Pilot programs take MTM to patients

"It's a logical move," said Joseph Nathan, MS, PharmD, director of the International Drug Information Center and associate professor of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, N.Y.

"You have patients in long-term care [LTC], a controlled environment, with a federal mandate to review their medications on a monthly basis. And you have patients at home, a totally uncontrolled environment, with no review. When you look at the numbers of patients admitted for avoidable medication errors, this is a disaster."

"Clinically, MTM for patients in the community is tremendous," Rosenberg said. "Financially, it is still a question."

Rosenberg is also a member of the Drug Topics editorial advisory board.

MTM house calls

The most ambitious program had Nathan and fifth-year pharmacy students making MTM house calls for patients referred by a local pharmacy. Patients had to be at least 65 years old and taking at least 9 prescription medications. Home visits typically lasted 45 to 90 minutes.

"Time wasn't an issue because we were not being compensated for the visit," he said. "The extended time let us see so much more than a pharmacist could ever learn in a more formal pharmacy interview."

Nearly every patient had medication problems, Nathan reported. Some patients were taking conflicting medications and some were taking medications irregularly.

Some medications had incomplete labels, such as a hydrochlorothiazide vial labeled "Take 1 tablet every." However, the more common problem was patients who did not understand label instructions.

One patient with drugs to be taken "twice a day" took 1 dose mid-morning and the second dose mid-afternoon.

A patient taking enalapril understood "Take 1 tablet by mouth twice daily" to mean that the tablet should not be swallowed but placed in the mouth and sucked on.

A patient taking glimepiride read "Take 2 tablets daily" to mean 1 tablet in the morning and 1 in the evening.

"We take a lot for granted about what patients do and do not understand," Nathan said. "Too often in pharmacy, we never see the outcome of what we do."

The program was highly effective but time-intensive. The time needed for scheduling, recordkeeping, travel, and other elements led Nathan to end the pilot.

"Going to patients' homes is a genuine opportunity to improve drug therapy, but there are some limitations," he said. "One of the most important is being compensated for services."

Nathan and Rosenberg tackled compensation head on. They placed ads in a local newspaper for in-home medication review consultations. "We were looking at charging $50 to $60 per hour, but there was not much interest," Nathan said.

Success with adult daycare

Both pharmacists receive occasional MTM referrals from the American Society of Consultant Pharmacists. Rosenberg has built a small MTM practice with adult daycare centers. It is economically viable, but with about 300 patients, MTM is not a stand-alone practice.

Each participant completes an information form with the help of the daycare center nurse, who faxes the information to Rosenberg. The form includes medical conditions, medications, and current lab results. He makes drug therapy recommendations using guidelines from The American Geriatrics Society.

"I can do a review and recommendations in under 10 minutes because the information is well-organized," Rosenberg said. "This is a way a pharmacist can become involved in MTM that is economically feasible. The therapeutic outcomes are fantastic, but widespread MTM is a question unless and until it is reimbursed by third parties."