MTM Module

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APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES
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APhA DELIVERING MEDICATION THERAPY

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A National Certificate Training Program
Module 1. The Current Landscape for MTM Services
2014, American Pharmacists Association. All rights reserved.

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Learning Objectives
After completing this module of the self-study activity,

pharmacists will be able to:
1.
Explain the key components of medication therapy

management (MTM).
2.
Define the five core elements of the MTM service

model.
3.
Discuss the MTM provisions of the Medicare Part D

benefit, including requirements established by the
Centers for Medicare and Medicaid Services and the
Affordable Care Act.
4.
List opportunities for providing MTM services

including those that were created by the Affordable
Care Act, such as patient-centered medical homes,
accountable care organizations, and transition of
care activities.
5.
Cite data that describe the current status of MTM

provision in the United States.
6.
Discuss quality measures that can be impacted by

MTM services or used to evaluate MTM services.
7.
Describe economic and clinical outcomes that

are affected by pharmacist-provided patient care
services.
Introduction
The U.S. health care system incurs annual costs of more than
$200 billion due to inappropriate use of medications. These
costs include approximately 10 million avoidable hospital
admissions, 78 million outpatient treatments, 246 million
prescriptions, and 4 million emergency department visits
and constitute 8% of total annual health care expenditures.1
Improving medication use in this country is an important public
health goal that is recognized in the national public health
initiative Healthy People 2020 (healthypeople.gov). Several
goals in this initiative focus on improving medication use.
Examples (and final objective numbers) include2:
Increase the proportion of adults with hypertension

who are taking the prescribed medications to lower
their blood pressure (HDS-11).
Reduce emergency department visits for common,

preventable adverse events from medications
(MPS-5).
Reduce the proportion of older adults with disabilities who use inappropriate medications (DH-7).
Medication therapy management (MTM) is designed to allow

health care providers to identify and resolve medicationrelated problems, and has been shown to both reduce health
care costs and improve clinical outcomes.3,4 Many pharmacists
are eager to expand their patient care activities and assist
patients with medication-related problems. However, they
may need to fine-tune various patient care skills, increase their
expertise in therapeutics, or develop the infrastructure required
to support these services.
This certificate program presents a systematic approach for
developing, implementing, delivering, and sustaining MTM
services. It includes an overview of the marketplace for
delivering MTM services, guidance for implementing MTM
services in pharmacy practice, a review of the essential skills
and knowledge needed for performing MTM successfully,
and an organized process for identifying medication-related
problems.
When the term patient is used in this program, it refers to
the patient or the patients caregiver who may be present
during delivery of MTM services or other health care visits.
The History of MTM
Pharmacists have provided individualized patient care services

in numerous settings for decades; these services were often
described as pharmaceutical care, a term that was coined
in 1990.5 The term medication therapy management has
been in wide use since the early 2000s, when the Medicare
Prescription Drug, Improvement, and Modernization Act of
2003 (MMA) put MTM on the health care map as part of the
Medicare Part D benefit.
The inclusion of MTM in the Part D benefit stimulated development of national standardization of such services by
expanding access to services for patients and compensation
opportunities for pharmacists. MMA includes a provision for
pharmacists and other health care professionals to deliver
MTM services to Medicare beneficiaries at high risk for
medication-related problems and allows prescription drug
plans to pay pharmacists for providing these services. (Of
note, the legislation did not grant Medicare Part B provider
status to pharmacists, and lack of this status continues to
impede payments to pharmacists in some settings.) Today,
pharmacists provide MTM to a wide variety of patient populations in addition to Part D beneficiaries.
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The Medicare Prescription Drug Benefit: Part D
Prior to January 2006, the Medicare program consisted

of Part A (inpatient hospital services, skilled nursing
facility benefits, and hospice care), Part B (physician and
outpatient hospital services, annual mammography and
other cancer screenings, and services such as laboratory
procedures and medical equipment acquisition), and
Part C (Medicare managed care plans). MMA added
Part D, an optional prescription drug benefit available to
any Medicare beneficiary, which included payment for
MTM services for selected beneficiaries.
Medicare Parts A, B, and C are administered by the
Centers for Medicare and Medicaid Services (CMS).
However, Medicare Part D is administered by private
insurersPrescription Drug Plans and Medicare Advantage
Prescription Drug (MA-PD) plansthat are reimbursed by
CMS. Plans offering Part D prescription coverage follow
regulations and guidelines that are developed by CMS.
What Is MTM?
MTM encompasses a broad range of health care services

