1. Establishing a Common Language for Comprehensive Medication Management
JCPP 4th Quarter Meeting
November 29, 2018

2. Questions Framing Today’s Discussion
What does implementation science tell us about defining and measuring innovations/interventions?
How does the Pharmacist’s Patient Care Process relate to specific services delivered by pharmacists?
How can we accelerate the dissemination and adoption of pharmacist-delivered services with fidelity?

3. Do the clinical services of pharmacists produce value in the health care system in ambulatory care?
AHRQ Effective Health Care Program
Provide valid evidence about the comparative effectiveness of different medical interventions
Systematic analysis of 44 studies
What are components and implementation features of medication management services?
Are medication management services effective in improving intermediate outcomes, patient-centered outcomes and/or resource utilization?
Does effectiveness of medication management services differ by implementation features or patient characteristics?
Are there harms from medication management services?
AHRQ Publication No. 14(15)-EHC037-EF. Rockville, MD: Agency for Healthcare2014.
AHRQ Publication No. 14(15)-EHC037-EF. Rockville, MD: Agency for Healthcare
Research and Quality; November

4. AHRQ Effective Health Care Program
MTM Interventions in Outpatient Settings Systematic review of 44 studies
Conclusion: The evidence base offers low evidence of benefit for a limited number of intermediate and health utilization outcomes. We graded the evidence as insufficient for most outcomes because of inconsistency in direction, magnitude and precision, rather than lack of evidence. Wide variations in populations and interventions, both within and across studies, likely explain these inconsistencies….
AHRQ Publication No. 14(15)-EHC037-EF. Rockville, MD: Agency for Healthcare2014.
New research, regardless of specific focus, will likely continue to find inconsistent results until underlying sources of heterogeneity are accounted for.

5. A Payer’s Perspective on Evidence
Integrated health care provider and health insurance company
Analyses: To determine if the medication therapy management (MTM) program has a positive effect on the total costs of care for fully insured members who have been identified as eligible for the program and have enrolled to participate
Methods: matched case/control analysis approach
Matched members from the fully insured MTM enrolled case study group to members of a self insured control group based on demographics as well as pre-invitation utilization information
Adjusted clinical groups, reimbursement amount, gender, age, CDC grouping sum
374 matched members

6. A Payer’s Perspective on Evidence
Results: Return on investment of 11:1 when annualized savings were compared to fully loaded expenses (including indirect expenses at 60%).
Repeated analysis in 2016, same results
Key Environmental Factors
Common patient care process (CMM) – fidelity of service
Face-to-face assessments
Competency of practitioners
Service integrated with medical providers
Integration with EMR
Population management – targeting highest utilizing patients

7. Are these questions the same?
Do the clinical services of pharmacists produce value to patients and payers?
Versus
Does a team-based medication management service defined and delivered consistently produce value to patients and payers?

8. Reasons for Mixed Results
Implementation Variability
Ill-defined intervention and delivery context
Lack of pharmacy-centric implementation measures
Lack of a systematic implementation strategy
The lack of conclusive results is attributed, in part, to implementation variability. Delivery of medication optimization interventions, like CMM, appears to be highly variable across pharmacists, patients, and settings.
The reason inconsistent implementation is important is because it is has been associated with inconclusive clinical outcomes.
There are several reasons that can lead to implementation variability including:
insufficiently defined interventions and lack of guidance on how to operationalize these interventions in practice
minimal efforts to monitor implementation to ensure that interventions are delivered as intended
limited use of proactive implementation strategies designed to facilitate successful uptake
Inconclusive Health Research Outcomes

9. Implementing an Intervention that Consistently Produces Value
Define the care process
Replication
Sustainability
Scaling
Implementation strategy, learnings, and tools
Successful Implementation
This study represented a huge opportunity to address these problems by exploring and creating the conditions and tools necessary for successful implementation of CMM…not only to enhance the likelihood of clinical outcomes but also to prepare for successful replication, sustainability, and scaling of CMM
CMM Fidelity Assessment
Context
Wraparound Infrastructure
Practice Management Self-Assessment
Content
CMM Patient Care Process
CMM Self-Assessment
Competence
Quality of Clinical Decision Making
Patient Responsiveness
Survey
Fidelity and other implementation outcomes measures

10. A Common Language for the Patient Care Process for Comprehensive Medication Management

11. JCPP Pharmacists’ Patient Care Process
Nursing Patient Care Process

12. What is unique about the pharmacists’ patient care process?

13. Defining a Usable Innovation
Clear description of the program
Clear Philosophy, Values, and Principles
Clear inclusion and exclusion criteria that define the population for which the program is intended
Clear description of the essential functions that define the program
Clear description of the features that must be present to say that a program exists in a given location
Operational definitions of the essential functions
Profiles describe the core activities that allow a program to be teachable, learnable, and doable in practice; promote consistency across practitioners at the level of service delivery
A practical assessment of the performance of practitioners (and patients) who are using the program
Michie and colleagues, 2005; 2009 Fixsen, Blase, Metz, & Van Dyke, 2013

