M.C. is to see Dr. Hart in the cardiology clinic in 2 days to discuss the laboratory

values and alternative therapies.

Discussed the entire plan with M.C., and she verbalized understanding of steps

that she is to take with respect to her current medication-induced problem.

CASE 1-5, QUESTION 2: From M.C.’s medication profile, what other problems can be identified with her

medication therapy? What can be done to address these issues?

There are two remaining issues that may need to be addressed. The first issue

relates to the pain medicine (indomethacin) that M.C. is taking. It is suggested that

indomethacin may have a higher rate of central nervous system side effects in the

elderly compared with other agents in the same class.

30 Furthermore, the American

Geriatric Society guidelines on the management of mild-to-moderate persistent pain

caution the use of nonsteroidal anti-inflammatory agents in older adults, preferring

acetaminophen as a first-line agent.

31 Other prescription medications or

nonprescription medication such as acetaminophen alone could be used to help treat

M.C.’s pain (see Chapter 55, Pain Management, and Chapter 107, Geriatric Drug

Use).

Second, it is not clear from the current information whether the various providers

are communicating. It is the responsibility of the pharmacist to help coordinate care

among multiple prescribers as described by the APhA MTMS consensus document.

1

Therefore, it is important to be sure that both providers (Drs. Smith and Hart) receive

a copy of the documentation of the issues addressed during the visit (SOAP note).

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CASE 1-5, QUESTION 3: What additional information can be provided to M.C. at this time?

Finally, M.C. came into the pharmacy asking for help with her medication costs.

To assess this problem, it is important to ask whether there are specific cost issues

with a particular drug or whether it is her overall medication regimen that causes her

concern. Another question to ask is whether she has stopped taking any medications

or changed the way she takes them because of cost. Many patients will discuss cost

and adherence issues with their pharmacist, because the point of sale for medications

occurs at the pharmacy. However, they may not discuss this problem with the

prescriber. Cost and lack of adherence because of cost are medication-related

problems that the pharmacist must communicate to the prescriber on behalf of the

patient. In assessing drug cost, there are several steps that can be taken. First,

determine the patient’s ability to pay for medications; implement low-cost, medically

appropriate interventions targeted to patient needs; facilitate enrollment into relevant

benefit programs; and confirm medication changes with the patient and prescribers.

For M.C., the rosuvastatin is her biggest concern, as it costs $60 per month and her

Medicare Part D plan lists it as a non-preferred (tier 3) agent on the formulary. With

the possible discontinuation of her rosuvastatin, it is important for the pharmacist to

anticipate an alternative lipid-lowering agent and determine a cost-effective

alternative that may be appropriate. This information can then be relayed to the

prescriber. Furthermore, the alternative lipid-lowering formulary choice can be

integrated into the plan developed for the primary issue of muscle soreness and

weakness (see Case 1-5, Question 1). The integration of multiple problems is a

complicated but an important aspect of the MAP.

As discussed previously, an important part of MTMS involves the MAP. The

MAP is a document that may empower the patient and promote self-care. The

information on the MAP is important for both the patient and the provider, and it

facilitates communication among multiple providers. When a patient presents the

PMR and MAP to all providers, complex medication information can be shared

across the continuum of care. An example of M.C.’s MAP is included in Figure 1-3.

Because extensive information was communicated to the patient and other

providers, follow-up (phone or face-to-face) would be appropriate and necessary to

determine the resolution to the medication-related issues identified. Follow-up

should occur in a timely manner, likely after M.C. has obtained the necessary

laboratory test results and has been evaluated by her cardiologist as outlined in the

plan. The follow-up should include questions related to the changes that were (or

were not) made based on the practitioner recommendations and any new issues that

have surfaced. Follow-up should be considered after any encounter in which an

action plan is developed to determine whether the medication-related problem has

been resolved. Additionally, problems may be identified and prioritized during the

initial visit but, because of time constraints, may not be addressed. A follow-up visit

allows for assessment of these problems.

CASE 1-5, QUESTION 4: Assuming that the pharmacy provider had an NPI number and a contract with

M.C.’s Medicare Part D prescription drug plan, how could the 30 minutes spent with M.C. be billed to her

insurance?

Provided that M.C. was identified by her Medicare prescription drug plan as

eligible for MTMS, the practitioner could bill for the 30-minute encounter. Using the

practitioner’s NPI number and the appropriate CPT codes, the practitioner could bill

for one CPT 99605 (for the first 15 minutes of initial face-to-face MTM encounter)

and one CPT 99607 (for an additional 15 minutes spent with the patient in a face-toface MTM encounter). M.C.’s Medicare Part D plan may require the practitioner to

bill the prescription drug plan initially, and then the plan would pay the community

pharmacy directly instead of reimbursing the individual pharmacist. Documentation

of the visit would need to be stored at the site of the encounter in case any

information was requested from M.C.’s prescription drug plan.