provided by pharmacists. As defined in a consensus definition
adopted by the pharmacy profession in 2004, MTM is a
distinct service or group of services that optimizes therapeutic
outcomes for individual patients (Appendix A).6 The definition
supports services that optimize therapeutic outcomes for
individual patients, promote collaboration with other health
care providers, and facilitate continuity of care. This definition
includes a range of professional activities and services within
the scope of pharmacy practice, applicable within the broad
range of pharmacy practice settings, and appropriate for any
patient in need of MTM services. (However, some limitations
may exist based on scope of practice regulations in individual
states.)
MTM services are distinct from medication dispensing and
the routine patient counseling provided by a pharmacist
when a patient picks up a prescription medication. These
brief counseling sessions usually involve instructions for the
particular medication being dispensed, and address the
patients questions specifically relating to that medication.
In contrast, MTM is a patient-centered process of care that
includes assessment and evaluation of the patient and his or
her complete medication therapy regimen rather than focusing
on an individual medication product.
Disease management programs and MTM services also are

distinct. MTM services comprehensively address a patients
full range of potential or actual medication-related problems;
disease management programs focus on patient education
and management of a specific disease. More advanced
MTM services may include aspects of disease management
programs, such as blood pressure monitoring and lipid
management. Likewise, MTM services, such as a comprehensive and targeted medication therapy reviews, may be
a component of a comprehensive disease management
program.
MTM services can be delivered face-to-face or telephonically. Face-to-face interaction helps establish the pharmacistpatient relationship while also allowing the pharmacist to
visually assess the patient for signs and symptoms of possible
medication-related problems (e.g., lethargy, confusion,
bruising, extrapyramidal symptoms). In-person encounters
give the pharmacist an opportunity to observe visual clues
that might provide insight to the patients comprehension and
acceptance of the pharmacists comments. The pharmacist also
may conduct physical assessments, vital sign measurement,
and point-of-care testing as needed during the face-to-face
visit.
Face-to-face services can occur in a variety of settings, such
as a community pharmacy, a hospital, a clinic, the patients
home, a community center, or other settings. Telephonic MTM
services enable pharmacists to provide services to patients
when in-person consultations may be challenging to arrange,
such as patients who are home bound or who live in remote
rural areas. Additionally, telephonic MTM services reach the
patient in a comfortable, private setting where they have
access to their medications and any medical records they keep
at home. Both telephonic and face-to-face services require
good communication skills and the ability to assess the patient.
Finally, although the terms MTM services and MTM programs
are often used synonymously, there is a distinction. As currently
used, MTM programs are developed by health plans or other
health care entities focused on optimizing patients therapeutic
outcomes. MTM services are components of MTM programs
and are delivered by health care professionals, such as
pharmacists.
Core Elements of an MTM Service
Not all MTM services will look exactly alike. The specific
services provided will vary based on the patients individual
needs and, to some extent, the pharmacists areas of expertise.
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Learning Activity
Match the word or phrase on the left with the statement on the right that best describes it.
1.
Counseling
2.
Disease management
3.
MTM programs
4.
MTM services
a. A brief, medication-centered discussion about a specific

medication that the patient picks up from the pharmacy.
b. A patient-centered process that includes an assessment of
the patients complete medication regimen and identification
of the individuals medication-related problems.
c. Focuses on patient education and the management of a
specific disease.
d. Developed by health plans to optimize therapeutic outcomes.
5. The consensus definition of MTM services adopted by the pharmacy profession supports the following three objectives:
Answers are located at the bottom of the page.

