instructions for the patient discussed during the visit are written down and left in the patient's home.
conditions, a medication list, a narrative of patient symptoms and concerns, laboratory values and vital signs, conditionspecific assessment and plan, including recommended medication changes and patient education needed, assessment of medication adherence, a succinct list of medication-related problems (MRPs), and time spent with the patient. In addition to these elements, home-based MTM notes include a brief narrative of the patient's living situation. For example, the pharmacist documents if the patient lived alone or in an unkempt environment. A “home visit” encounter type is created in the EHR so that when providers and schedulers look at a patient's appointments, they would recognize when a homebased MTM visit is scheduled as opposed to a clinic MTM visit. This prevents patients from having clinic appointments scheduled right before or right after a home visit. When home-based MTM was established, the goal was to use a home visit as a bridge to the clinic. After a home visit, a patient would receive follow-up MTM in the clinic. To promote this continuity of care, communication among the home visit pharmacist and the rest of the care team was essential. Home visit notes were shared with a patient's PCP, clinic pharmacist, and any other specialty providers via the EHR. Additionally, the home visit pharmacist communicated with community-based providers such as community pharmacies and home health care nurses.
Recruitment and scheduling
Billing for services
Initially, hospital discharge patients at high risk of readmission were targeted, and home visits were scheduled at the point of hospital discharge. The objective of targeting these patients was to schedule a home visit within 1 week of hospital discharge. This method was unsuccessful because scheduling a home visit was logistically difficult when many other post-discharge appointments were being scheduled. Feedback from Nurse Clinical Coordinators indicated that the discharge process was already overwhelmed by numerous readmission-reduction initiatives, and scheduling home visits was easily overlooked. As a result, the focus was changed to patients in ambulatory care clinics. Providers, including physicians, advanced practice providers (i.e., nurse practitioners and physician assistants), registered nurses, and pharmacists were educated about home-based MTM. Pharmacy leaders attended department meetings across the health system to give presentations describing what home-based MTM was, what patients were candidates, and how to place referrals. Providers were encouraged to refer a patient for home-based MTM for the following reasons: transportation barriers getting to the clinic, patient unwillingness to bring medications to the clinic, and concerns that environmental factors were affecting medication use. Providers ordered a referral in the EHR, which alerted the MTM support analyst to contact the patient to schedule a 60minute new patient appointment. No geographic restrictions were placed on who could receive home-based MTM.
Charges for services are entered in the EHR and processed by the billing department. In Minnesota, Medicaid and one commercial insurance plan cover MTM delivered in the homes of those patients who take 3 or more prescription medications to treat or prevent one or more chronic conditions.15 Reimbursement rates for home-based MTM are the same for MTM delivered elsewhere (i.e., clinic or pharmacy) and are based on the number of medications and conditions reviewed and the number of MRPs identified. Facility fees are not used for homebased MTM. The health system bills all insurers for MTM visits whether they are provided in clinics or in the patient's home. If coverage for MTM is not provided by the insurance, patients may incur a bill. The health system has negotiated contracts with insurers to cover clinic-based and home-based MTM as MTM services have expanded. In addition to revenue from insurance payments, the health system had a contract with the Metropolitan Area Agency for Aging that supported the cost of home visit for patients 60 years of age and older. The health system reimburses the pharmacist for mileage expenses incurred travelling to patients' homes.
Documentation of services and care coordination A documentation template was created for home-based MTM that mirrored the template used for MTM provided in the clinic. Clinic-based MTM notes include a list of medical 180
Evaluation Home-based MTM was evaluated by the number of referrals, the reason for referral, type of referring provider and the number and type of MRPs. Continuity of care was measured by whether or not patients received clinic-based MTM within 120 days after a home-based MTM visit and whether they received follow-up care from their PCP within 120 days after a home-based MTM visit to address problems identified during the home visit. The PCP was not necessarily the referring provider but was defined as the provider (physician, advanced practice provider) designated in the EHR.
