1.3 Medication Therapy Management in the 21st Century

The trends of an aging population and increased dependence on drugs and supplements for healthcare have continued into the new century. The potential for dangerous side effects, overuse, and harmful medication interactions has risen exponentially. Providers and pharmacists recognized they had only partial information about the supplements and drugs (including OTC drugs and alcohol) that patients were using and the drug reactions the patients had in the past.

Insufficient patient information was leading to great safety issues as well as overall inefficiencies, waste, and other problems. From this arose the push for electronic health records for shared health information among care providers and more education about drugs and their interactions from the pharmacist. The pharmacist was the ideal professional to act as a counselor and case manager to help patients choose, use, and monitor their drugs in a more holistic manner for the best health outcomes. This is called medication therapy management(MTM).

The pharmacist, with the support of the pharmacy technician, works to ensure positive outcomes for drug therapy through careful medication counseling and monitoring when appropriate.

The growing costs of drugs and adoption of generic drugs and drug formularies by insurance companies (following the lead of HMOs) raised new questions about drug equivalencies and compatibilities. Patients and prescribers didn’t know which drugs were covered by insurance and which were not. Pharmacy personnel needed to be a source of this information, which added to the advantage of pharmacists overseeing patient medication therapy management.

MTM includes a review of all medications, supplements, and OTC products used by a patient; this review helps identify and address any potential problems. Other MTM practices include recommending a less costly drug to a physician; identifying potential serious drug-drug interactions, side effects, or adverse reactions; and counseling patients on the importance of wellness activities and adhering to a prescribed drug therapy to better control their diseases. MTM patient-pharmacist interactions and the amount of pharmacist time they require are gradually being recognized and reimbursed by insurance companies because they have been proven to result in better health outcomes and less waste from ineffective or problematic medication use. Pharmacy technicians are assisting in MTM with some technicians even specializing in medical assistant advocacy.

Collaborative Practice Agreements

As the patient care role of the pharmacist advanced, formal relationships between pharmacists and prescribers were created. One such relationship is called a Collaborative Practice Agreement (CPA). Collaborative Practice Agreements, or CPAs, are formal agreements where licensed providers (such as physicians) make a diagnosis, supervise patient care, and refer patients to a pharmacist for protocol-based care.

Under CPAs, pharmacists can independently provide specific patient care functions after a diagnosis and referral is made by a prescriber. CPA services may include patient assessment as well as selecting, initiating, administering, monitoring, and adjusting medication regimens. Almost all states now allow some form of CPA. The Centers for Disease Control and Prevention (CDC) encourages the use of CPAs as studies show pharmacist involvement in the healthcare team improves patient care. These expanded services would be difficult for a pharmacist to perform without the support of pharmacy technicians. Technicians address the ongoing needs of the pharmacy, including scheduling of patient appointments, obtaining medication histories, reconciling medications, and prior authorization assistance.

Note that CPAs are not required for pharmacists to provide many patient care services, such as performing medication reviews, counseling patients, providing disease screening, and referring to other providers.

Pharmacy Practice Model Initiative

In order for pharmacists to provide expanded patient care services, they require support and assistance to fulfill other pharmacy-related responsibilities. Pharmacists need the help of trained pharmacy technicians. Hence a related movement to improve patient outcomes was developed by the ASHP called the Pharmacy Practice Model Initiative (PPMI). The PPMI required the education and certification of pharmacy technicians and encouraged implementation of pharmacy practices that will not only improve the quality of healthcare, but also lower its costs through enhanced roles, education, and responsibilities for both pharmacists and pharmacy technicians. The overall mission was to further empower the pharmacy team with better tools “to take responsibility for patient outcomes.” The ASHP has expanded the scope of its offerings for reform and assessment, calling it the Practice Advancement Initiative (PAI).

Advanced Technician Practice

An essential part of the PAI is the utilization of emerging advanced technician positions, including technician supervisor, Tech Check Tech, informatics or business administration specialist, and insurance or medical assistance advocacy specialist. A more complete listing of advanced positions can be found at https://PharmPractice7e.ParadigmEducation.com/AdvRoles. Pharmacy technicians may also find expanded roles in documenting clinical monitoring statistics, inventory control and management, or quality and safety monitoring.

Pharmacy technicians may also get specialized training and/or certificates in IV infusions, nonsterile and sterile compounding and aseptic technique, chemotherapy and hazardous compounding, pediatric medication preparation, and prenatal or parenteral nutrition. These advanced technician roles are being implemented in various institutional (especially hospital) and community settings across the country, varying from state to state. For a glimpse at this future, see the Advanced Technician case studies at https://PharmPractice7e.ParadigmEducation.com/PAI. More information on career options is provided in the final chapter.