Third-party payers also may influence services that are
offered. However, to establish a set of standardized components for MTM services, the American Pharmacists Association
(APhA) and the National Association of Chain Drug Stores
(NACDS) Foundation built on the consensus definition and
developed an MTM model framework (Appendix B).7
The MTM model framework is designed to improve collaboration among pharmacists, physicians, and other health care
professionals; enhance communication between patients and
their health care team; empower patients to be self-advocates;
and optimize medication use for improved patient outcomes.
This framework establishes core elements for all MTM services
provided by pharmacists.
The model framework consists of five core elements that can
be provided by pharmacists across the spectrum of pharmacy.
Its structure improves efficiency and creates consistency of
MTM services while meeting the expectations that CMS has
for MTM: enhancing patients understanding of appropriate
drug use, increasing adherence to medication therapy, and
improving detection of adverse drug events. The framework
does not represent a specific minimum or maximum level of
services that could be delivered by pharmacists. Instead, it
delineates a structured approach for medication review that
promotes ongoing evaluation of the patients medication

therapy, recommendations to prescribers, and documentation
of interventions and results. It creates a solid foundation for
pharmacists to build and expand MTM services.
The core elements of MTM service delivery were designed to
help patients take an active role in managing their medications. The five core components of an MTM service include7:
Medication therapy review (MTR).
Personal medication record (PMR).
Medication-related action plan (MAP).
Intervention and/or referral.
Documentation and follow-up.
The following descriptions summarize each of these elements.

Specific details and examples of forms can be found in
Appendix B.
Learning Activity Answer Key

1. a; 2. c; 3. d; 4. b; 5. Optimization of therapeutic outcomes for
individual patients, collaboration with other health care providers,
continuity of care.
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Core Elements of an MTM Service Model
Medication Therapy Management in Pharmacy Practice:

Core Elements of an MTM Service Model Version 2.0 is a
collaboration between APhA and the NACDS Foundation.
It focuses on the provision of MTM services in settings
where patients (or their caregivers) can be actively
involved in managing their medications. This service model
was developed with the input of an advisory panel of
pharmacy leaders representing diverse pharmacy practice
settings.
Medication Therapy Review
The MTR is a systematic process in which the pharmacist

collects patient-specific information, assesses medication
therapies, identifies medication-related problems, develops a
prioritized list of medication-related problems, and creates a
plan to resolve them. It is designed as a collaborative process
to improve patients knowledge of their medications, address
problems or concerns they may have, and enable patients to
self-manage their medications and health conditions.
MTRs are either comprehensive or targeted for a specific
medication-related problem. During a comprehensive MTR,
the pharmacist reviews all current medications for clinical
appropriateness, including prescription and nonprescription
medications, herbal products, and other dietary supplements.
The pharmacist assesses the patients medications for the
presence of any medication-related problems, and works with
the patient, the prescriber, and other health care professionals
as needed to determine appropriate options for resolving
identified problems. In addition, the pharmacist supplies
the patient with education and information to enhance
the patients medication self-management and assist with
promoting appropriate lifestyle changes.
The targeted MTR addresses a specific medication problem
or ongoing medication monitoring. It usually is performed for
patients who previously have received a comprehensive MTR.
The targeted MTR also can be a component of the prospective
medication review that pharmacists may perform during the
dispensing process. Whether for a new problem or subsequent monitoring, the pharmacist assesses the specific therapy
problem in the context of the patients complete medical and
medication history. Following assessment, the pharmacist intervenes and provides education and information to the patient,
the prescriber, community advocates, or other health care
professionals, as appropriate.
The MTR is tailored to the individual needs of the patient at

