By Kelly Frisch, MD

The Vital Role Pharmacists Play Within Today’s Primary Care Team

Contributed by Taylor Hill, PharmD, BCACP, Mary Sauer, PharmD, BCACP, AE-C, CDE and Kyle Walburg, PharmD

The CDC 1 says 74% of physician visits involve drug therapy while 80% of all treatment plans include medications. 2 In 2018, $344 billion were spent on 5.8 billion prescriptions in the United States and that’s projected to grow by 18 to 26% over the next five years. 3 Medications only work if you take them, but two out of every three prescriptions are actually filled the first time 4 and only half of those get refilled six months later. Compliance rates decline even further as time passes and barriers like affordability and lifestyle multiply. The reasons range from not understanding why the medication is needed to affordability and convenience. Medication adherence can impact outcomes more than the treatment itself according to the World Health Organization. Nonadherence accounts for up to 50% of treatment failures, 125,000 deaths, and a quarter of hospitalizations annually in the US. Customers working with their care team are key to changing this pattern and saving $100 to $300 billion in healthcare costs annually. 5 Personalized Med Management Medication Therapy Management (MTM) at North Memorial Health takes a personalized, holistic view of pharmaceutical care by bridging the knowledge gap and making each customer an expert in their medicine. Equipped with a deep understanding of medications and treatments along with allergens, drug interactions and contraindications, MTM pharmacists meet with customers to glean personal lifestyle preferences, formulary restrictions and a complete list of supplements. With an eye toward evaluating medication effectiveness, safety and convenience, the MTM pharmacist considers each customer’s health condition, history, problem list and clinical notes to identify medication regimens that are understandable and affordable. MTM pharmacists are well-versed in evidence-based guidelines and the clinical nuances of medication selection. By creating care plans collaboratively, pharmacists work in lockstep with primary care providers (PCP), specialists and other clinicians under a collaborative practice agreement that defines where they can start, stop or adjust medications without physician approval. North Memorial Health experienced quality score improvements following MTM pharmacist visits (diabetes outcomes increased 14%) and received positive customer feedback about the enhanced clinic experience and ease in managing their medications. Providers also felt less overwhelmed and burned out after a MTM pharmacist joined the care team. Integrated Into the Clinic Experience Pharmacists physically located and embedded within the primary care clinic are integral to MTM and foster strong, trusting working relationships. Consults over the phone or via home visits are also available and telehealth is currently under consideration. While providers can easily refer customers via Epic to a MTM pharmacist, they frequently seek curbside consults to discuss a specific customer’s challenge. MTM pharmacists can review physician schedules to identify customers with long medication lists and request time with customers already on the schedule. The pharmacist can join an existing customer appointment or see them after a provider has identified that they would benefit from MTM. Customers truly value MTM pharmacists and say things like, “That’s the person I see at my doctor’s office who saved me $1,500/year on my meds,” or “She brought down my A1C from 11 to 7 and helped me reach my goal.” MTM Impacts Quadruple Aim A recent study published in the Journal of the American Board of Family Medicine 6 explored the impact of MTM in the primary care setting and found that adding a pharmacist’s deep knowledge of pharmacotherapy freed up PCPs to focus on medical issues. PCPs felt better supported, “less burned out” and had a higher quality of work life. They described seven outcomes including: • decreased workload Kyle Walburg, PharmDTaylor Hill, PharmD, BCACP Mary Sauer, PharmD, BCACP, AE-C, CDE