SCIENCE AND PRACTICE Home-based MTM in a health system
Data were collected from the EHR and entered in a Microsoft Excel spreadsheet. Descriptive statistics were used for age, sex, race, referral type and referral reason, and follow-up time with pharmacists and PCPs. Approval was granted by the Institutional Review Board (IRB) of the health system and the University of Minnesota. Results From September 2012 to December 2013, 74 home-based MTM visits were provided to 53 patients. Fifty-five percent of patients were 65 years of age or older, and approximately one-half were black (55%) and female (57%). Patients took a median of 12 prescription and over-the-counter (OTC) medications and had 7 chronic conditions (Table 1). Most patients received 1 home visit; however, 8 patients received more than 1 home visit (range 3 to 9). Patients who were unable or unwilling to see a pharmacist in clinic to follow up on medication changes or adherence counseling received more than 1 home visit. A majority of home visits occurred within a 10-mile radius from the hospital; however, patients living up to 20 miles from the hospital were also seen. The pharmacist spent approximately 10 minutes reviewing the patient's chart before the home visit, and the visit lasted from 30 to 60 minutes. The pharmacist spent approximately 15 minutes documenting each visit. Sixty-six percent of the patients were referred from the Downtown Internal Medicine Clinic, and approximately 50% of referrals were made by physicians. The most common referrals were for patients with nonadherence or transportation barriers preventing them from receiving MTM in the clinic. Additionally, patients who had home health care nurses were often referred, so the pharmacist could reconcile the medications being set up in pillboxes with those on the health system medication list. Nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse accounted for 51% of all referrals. Referrals for patients Table 1 Patient demographics (n ¼ 53) Patient characteristics Age (y) 18e50 51e64 65 Sex Male Female Race Black White American Indian Asian Other Insurance type Medicaid Medicare Commercial Uninsured No. of medications (Rx and OTC) per patient, median (range) No. of medical conditions per patient, median (range) No. of medication-related problems per patient, median (range)
No. of patients (%) 7 (13) 17 (32) 29 (55) 23 (43) 30 (57) 29 20 2 1 1
(55) (38) (4) (2) (2)
4 29 19 1 12
(8) (55) (36) (2) (4e49)
7 (3e17) 3 (0e6)
Table 2 Home medication therapy management (MTM) patient referrals Home MTM referral Clinic Internal medicine Senior care Coordinated care Psychology Provider type Physician Advanced practice provider (nurse practitioner, physician assistant) Pharmacist Registered nurse Patient self-referral Referral reason Nonadherence Transportation barriers Medication reconciliation with public health nurse Will not bring medications into clinic Medication review with caregiver History of no-show clinic appointments Medication reconciliation Hospital discharge follow-up Medication organization Polypharmacy
No. of referrals (%) 33 12 7 1
(62) (23) (13) (2)
27 (51) 11 (21) 12 (23) 1 (2) 2 (4) 9 (17) 9 (17) 9 (17) 7 6 4 4 2 2 1
(13) (11) (8) (8) (4) (4) (1)
with caregivers who could not attend clinic appointments and patients who did not want to bring medications to the clinic were also common (Table 2). Regarding continuity of care, 54% of patients saw their PCP within 30 days of the home visit to address problems identified during the home visit, and 92% followed up with their PCP within 120 days. Within 30 days of the home-based MTM visit, 11% of patients followed up with a clinic pharmacist, and 17% followed up within 120 days (Table 3). MRPs were identified at each home visit and were classified according to type: indication, effectiveness, safety, and compliance.16 A median of 3 MRPs were identified at each home visit. The most common problems identified (40%) were associated with compliance (Table 4). Compliance-related problems were classified for patients who did not understand how to use their medications or preferred not to take their medications. Patients were often using medications, such as inhalers and insulin pens, incorrectly. Compliance-related problems also classified those
Table 3 Continuity of care after home MTM visit (n ¼ 53) Measure
No. of patients (%)
Days elapsed between MTM visit and clinic visit 1e14 0 15e30 6 (11) 31e60 4 (8) 61e120 5 (9) No clinic MTM 34 (64) Days elapsed between home MTM visit and PCP follow-up 1e14 14 (26) 15e30 15 (28) 31e60 10 (19) 61e120 10 (19) No follow-up 4 (8) Abbreviations used: MTM, medication therapy management; PCP, primary care provider.