each encounter. Ideally, a patient receives an annual comprehensive MTR with additional targeted MTRs to address new
or ongoing medication-related problems. A comprehensive
MTR may be needed sooner if a significant event occurs,
such as changes in the patients health status, an emergency
department visit, or an admission to or discharge from a
hospital or long-term care facility. Patients are more vulnerable
to medication-related problems during transitions of care,
therefore systems that support MTM during transitions are
crucial.
Personal Medication Record
The pharmacist develops a PMR for the patient after the MTR
has been completed. A PMR is a comprehensive document
listing the patients medications, including prescription,
nonprescription, herbal, and dietary supplement products.
The PMR is completed and updated either by the pharmacist
or the patient with the pharmacists assistance. Engaging the
patient in completing the PMR may help reinforce education
concepts and enhance the patients understanding of his or
her medication therapy. The PMR is a portable record of all
the patients medications with a summary of important details
written so the patient understands its contents.
Patients use the PMR as a tool to self-manage medications
and to improve continuity of care among multiple prescribers.
Maintenance of the PMR is a collaborative effort among the
patient, pharmacist, prescriber, and other health care professionals. Pharmacists should encourage patients to maintain
and update the PMR and carry it with them at all times.
Patients should be advised to share their PMRs at all health
care visits, including routine appointments and admission to or
discharge from an institutional setting. To ensure a complete
and accurate record, patients should be instructed to bring
the PMR to all visits for the pharmacist to update as needed.
Ultimately, patients (who are able) have a responsibility to
ensure that their PMR is updated in collaboration with their
care team, share this information with all of their health care
providers, and be knowledgeable about their medications.
Medication-Related Action Plan
The document known as the MAP is typically provided to the

patient at the end of the MTR, or shortly thereafter. It contains
specific information for the patient to use for optimizing
medication self-management and making positive lifestyle
changes. The MAP may include a list of medication-related
issues identified, proposed actions to resolve the medication-
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related issues, the person responsible for action, and other

pertinent information. The pharmacist creates this document in
collaboration with the patient, physician, and other health care
providers, as appropriate. The MAP is primarily intended
for patient use, therefore it should be written in language the
patient easily understands and at a literacy level appropriate
for the patient. The MAP should include only items that the
patient can act on and are within the pharmacists scope of
practice or agreed to by relevant members of the health care
team. It should not contain outstanding items that require
review or approval from other health professionals; these
outstanding items should be included in separate internal
documentation that facilitates follow-up.
Pharmacists should encourage patients to voluntarily share
both the MAP and the PMR with other health care providers.
Patients should be instructed to bring the MAP with them to
all future visits thereby allowing the pharmacist who provides
MTM to record the date and the results of interventions and/
or resolutions of medication-related problems. The pharmacist
can use the MAP as a resource when communicating action
plan information to the patients physician and other health
care providers. Additionally, the patient can bring the MAP
to visits with other health care providers to aid continuity of
care. Widespread use of the MAP will support uniformity and
consistency in information sharing among members of the
health care team.
MTM Documentation for Medicare Part D
The Affordable Care Act of 2010 directed CMS to develop

a standardized format for the comprehensive medication
review action plan and summary of MTM services provided
to Medicare Part D beneficiaries.8 CMS developed a
standardized format containing three components: a
beneficiary cover letter, a medication action plan, and a
personal medication list (PML). The PML is similar to the
PMR. CMS noted that the format of the documents is
consistent with MTM forms that were currently in use (i.e.,
those included in the core elements). Part D plans were
required to begin using the CMS format in January 2013.9
The final forms and instructions for their use are available
at: www.cms.gov/Medicare/Prescription-Drug-Coverage/
PrescriptionDrugCovContra/Downloads/MTM-ProgramStandardized-Format-English-and-Spanish-InstructionsSamples-.pdf
Intervention and/or Referral
The intent of providing intervention and/or referral is to

optimize medication use, enhance continuity of care, and
encourage patients to use appropriate health care services
to prevent adverse outcomes. The pharmacist intervenes to
resolve, minimize, or avoid medication-related problems
identified during the MTR. When a patients needs are
complex and extend beyond the basic MTM services,
pharmacists may provide additional care based on their level
of expertise, while staying within the scope of pharmacy
practice. The value of MTM is determined by the quality of the
pharmacists interventions. These interventions may include
activities such as making recommendations to prescribers to
change a patients therapy, implementing strategies to improve
adherence, administering vaccines, and other activities.
Pharmacists need to have updated clinical knowledge,
be able to effectively and efficiently identify drug therapy
problems, and provide clinically relevant recommendations to
prescribers to ensure optimal outcomes.
However, in some cases, the pharmacist will need to refer the
patient to another pharmacist with additional qualifications,
a physician, or another health care provider. Examples of
circumstances that may require referral include:
Evaluation of a new problem discovered during the