• increased customer satisfaction about receiving better care • reassurance • decreased mental exhaustion • enhanced professional learning • increased provider access • achievement ofquality measures Save Time and Money With MTM, it’s common to save customers thousands of dollars annually by taking a closer look at what’s on their formulary or realizing they qualify for drug manufacturer assistance. If a customer needs an expensive drug, test claims can determine which medication is covered at the best rate before the provider even sees the customer. While Medicaid and Medicare cover MTM services, commercial insurance coverage varies; value and risk-based contracts often incentivize comprehensive MTM visits. Best Use of Expertise Doctors only have 20 minutes to discuss all health concerns with each customer. They don’t have time to focus on the nuances of each medication or delve into what may be a barrier for the customer to take a medication. By changing the care team landscape and viewing the pharmacist as a key component to the team, doctors and staff save time and are able to work at the top of their expertise. And, there is more access to care with customers following-up with their pharmacist on things like hypertension, asthma and diabetes. After working with MTMs and experiencing their impact first-hand, clinicians said, “You’re the best resource I never knew I needed,” and “You make me a better doctor every day I work with you.” Doctorate-trained Pharmacists MTM pharmacists are doctorate-trained with a minimum of six-years of education. Most have a bachelor’s degree followed by a four-year doctor of pharmacy program. They are all board-certified pharmacological specialists and many also complete residency training and board-certification in specialties like ambulatory care, asthma, diabetes, oncology, pediatrics or geriatrics. The North Memorial Health Difference MTM pharmacists at North Memorial Health are embedded in the primary care team and trained in motivational interviewing and setting SMART goals. They practice shared decision making with customers and are empowered to do what’s right for each customer. Recently, a customer called their MTM pharmacist saying, “I’m running out of insulin and I’m due for my shot. I can’t draw it up. I just can’t do it!” The pharmacist immediately closed his schedule, drove to the customer’s home and drew up enough insulin for the remainder of the month. The customer is always at the forefront, particularly when confronted by time sensitive, critical issues. Customer satisfaction data bears this out with 99% of North Memorial Health customers feeling more confident managing their medications after seeing a MTM pharmacist and 100% saying they would recommend their MTM pharmacist. To learn more or get a curbside consult with a North Memorial Health MTM pharmacist, call (763) 581-2153. Taylor Hill, PharmD, BCACP, Medication Therapy Management. Dr. Hill also focuses on caring for customers with diabetes, asthma and high cholesterol. Dr. Hill received his Doctorate Degree from the University of Minnesota College of Pharmacy and completed his Ambulatory Care Pharmacy Residency at Essentia Health, Duluth. Mary Sauer, PharmD, BCACP, AE-C, CDE, Medication Therapy Management, Asthma Educator, Certified Diabetes Educator. Dr. Sauer focuses on caring for customers through shared decision making. Dr. Sauer received her Doctorate Degree from the University of Minnesota College of Pharmacy and completed her Family Medicine Residency at Park Nicollet. Kyle Walburg, PharmD, Medication Therapy Management. Dr. Walburg’s main passion is diabetes management, but she also focuses on caring for individuals with asthma, COPD, hypertension and more. Dr. Walburg received her doctorate degree from the University of Minnesota College of Pharmacy and is in progress of completing her Pharmaceutical Care Leadership Residency at the University of Minnesota Twin Cities. (Endnotes) 1. CDC Therapeutic Drug Use. 2. American College of Clinical Pharmacy Comprehensive Medication Management in Team-Based Care. 3. IQVIA Market Prognosis, Mar 2019; IQVIA Institute, April 2019. 4. Ann Intern Med 2014;160(7):441-450. 5. US Pharmacist January 19, 2018, 018;43(1)30- 34. 6. The Journal of the American Board of Family Medicine July 2019, 32 (4) 462-473. Who is Medication Therapy Management Best Suited For? Complex customers often have many medication-related problems. A Medication Therapy Management (MTM) pharmacist’s assessment can simplify, organize and resolve many medication-related problems leaving providers more accessible. MTM is beneficial for customers who are: • polypharmacy, taking six-plus medications • not meeting their health goals including diabetes care, hypertension, asthma, COPD, depression, anxiety, insomnia, or cholesterol • having adherence issues due to affordability or lack ofinsurance • having trouble understanding why they’re taking various meds • recentlydiagnosed with diabetes, osteoporosis, COPD orneed smokingcessation • transgender on HRT • on multiple supplements • in need ofa step-up with additional medication(s) that may cost a lot • in need ofan infusion or self-administering an injection Medication Therapy Management pharmacists embedded in the clinical care team positively influence all quadruple aim goals with improved outcomes and decreased drug expenditures, readmissions, hospitalizations and provider burnout.