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  • Jim Riopelle, MD, CPE

I would be uncertain too!

I believe we can all agree that the patient should be the most central figure in their own healthcare decisions. That is what I love about this article by Taylor and colleagues at the University of Arizona: https://www.jmcp.org/doi/full/10.18553/jmcp.2018.24.9.904


They are actually talking to patients to learn about their experiences and preferences with Medication Therapy Management programs. This study has its limitations to be sure, but the take home message is still relevant. As healthcare providers and administrators, we need to design solutions around our patients and stop expecting our patients to adapt to our convenient solutions. I admit, I am guilty of the latter. Throughout my career, I have found myself making the convenient decisions in response to new regulatory guidance or quality incentives. I never stopped to ask if my health plan members would understand what “Medication Therapy Management” was or how they would respond if I sent them a letter using this CMS’ vernacular. Taylor and colleagues asked and it ends up that they don’t understand the term Medication Therapy Management. Our patients would prefer “Medication Management”. That seems simple enough!


Taylor and colleagues also discovered that patients are “uncertain of the identity of the telephone caller”. That shouldn’t be a surprise to any of us. When is the last time we picked up a cold call from a number we didn’t recognize? For a moment, lets assume we really had nothing better to do and decided to answer the phone call from an unknown or unrecognized number. Now, what is going to possibly convince us that we should spend 30 minutes talking with a stranger, with unknown credentials, from across the country about our most personal & sensitive information. Clearly, my commentary is rhetorical because most of us just wouldn’t engage with this model of care. So, why have so many of us designed or implemented a Medication Therapy Management program that expects our Medicare population to do just this? Is it because we don’t respect the perspectives of our members? Not likely. Perhaps, we think that deploying pharmacy students telephonically rather than embedding clinical pharmacists into our communities will result in superior outcomes. Nah, we are smarter than that. During my time as the Medical Director at a health plan, I know I did it because I didn’t have any better options. However, this isn’t the case anymore.


After years of using telephonic vendors to try and change physician prescribing practices and educate patients, my pharmacist colleagues and I have decided to design a solution that actually puts the patient at the center of their own healthcare. Very literally, our "Medication Management" Teams go to the patient and conduct our visits with the patient in their environment. By visiting patients in their home, our specially trained team is able to establish trust with the patient. We are able to actually see which medications they are taking, how they are organizing their medications (or not) and what kind of risk factors exist in the home. After having a personal conversation with our patients in their home, we are able to provide valuable information to the provider that they otherwise wouldn’t be aware of.


In one recent example, our team met with a very nice, well-spoken 88-year-old woman. We’ll call her Ethel. Ethel and her husband still lived independently and had every confidence in the medication support that they were receiving from two different adult children. We had a list of 10 medications that she should be taking from her health plan and in reviewing each one with her, she confidently confirmed that she was indeed taking them just as the label described. With our Pharmacy Care Advocate sitting in Ethel’s living room, we asked to see how she organized all of these medications. Ethel confidently showed us the large pill box that she used, but there was something wrong. It was empty! After some additional discussion, we learned that Ethel relies on her two daughters to coordinate visits to her home and fill her pill box. Unfortunately, neither had been there in the last 10 days, so she hadn’t taken her medications for at least 3 days! As a doctor, I can’t imagine my 88-year-old patient just not taking her Xarelto for 3 days and me not knowing about it.


When our pharmacist called the doctor to discuss the situation with him, he explained that the patient had dementia but was quite adept at covering that up with affirmative dialogue. Unfortunately, her husband was very unhelpful with her healthcare and the doctor had been encouraging the family to move mom into a nursing home for over a year now. Of course, Ethel was resistant to this and her daughters couldn’t stand the idea of breaking mom and dad apart. We spent time talking with both of the daughters and the provider and decided that we weren’t going to change their minds, but we could still help out. After some additional care coordination, we confirmed that Ethel could have her prescriptions transferred to a new pharmacy that would bubble pack all of her medications and deliver them every 7 days with directions right on each label for how she should take them each day. We called our dedicated contact at the health plan to ensure there was no additional cost, received patient, caregiver, & provider consent and then proceeded to help coordinate with the new pharmacy and the doctor’s office. It took a lot of work on our part, but we feel confident that Ethel and her husband will be able to live together independently for a few more years. Furthermore, we believe we are executing on a Medication Management model of care that puts patients first, coordinates with their primary care team, and ensures health plans meet all of their quality of care measures.


Let's remember who we are designing our clinical programs for.


- Jim


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