14. Research Methods for Producing a “Common Language” for CMM

15. Establishing a Common Language for the Patient Care Process for Delivering CMM
Literature Review
Vetting & Consensus
Focus Groups
First Draft
Second Draft
Expert Panel Review
Third Draft
Stabilized Draft
Key Informant Interviews
Document Review
TAP
Interviews
Phase 1
Phase 2
Phase 3
Phase 4

16. JCPP Pharmacists Patient Care Process
Alignment of JCPP and the CMM Patient Care Process
JCPP Pharmacists Patient Care Process
CMM Patient Care Process
Collect and Analyze Information
Assess Information and Formulate a Medication Therapy Problem List
Develop the Care Plan
Implement the Care Plan
Follow-up and Monitor
Note: Same 5 Essential Functions or Steps

17. Operational Definition
Essential Function
Assess the Information and Formulate a Medication Therapy Problem List
The clinical pharmacist assesses the information collected and formulates a problem list consisting of the patient’s active medical problems and medication therapy problems in order to prioritize recommendations to optimize medication use and achieve clinical goals.
Operational Definition
Assess and prioritize the patient’s active medical conditions taking into account clinical and patient goals of therapy.
Assess the indication of each medication the patient is taking.
Assess the effectiveness of each medication the patient is taking.
Assess the safety of each medication the patient is taking.
Assess adherence of each medication the patient is taking.
Formulate a medication therapy problem list via the medication therapy problem categories established by the Pharmacy Quality Alliance
Prioritize the patient’s medication therapy problems.
The pharmacist assesses the information collected and analyzes the clinical effects of the patient’s therapy in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care. This process includes assessing: • Each medication for appropriateness, effectiveness, safety, and patient adherence • Health and functional status, risk factors, health data, cultural factors, health literacy, and access to medications or other aspects of care • Immunization status and the need for preventive care and other health care services, where appropriate

18. Operational Definition
Assess and prioritize the patient’s active medical conditions taking into account clinical and patient goals of therapy.
Assess the indication of each medication the patient is taking by considering the following:
Does the patient have an indication for the medication?
Is the medication appropriate for the medical condition being treated?
Does the patient have an untreated medical condition that requires therapy, but is not being treated or prevented?
Assess the effectiveness of each medication the patient is taking by considering the following:
Is the patient meeting clinical goals of therapy?
Is the patient meeting overall personal goals of therapy?
Is the most appropriate drug product being used for the medical condition?
Is the dose, frequency, and duration appropriate for the patient?
Do additional labs need to be obtained to monitor the effectiveness of the medication therapy?
Assess the safety of each medication the patient is taking by considering the following:
Is the patient experiencing an allergy or adverse effect from a medication?
Is the dose too high for the patient? Is the frequency and duration appropriate for the patient?
Do safer alternatives exist?
Are there any pertinent drug-disease, drug-drug, or drug-food interactions?
Do additional labs need to be obtained to monitor the safety of the medication therapy?
Assess adherence of each medication the patient is taking by considering the following:
Is the patient receiving the most affordable option to optimize adherence?
Is the patient able to obtain his/her medications, and, if not, why?
Are the medications taken at times during the day that are convenient for the patient?
Is the patient taking the medications as prescribed/instructed or missing doses?
If the patient is not taking as instructed or missing doses, why?
Is the frequency and formulation appropriate for the patient to optimize adherence?
Formulate a medication problem list via the medication therapy problem categories established by the Pharmacy Quality Alliance
Prioritize the patient’s medication therapy problems.

19. Pharmacists Patient Care Process vs
Pharmacists Patient Care Process vs. Patient Care Process for a Defined Service
Patient Care Process for Comprehensive Medication Management
Patient Care Process for Targeted Disease Management

20. The Diffusion-Dissemination-Implementation Continuum
The passive, untargeted and unplanned spread of new practices.
Active spread of new practices to the target audience using planned strategies.
The process of adoption, integration and use of new practices within a setting
Implementation
Dissemination
Diffusion

21. How can we accelerate the dissemination and adoption of a consistent approach to the delivery of CMM in the context of the PPCP?
Current Dissemination Strategies
Additional Venues for Dissemination
ACCP communications channels
ACCP Team-Based Practice Forum
“Pharmacy Forward” podcast
Web-based CMM Implementation Platform hosted by UNC
“Intro to CMM” online course hosted by UMN
Foundational component of the A3 Collaborative
JCPP organizations
Social media
Practitioner programs
Professional education
Students
Preceptors
Residency education
Other workforce development strategies

22. A special thank you to ACCP and the ACCP Foundation