MTR.
Advanced education to help the patient manage a

chronic disease (e.g., diabetes, hypertension).
Monitoring of high-risk medications (e.g., warfarin,

digoxin).
Laboratory monitoring (e.g., cholesterol panel,

blood glucose levels, liver function tests).
Medication therapy dose adjustments or changes.
Communication of timely and appropriate information to

the prescriber or other health care professionalincluding
complete yet succinct information regarding the selection of
medications, suggestions to address medication problems,
a complete reconciled medication list, and recommended
follow-up careis integral to the intervention component of the
MTM service model.10
Documentation and Follow-Up
Documentation and follow-up are essential elements of the

MTM process. Services performed should be documented in
a consistent manner that is appropriate for evaluating patient
progress and meeting billing requirements. Follow-up visits
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Learning Activity
Match the phrase on the left with the correct definition on the right.
1.
Medication therapy review
2.
Personal medication record
3.
Medication-related action plan
a. Patient-centric document containing specific

information for the patient to use for optimizing
medication self-management, including the
medication-related issues identified, proposed
actions, and the person responsible for action.
b. Systematic process that requires collecting
patient-specific information, assessing medication
therapies, and identifying medication-related
problems.
c. Patient-centric portable record of all the patients
medications with a summary of important details.
4.
Under what circumstances should a pharmacist refer a patient to another provider?
5.
List three stakeholders that are the intended audience for SOAP notes.
with the patient should be scheduled according to the patients

medication-related needs or circumstances, such as follow-up
monitoring when dose adjustments are made and following a
patients transition from hospital to home.
Documentation
Recording the information obtained during the MTR, such as

the patients medication history and the actions needed to
prevent adverse outcomes, helps create consistent documentation. A chronological record of the pharmacists care,
provided in a standard format, such as a SOAP note (i.e.,
notes on Subjective observations, Objective observations,
Assessment, and Plan of action), also should be included in
the documentation.7,11
Documents resulting from the patients MTR are distributed to
the patient, prescribers, other health care professionals, and
payers, as applicable. Copies of these documents should
be kept on file at the pharmacists practice site. Optimally,

documentation should be electronic (with appropriate patient
privacy security parameters in place) and should be shared
with other health care professionals through secure electronic
portals or health information exchanges. At the end of a visit,
patients should receive their PMR, MAP, and other suitable
educational materials. Patient materials should be written in
easily understood language, free from medical jargon. Patient
materials should be developed at an appropriate health
literacy level, taking into account the patients ability to read,
understand health care topics, and perform simple calculations

1. b; 2. c; 3. a; 4. Referral is indicated when the patients needs
exceed the pharmacists knowledge or scope of practice; 5. Other
pharmacists, prescribers, third-party payers.
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if needed. Documentation to prescribers and other health

care professionals may include a cover letter, the patients
PMR and MAP, and the pharmacists chronological record of
care and plan of action.
Payers usually will require documentation of the services
performed, the amount of time spent on those services, and
other billing information, such as billing codes and pharmacy
or pharmacist identifiers (e.g., National Provider Identifier).
More information about billing is included in Module 2.
Follow-Up
The level of follow-up with the patient should correspond with

individual patient requirements. Follow-up may take the form
of a targeted MTM visit. However, follow-up does not necessarily have to be a face-to-face encounter. Instead, it may
include a phone call to the patient and/or other providers
on the patients health care team. When the patient transitions from one care setting to another (e.g., from home to
a long-term care facility), follow-up with providers at the
new setting promotes continuity of care. Patients should be
instructed to bring their PMR and MAP to all follow-up visits so
the pharmacist can document the results of the interventions
and any new items.
The Value of MTM Services
The value associated with MTM services can be measured in

many ways, including the impact on patient care, the value
to other members of the health care team in assisting with
medication issues, and value to third-party payers through
reduced overall health care costs and improvements on
quality measure performance. Many pharmacists also derive
professional and personal satisfaction in addition to financial
compensation for providing the service to patients. A variety
of metrics can be used to demonstrate value associated with
pharmacists patient care services. (More information about
quality measures appears in the next section, Opportunities for
Pharmacists to Provide MTM Services).
Examples of the Impact of MTM on Patient Outcomes

and Health Care Costs
A review of the literature reveals numerous studies showing

that pharmacist-provided clinical services such as MTM significantly improve patient outcomes and reduce overall health
care costs.4
One example of the benefits of MTM services comes from the

