Medication problems (i.e., overuse, underuse, and misuse) are a significant burden to the U.S. healthcare system, leading to high financial costs and poor patient outcomes. Suboptimal medication use plays a role in 275,000 deaths, and costs $500 billion in excess healthcare costs each year.1 To address this, a variety of pharmacist delivered medication optimization services exist to help improve patient care, including Medication Therapy Management (MTM), Comprehensive Medication Reviews (CMRs), and Comprehensive Medication Management (CMM).
While individual studies show evidence to suggest services like CMM can improve patient care,2,3 overall results for other services (i.e., MTM) have been mixed when examined via systematic review.4 This begs the question, why are these results inconsistent? As the authors point out, not all services are implemented equally (even when they are the same service!).4 A specific pharmacy service can be implemented in different healthcare contexts, with different patient populations, and with varying levels of fidelity. Therefore, prior to evaluating service effectiveness, it is critical to ensure the service is delivered consistently and as intended. Unfortunately, there is limited guidance to facilitate selection of effective strategies to ensure consistent delivery of CMM – until now!
Researchers at the Center for Medication Optimization (CMO) partnered with Geisinger’s Center for Pharmacy Innovation and Outcomes (CPIO) to explore how best to implement CMM within Geisinger Health, an integrated healthcare delivery system in northeast and central Pennsylvania. Specifically, this partnership set out to better understand what strategies were most helpful to implement CMM into a new at-home program. Seven different implementation strategies were used to ensure consistent delivery of this service. Pharmacists and team members provided key insights into the perceived usefulness of these strategies. To evaluate the effectiveness of these strategies, the researchers assessed the acceptability, feasibility, appropriateness, and adoption (using the Implementation Outcomes Questionnaire) of CMM within this program. Fidelity to the CMM process was also assessed.
As the first study to describe implementation strategies to support the delivery of CMM, a number of key findings emerged.
- Use of successfully employed implementation strategies improved fidelity to the CMM process. Implementation strategies that were successfully used, such as audit and feedback, changing the documentation system, and developing educational materials, improved how consistently pharmacists followed the CMM patient care process.
- Some implementation strategies were perceived to be more useful than others. While seven different implementation strategies were studied, audit and feedback was identified as most beneficial. This process increased the consistency of documentation and decreased rates of non-compliance with clinical documentation. On the other hand, forming an implementation team and using a readiness assessment were not fully utilized. Thus, these strategies were perceived as the least helpful, and were ultimately abandoned.
- CMM was viewed as an acceptable, feasible, and appropriate service, but was not sustained in this context. Pharmacists and other care team members perceived the delivery of CMM within a team-based at-home care program as acceptable, feasible, and appropriate for the targeted patient population. However, due to the evolving needs of the program (i.e., focus shifted from chronic care management to stabilizing acute needs) the service was not sustained due to fit of CMM within a shifting focus of the program. (Read more about the importance of service fit considerations).
- Team members found value in pharmacists and pharmacy services. Even though CMM was not sustained in this particular context, team members perceived pharmacy services in general as acceptable, feasible, and appropriate. They also considered pharmacists as valued members of the care.
While previous studies have reported on effectiveness of CMM, this is the first to describe the implementation strategies used to facilitate service delivery. This study provided important insights into the strategies that may be most helpful when implementing a new service.
To learn more about this project, read the full article “A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program”. If you are interested in more of CMO’s work, read our other blogs, check out our Center’s webpage, and follow us on twitter @unc_cmo.
This work described here was supported by a grant from the Geisinger Health Plan/Geisinger Clinic Quality Pilot Fund for the fiscal year periods of 2019 and 2020.
- Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug–related morbidity and mortality. Annals of Pharmacotherapy. 2018:1-9.
- Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185-195.
- The Outcomes of Implementing and Integrating Comprehensive Medication Management in Team-Based Care: A Review of the Evidence on Quality, Access and Costs (October 2020). Published June 2020. https://gtmr.org/resources/the-outcomes-of-implementing-and-integrating-cmm-in-team-based-care-a-review-of-the-evidence-on-quality-access-and-costs/. Accessed February 2, 2021.
- Viswanathan M, Kahwati LC, Golin CE, et al. Medication therapy management interventions in outpatient settings: A systematic review and meta-analysis. JAMA Intern Med. 2015;175(1):76-87. doi:10.1001/jamainternmed.2014.5841