CASE 1-5, QUESTION 5: M.C. has just been hospitalized in a large medical center for renal failure and

urosepsis. The pharmacist has access to the medical chart, nursing record, MAR, and a computer that directly

links to the clinical laboratory. The pharmacists at this facility assess the patient’s drug therapy and routinely

provide clinical pharmacokinetic monitoring. How would the pharmacist approach M.C. differently in this

inpatient setting compared with the pharmacist in Question 1 who worked in a community pharmacy?

MEDICATION THERAPY MANAGEMENT IN THE

ACUTE CARE SETTING

Similar to the outpatient setting, the SOAP format is often used when documenting the

encounter of the hospitalized patient; however, obtaining the information needed

poses unique challenges. In this setting, subjective information may be more difficult

to obtain at the time of assessment in those patients presenting with cognitive

impairment resulting from their acute condition, such as the seriously ill or injured

patient. Objective data, on the other hand, are more readily available and retrievable

with access to pharmacy, laboratory, and other medical record information. On

admission to the health care facility, the medication reconciliation process should be

initiated to identify any variances in the admission orders when compared with the

patient’s home medication list. With acute medical problems superimposed on

chronic conditions, it is not unusual to have new medications added and home

medications held, changed, or discontinued.

Assessing the appropriateness of drug therapy requires a basic understanding of

both pharmacokinetic (e.g., absorption, distribution, metabolism, and elimination)

and pharmacodynamic (e.g., relief of pain with an analgesic or reduction of BP with

an antihypertensive agent) principles. This detailed assessment and monitoring is

dependent on the availability of robust patient and laboratory data. The inpatient

setting is a relatively data-rich environment in which access to needed information is

readily available. Knowledge of the patient’s height, body weight, and hepatic and

renal function are essential for proper dosage considerations. The type of

hospitalized patient will vary from the short-stay elective surgery patient to the

critically ill hemodynamically compromised patient. The pharmacist must be aware

of how pharmacokinetics and pharmacodynamics can be altered throughout the

hospitalization or disease-state process in each patient evaluated. This heightened

awareness will allow for timely interventions and minimize medication errors

resulting from improper or delayed dosage adjustments because the clinical status of

the patient changes. Drug level monitoring may be suitable for certain medications

and is of great clinical value; nevertheless, it is important to take into consideration

clinical response to drug therapy along with the assessment of a specific laboratory

value. Accurate interpretation of any drug level requires review of the nursing MAR

(or eMAR), evaluating time of drug administration to serum sample acquisition.

When serum drug levels are obtained, they must be reviewed for validity before

alterations in medication regimens are made. If a serum drug concentration seems

unusually high or low, the clinician

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must consider all of the various factors that might influence the serum

concentration of the drug in that particular patient. When the reason for an unexpected

abnormal serum drug concentration is not apparent, the test should be repeated before

considering a dose change that may cause supratherapeutic or subtherapeutic

concentrations resulting from erroneous data (see Chapter 2, Interpretation of

Clinical Laboratory Tests).

When M.C. was seen in the community pharmacy, the pharmacist assessed her

chronic conditions, her cost issues, and her drug therapy. Monitoring in the

community pharmacy–based MTM program occurs at regular time intervals and is

less sensitive to the day-to-day changes of the patient. However, in the inpatient

setting, M.C. has acute conditions (renal failure and urosepsis) in addition to her

chronic conditions. Monitoring of medication therapy will occur frequently, resulting

in a dynamic treatment plan for her acute and chronic conditions.

Although the inpatient setting is relatively data rich, the information gathered and

the assessment and plan formulated in the facility must be communicated to other

providers once the patient is discharged. At discharge, it is critical to ensure that the

patient has follow-up with his or her primary care physician or coordinated care

team in a timely fashion. At this point, it is again critical for the pharmacist to

perform medication reconciliation to determine exactly what did happen once the

patient returned home. This closes the loop at a critical time when the patient is

prone to medication errors and readmission.

MEDICATION THERAPY MANAGEMENT AND

PHARMACOGENOMICS

The use of genetic information to predict an individual’s response to a drug, known

as pharmacogenomics, is currently factoring into drug design and development. Using

genetic information to tailor drug therapy to an individual will reduce the risk of

adverse events, potentially improve patient outcomes, and create a more efficient

drug development process. By transforming drug therapy into a patient-specific

approach, the health care community is one step closer to achieving the new medical

paradigm of personalized health care