1. Polypharmacy in a Patient Centered Medical Home Carilion Clinic – VTC Family Medicine Roanoke, Virginia

2. o To improve polypharmacy in a selected patient panel by decreasing the total number of medications via Medication Therapy Management (MTM) interventions performed by a Clinical Pharmacist in the Patient Centered Medical Home

3. Polypharmacy One patient on equal to or greater than 5-7 medications in patients greater than 60 years of age Older adults consume ~ 32% of all prescription meds in the US Why is Polypharmacy bad? 1 Increase risk of drug/drug interactions Increase non compliance Increase adverse drug events Increase medication duplication Increase hospitalizations Increase morbidity and mortality 1-Jajjar, ER, Cafiero, AC, Hanlon, JT, Polypharmacy in Elderly Patients, Am J Geriatric Pharmacotherapy, Dec 2007;5:4:345-51

4. Patient list comprised using EMR search of Attending and Resident PCP panel Greater than or equal to 60 years of age with 10 or more medications Specific for the number of total medications for ALL chronic conditions, not not for specific chronic conditions only Patients were contacted by phone and/or letter MTM visits performed by Clinical Pharmacists Six month study

5. Exclusion criteria Inability to contact patient via phone and/or letter Patient declined to participate Patient had switched PCPs or offices Language barrier

6. A systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating and implementing a plan to resolve them Medication Therapy Management (MTM)

7. Extensive chart review via EMR based on the selected patient list prior to visit Contacting patient Reviewing pharmacy claims Contacting specialist offices Discussion with PCP prior to visit if concerns Medication reconciliation Inappropriate medications, duplicates, dosage discrepancies, dangerous medication interactions, previous adverse drug reactions, compliance barriers STOPP criteria

8. Patient meeting Extensive medication review Patient education Collaborative plan with patient and PCP to manage medications Real time PCP contact Creative ways to improve patient compliance MTM report to PCP Occasionally completed by phone

9. Carpenter, Randi N, PharmD 3/23/2012 4:15 PM Pharmacy Note: Medication Therapy Management S: Met with patient at request of provider (Wilson) for Medication Therapy Management. Patient brought all of her medications to the visit today. She keeps the pill boxes in a large shoe box. Medication issues reported by patient: "I think I am on too many medications".

10. O: Prescription Insurance: Humana Medicare Other prescribers patient sees: Dr. Mann: Ortho Pharmacies patient uses: Kmart for medications that she needs acutely and Right Source for maintenance medications Significant renal or hepatic dysfunction: 3/16/12: Scr: 1.5 Est CrCl: 46ml/min Number of chronic disease states: 6 Total number of medications at start of encounter: 17 Number of medications for chronic dieases: 8

11. Assessment: Assessment of patient’s understanding of medication regimen: Adequate. For most of the medications the patient has labeled the prescription bottle with the indication for that medication. She is aware of what each medication is used for. Assessment of medication adherence: Patient reports compliance with most all medications. She does report that she often misses the mid-day dose of Oxybutin. "I forget to take the one in the middle of the day". Potential barriers to achieving drug therapy goals: None

12. Medication Action Plan for patient: 1) Update the patient's medication list and remove duplications. 2) Consider changing the PPI to H2 antgonist (Ranitidine 150mg qday d/t CrCl <50ml/min) 3) Called Right Source mail order pharmacy and requested a refill of the patient's Paxil. It should reach the patient in 7-10 per the representative. 4) There is an extended release version of the oxybutin that is taken once daily. Could this be prescribed for the patient to increase compliance vs the tid dosing? 5) Would recommend d/c of Mobic at this time.

13. 6) Would recommend taper of Clonidine off of the patient's profile. Advise tapering the drug no faster than dose adjustments every 3 days. This does not seem to be a good agent for the patient. 7) Advised patient to change dosing time of Lisinopril-HCTZ to in the morning to avoid the issues of frequent night time urination. Follow-up: The patient was seen by her PCP (Stubbs) following the MTM visit and will be having TKA on 3/28. Time spent: Spent 60 minutes on MTM with the patient in communication with provider. Number of medications recommended to continue at the end of the encounter: 14 (initial # meds – 17) Thank you for the opportunity to participate in this patient’s care. Please contact me if you have any questions. Thank you, RANDI N CARPENTER, PharmD 3/23/2012 4:13 PM

14. Total number of patients on list: 39 Total number of MTMs completed: 23 Total number of patients unable to contact via phone and/or letter: 11 Total number of patients that had changed PCP: 5 Total number of patients with decrease in medications: 14 Total number of patients with no change in medications: 5 Undocumented in MTM: 4 These were excluded from data analysis

15. Of completed 19 MTM reviews with data (n= 19) Applied a paired students t test Beginning mean medications -15.16 SD= 2.75 Stand error= 0.63 Ending mean medications – 12.79 SD= 2.46 Stand error= 0.56 P value = 0.001 Despite small n, was statistically significant

16. Successful MTMs Patient contacted and had MTM Number of medications reduced Unchanged number of medications Unsuccessful MTMs Degree of severity of chronic diseases of patient made the number of medications appropriate for that patient, involvement of Specialist Care Inability to contact Lack of detailed documentation on 4 patient MTMs Real time PCP interaction is key Difficult to measure the true value of what our Clinical Pharmacist in the PCMH are doing for our patients

17. Longer study time Determine how to measure increased patient compliance after MTM More detailed way to objectively measure the MTM (i.e. Connecticut study) Include prevention of hospital admissions secondary to polypharmacy after MTM as a patient oriented outcome instead of disease oriented outcome How to objectively measure?? Improving contacting patients to have increased participation

18. Patients with a higher number of starting medications are more likely to have a lower number of medications after MTM Non-blinded, non-randomized so those doing intervention aware of primary outcome as are patients, no control group

20. Jajjar, ER, Califero, AC, Hanlon, JT. Polypharmacy in Elderly Patients. The American Journal of Geriatric Pharmacotherapy. Dec 2007. 5;4:345-351. Rossi, MI, et al. Polypharmacy and Health Beliefs in Older Outpatients. The American Journal of Geriatric Pharmacotherapy. December 2007. 5;4:317-323. Smith, M, Giuliano, MR, Starkowski, MP. In Connecticut: Improving Patient Medication Management in Primary Care. Health Affairs, 30, no.4 (2011):646-654.