Student observations: How are we doing on MTM?


One pharmacy student laments that MTM has not been widely implemented at any level. In her rotation with a group of public-health pharmacists, she encounters a patient confused by her medication regimen and pharmacists not being involved in medication consultation at discharge.

For the past several years I have been reading articles about medication therapy management (MTM) in many healthcare publications. MTM has been described as a collaboration between a patient, a pharmacist, and other healthcare professionals whose goal is improvement of the patient’s health outcomes. My impression was that pharmacists were practicing medication therapy management in all aspects of patient care, including visits to doctors’ offices, hospital admissions and discharge, and the dispensing of medication.

However, as a pharmacy student who works in a retail pharmacy and has completed several clinical and community rotations, I have not seen wide implementation of MTM at any level. Moreover, in my current rotation with a group of public-health pharmacists, I have encountered 2 very interesting problems that I would like to discuss.

The first issue I faced concerned the role of pharmacists in hospital discharge. I had a chance to be present at a closed meeting at a major local hospital where high rates of recidivism were under review. I was surprised that no one at that meeting even thought about involving pharmacists in medication consultation with patients at discharge.

The hospital representatives were discussing how the patients who were readmitted within a few weeks of discharge reported that the discharge process had been overwhelming, that they had been given a stack of papers along with prescriptions they could not separate, and that they had not understood which medications were discontinued, which were new, and how and when they should be taken.

I asked whether a clinical pharmacist had gone over the medications with the patient during the discharge process and the answer was “No,” with no discussion of the possibility of bringing clinical pharmacists into the discharge process in the future. It seemed that many of those present had little knowledge about the services pharmacists can provide.

After this meeting I did some research and found out that in fact the involvement of pharmacists in discharge procedure may improve patients’ overall health outcomes, decrease hospital readmissions, and decrease healthcare costs. Among my findings:

  • According to a randomized trial conducted at University of California, San Francisco, when pharmacists provided telephone follow-up 2 days after hospital discharge, more patients (86%, P=.007) in the intervention group (n=110) were satisfied with discharge medication instructions provided by pharmacists than were patients (66%) in the control group (n=111), and fewer patients from the intervention group returned to the emergency department within 30 days (10% intervention group vs. 24 % control group, P=.005).1
  • A University of Tasmania, Australia, study of a prospective nonrandomized controlled cohort evaluated clinical outcomes of a collaborative, home-based, post-discharge warfarin-management service. In this study, patients discharged from the hospital with warfarin therapy received either usual care (n=139) that did not involve a pharmacist’s home visit or post-discharge service (n=129) that involved 2 to 3 home visits from a trained pharmacist during the first 8 to 10 days after hospital discharge. The results showed significant decrease in combined major and minor hemorrhagic events rates in the intervention group (Day 8: 0.9% vs. 7.2%; P=.01, and Day 90: 5.3% vs. 14.7%; P=.03).2
  • Finally, a literature review of 7 studies evaluated outpatient and post-discharge pharmacy services for patients with heart failure. The results stated that disease-management programs involving pharmacists have shown positive patient outcomes, with reduction of morbidity and mortality associated with heart failure.3

The second issue that captured my attention also pertains to post-discharge patient care. This time I had a chance to observe exactly how confused a patient can become.

A group of us (2 pharmacy students with our pharmacist preceptor, 2 nursing students, and a social worker from a local county public health office) visited the home of a 59-year-old African American female patient. As we walked in, the patient was coughing and seemed short of breath. She reached for her inhalers, picked one, and inhaled multiple puffs to help with coughing and breathing. (The inhalers had no labels, and she could not distinguish which one was for immediate relief and which one was for maintenance therapy.)

After a brief introduction, with the patient’s permission we began sorting her medications and questioning her about her medical history, medication therapy, etc. We opened a drawer filled with medication vials and bottles, and various asthma/COPD inhalers. Many of her medications had never been used and most were expired. Recorded on various medication labels were the names of several doctors she didn’t even recognize.

We discovered that the patient had diabetes, hypertension, asthma, chronic pain, hyperlipidemia, and heart problems. She was very confused about her diseases, diagnosis, treatments, and medications. She was unaware that pharmacists could discuss her health conditions and assist her with proper medication treatment.

We separated the medications that were current (22 bottles, inhalers, and insulin pens), confiscated the old/expired/never used medications (24 bottles and inhalers), instructed her on how to take her medications, and left, planning to review her medications again and call her various pharmacies and doctors to find an easy way of managing this patient’s care.

Clearly, this patient has not been receiving proper treatment and she has not been adherent with her medications. No matter how many medications we prescribe, dispense, and deliver, she will not get better until someone educates her about the importance and proper use of these medications.

The issues discussed above come down to one thing: medication therapy management. We hear about MTM everywhere, but we don’t see it often in real life.

Some pharmacists are just waiting for MTM models they can follow. I agree that we do need established models to be more productive. But in the meanwhile, if each pharmacist were to make an impact in one patient’s life each day, we can make a huge difference in overall public health.

Healthcare professionals should unite. And other healthcare professions should accept that pharmacists are well trained in MTM and can be highly helpful in the achievement of better treatment outcomes, decreased hospital readmission rates, and overall healthcare cost savings.


  • Dudas V, Bookwalter T, Kerr K, Pnatilat S. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001; 111:26-30.
  • Stafford L, Peterson GM, Bereznicki LR, et al. Clinical outcomes of a collaborative, home-based postdischarge warfarin management service. Ann Pharmacother. 2011; [Epub ahead of print, PMID: 21386021].
  • Ponniah A, Anderson B, Shakib S, Doecke CJ, et al. Pharmacists’ role in the post-discharge management of patients with heart failure: a literature review. J Clin Pharm Ther. 2007; 32(4): 343-52.

Leann Hakobyanis a 2012 PharmD/MPH candidate at Touro University. She can be reached at

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