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Table 4 Medication-related problems identified Medication-related problem Indication Effectiveness Safety Compliance Total
n (%) 35 (18) 44 (22) 39 (20) 80 (40) 198
instances when patients were using expired or family members' medications. The pharmacist made interventions during the home visit that were typical of clinic-based visits. For example, the pharmacist recommended laboratory monitoring and initiating, discontinuing, or modifying medications. Having access to all medications in the home, the pharmacist was also able to make interventions that may have been difficult to make in a clinic. For example, the pharmacist eliminated duplicate bottles of medications or expired medications and identified a safe and convenient location to store medications. Medication disposal and organization were typical interventions that occurred when patients were using more than 1 pharmacy or continued to receive refills for medications that had been discontinued by a prescriber. Medications were disposed of in the patient's home according to Food and Drug Administratione recommended practices,17 and the pharmacist documented the names of the disposed medications in the EHR. Because 40% of identified MRPs related to compliance, adherence counseling interventions were common. The pharmacist worked with the patient to develop strategies to improve compliance. By observing the patient in his or her home environment, the pharmacist was able to suggest ways that the patient could incorporate taking medications into his or her daily routine. The pharmacist's assessment of compliance often uncovered reasons, besides forgetfulness, for noncompliance, such as not understanding directions, fear of side effects, belief that medications would not work, or poor coordination with caregivers and home health care nurses. When such reasons were uncovered, patients sometimes reported that they would not be willing to have in-depth and candid conversations about compliance in a clinic or pharmacy. Once reasons for noncompliance were identified, the pharmacist and patient agreed on appropriate interventions. Common interventions included patient education tailored to the patient's interests and concerns. Discussion Home-based MTM met the needs of the health system by helping patients with a history of nonadherence and bridging communication gaps between the health system and community-based providers. Home visits offered an opportunity for caregivers, such as personal care attendants, to be involved in the medication assessment, which was important given their valuable insight in identifying and overcoming barriers to compliance. Referral reasons observed in this project may identify patient populations that should be targeted to receive this service. Providers often referred patients with a history of nonadherence that could not be fully understood in the clinic. In the patient's home, the pharmacist could observe environmental factors that might be affecting
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adherence and could make appropriate interventions. Patient complexity and number and type of MRPs observed in this study are similar to those reported by Reidt et al., who also found compliance-related problems to be the most prevalent. The interventions in this paper are similar to those reported in other studies8,9 that emphasized patient education and care coordination between health systems, home care nurses, and community pharmacies. Patients were referred by providers who were unable to reconcile medications with home care agencies or caregivers. In these cases, medication changes had often been made but were not clearly communicated to the home care agency or caregiver, and providers were uncertain what medications were being set up in a patient's pillbox. Home-based MTM enabled a pharmacist to inspect the pillbox, resolve discrepancies with a home care nurse or caregiver, and collaborate with the nurse or caregiver to develop a care plan to resolve any MRPs. In these cases, the pharmacist was the bridge between the health system and the patient's home support system. There was a low volume of home visits provided during the first 15 months that this service was available, and most patients received only one encounter. The health system expected a low volume of service because home-based MTM was viewed as an option for a select group of patients who were not able to access MTM in the clinic or for whom clinic-based MTM had not resolved all MRPs. Home-based MTM was designed to be a consultative service where the pharmacist would provide a limited number of in-home encounters and then facilitate follow-up with clinic pharmacists. Follow-up with PCPs was much more common than follow-up with clinic pharmacists and this is an area for improvement. The home visit pharmacist often assisted the patient in setting up a PCP appointment, which may explain the high rate of PCP follow-up rate. This same assistance was not provided for follow-up with clinic pharmacists but will be in the future. Promotion of this service primarily relied on word of mouth, which may also explain the low volume of patients served. Because many of the health system clinics are staffed by medical residents who are rotating through clinical sites, communicating information about the service was difficult. Although not formally tracked, very few patients refused a home-based MTM visit. Patients were more likely to agree to the service if the referring provider had discussed the service with the patient before the MTM support analyst called the patient to schedule the visit. Payment for home-based MTM is a limitation to its implementation. Few reimbursement opportunities exist in fee-for-service models, although our health system has successfully included reimbursement for home-based MTM in contract negotiations with insurers and has had grant funding to help cover costs. Currently, the cost of delivering homebased MTM is greater than revenue from insurance payments; however, the health system sees value in this service, because it provides MTM to patients who have a history of nonadherence and may not otherwise access MTM. The health system has made changes to improve the service since its initiation. Coordinating home-based MTM visits with home health care nurse visits has made communication between the pharmacist and nurse more efficient. Reminder calls to patients one day before the home visit has helped to decrease the incidence of patients not being home for the visit.
SCIENCE AND PRACTICE Home-based MTM in a health system
Pharmacy students and residents on clinical rotations have been incorporated in the visits, but they do not conduct home visits without direct supervision. There are a number of limitations to evaluation of homebased MTM in this article. Continuity of care was considered only for care that occurred after the home-based MTM visit; therefore, it is uncertain how often patients were seeing their PCPs before the home-based MTM visit. Patients receiving home-based MTM were not compared with those who received clinic-based MTM, so it is uncertain if the types of MRPs experienced by both groups are the same and if homebased MTM contributes to easier identification of some MRPs. Because a broad ambulatory care population was targeted for home-based MTM, disease-specific clinic outcomes (e.g., blood pressure, blood glucose) were not evaluated. Home-based MTM is resource intensive, so demonstrating its value is essential. Future research should evaluate how identification of MRPs may differ between home-based and clinicbased MTM. Other outcomes that may measure the impact of home-based MTM include patient self-efficacy to manage medications, patient satisfaction, and adherence. Finally, it is unclear what patients benefit most from home-based MTM or if telephone-based MTM may serve the needs of health system patients who do not access MTM in a clinic.
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Conclusion Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service. The service meets the needs of the health system by addressing nonadherence and bridging the gap between clinicbased and community-based providers. The service is resource intensive, and research is needed to evaluate its impact.
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Acknowledgments The authors thank Don Uden, PharmD, FCCP, for review of the manuscript and Candace Mealey for assistance in compiling data. References 1. Asiri FY, Marchetti GF, Ellis JL, et al. Predictors of functional and gait outcomes for persons poststroke undergoing home-based rehabilitation. J Stroke Cerebrovasc Dis. 2014;23(7):1856e1864. 2. Mohammadi F, Jowkar Z, Khankeh HR, Tafti SF. Effect of home-based nursing pulmonary rehabilitation on patients with chronic obstructive
pulmonary disease: a randomised clinical trial. Br J Community Nurs. 2013;18(8):400e403. Cooper J, McCarter KA. The development of a community and homebased chronic care management program for older adults. Public Health Nurs. 2014;31(1):36e43. Lenaghan E, Holland R, Brooks A. Home-based medication review in a high risk elderly population in primary caredthe POLYMED randomised controlled trial. Age Ageing. 2007;36(3):292e297. Stafford L, Peterson GM, Bereznicki LR, et al. Clinical outcomes of a collaborative, home-based postdischarge warfarin management service. Ann Pharmacother. 2011;45(3):325e334. Triller DM, Hamilton RA. Effect of pharmaceutical care services on outcomes for home care patients with heart failure. Am J Health Syst Pharm. 2007;64(21):2244e2249. Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med. 1998;158(10):1067e1072. Reidt SL, Larson TA, Hadsall RS, et al. Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits. Home Healthc Nurse. 2014;32(3):146e152. Pherson EC, Shermock KM, Efird LE, et al. Development and implementation of a postdischarge home-based medication management service. Am J Health Syst Pharm. 2014;71(18):1576e1583. Brummel AR, Soliman AS, Carlson AM, et al. Optimal diabetes care outcomes following face-to-face medication therapy management services. Popul Health Manag. 2013;16(1):28e34. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43(2):173e184. Isetts BJ, Brown LM, Schondelmeyer SW, et al. Quality assessment of a collaborative approach for decreasing drug-related morbidity and achieving therapeutic goals. Arch Intern Med. 2003;163(15):1813e1820. Isetts BJ, Brummel AR, de Oliveira DR, et al. Managing drug-related morbidity and mortality in the patient-centered medical home. Med Care. 2012;50(11):997e1001. Doucette WR, McDonough RP, Klepser D, et al. Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy. Clin Ther. 2005;27:104e111. Minnesota Department of Health and Human Services. MTM provider manual. Available at. Accessed www.dhs.state. mn.us/main/idcplg?IdcService¼GET_DYNAMIC_CONVERSION&; RevisionSelectionMethod¼LatestReleased&dDocName¼dhs16_136889; September 26, 2015. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the clinician's guide. 2nd ed. New York: McGraw-Hill; 2004. Food and Drug Administration. Disposal of unused medicines: what you should know. Available at: www.fda.gov/Drugs/ResourcesForYou/ Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/ SafeDisposalofMedicines. Accessed July 4, 2015.
Shannon Reidt, PharmD, MPH, BCPS, University of Minnesota College of Pharmacy, Minneapolis, MN, and Hennepin County Medical Center, Minneapolis, MN Haley Holtan, PharmD, BCPS, BCACP, Hennepin County Medical Center, Minneapolis, MN Jennifer Stender, PharmD, AE-C, Hennepin County Medical Center, Minneapolis, MN Toni Salvatore, Pharmacy student, University of Minnesota College of Pharmacy, Minneapolis, MN Bruce Thompson, RPh, MS, Comprehensive Pharmacy Services, Former Director, Hennepin County Medical Center, Minneapolis, MN
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