Iowa Medicaid Pharmaceutical Case Management Program,
which pays pharmacist-physician teams to manage the
medication regimens of qualified Medicaid beneficiaries. In
this program, the pharmacist performs an initial assessment for
beneficiaries who are receiving four or more medications and
have at least one of twelve specified diseases (i.e., congestive
heart failure, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation,
osteoarthritis, gastroesophageal reflux disease, peptic ulcer
disease, and chronic obstructive pulmonary disease). When
problems are identified, the pharmacist makes written recommendations to the physician. Over the 2-year evaluation
period for the program, the appropriateness of the patients
medications improved and the use of high-risk medications
decreased by nearly 25%.12
Another example comes from a CMS demonstration project
in Connecticut that evaluated the impact of MTM services
provided by nine pharmacists to 88 Medicaid patients over
a 10-month period. Pharmacists identified 917 medicationrelated problems and resolved nearly 80% of them, resulting
in an estimated annual savings of $1,595 per patient ($1,123
on medication costs and $472 on medical, hospital, and
emergency department costs) compared with patients costs
the previous year.13 Total savings achieved were 2.5 times
the cost associated with pharmacists professional fees and
network administration.13
In yet another analysis, researchers reported data from a
1-year study of MTM services provided to patients enrolled
in a state-wide private insurance program in Minnesota.14
Patients who received MTM services at six ambulatory care
clinics in Minnesota had improved outcomes, compared with
similar patients who did not receive MTM services. A total
of 637 drug therapy problems were resolved among 285
intervention patients, and the patients achievement of goals
of therapy increased from 76% to 90% during 1 year of MTM
services. Healthcare Effectiveness Data and Information Set
(HEDIS) measures were improved for hypertension and cholesterol management for patients receiving MTM services. Total
health expenditures for patients enrolled in the MTM service
decreased from $11,965 to $8,197 (P <.0001), resulting in a
return on investment (ROI) of 12:1.14 (Further information on
ROI is discussed in Module 2.)
The Patient Safety and Clinical Pharmacy Services
Collaborative (PSPC) provides further evidence of the value
of MTM services. The PSPC is working to bring pharmacy
services, such as MTM, to more than 450 organizations of
community-based health care providers including community
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health centers, primary care associations, and rural health

clinics. The PSPC has demonstrated that pharmacists
services result in improved health outcomes and patient
safety in high-risk, high-cost, complex patients. The incidence
of adverse drug events has fallen by 49% in this patient
population and the majority of patients whose medical conditions were once identified as out of control are now under
control.15
Value of MTM for Pharmacists
Annual surveys of MTM providers have repeatedly shown

that pharmacists report the greatest value of providing MTM
services comes from increased professional satisfaction,
followed by increased patient satisfaction, and increased
quality of care/outcomes based on performance measures.3
Pharmacists report that MTM has helped them to3:
Build connections with patients.
Enhance professionalism.
Establish collaboration.
Enhance the pharmacists image with the public and

colleagues.
Increase respect from patients.
Improve patient-provider-pharmacist interaction.
Establish trust with patients.
Create more personal interaction with patients.
Feel more connected with the health care team.
Increase patient loyalty.
Target patients who can benefit the most from

pharmacists services.
Build confidence and retention.
Identify and resolve medication-related problems for

patients before they occur.
Differentiate their practice from competition.
Create new partnerships with other organizations

and opening new opportunities.
Value of MTM Services for Payers
Annual surveys of MTM payers have found that improved

quality of care and patient outcomes related to performance
measures were the primary source of value for payers.3 Payers
also reported overall health care cost savings and improved
patient satisfaction were key aspects of the value of MTM
services. Payers have reported that several outcomes have

been shown to be improved by MTM services, including:
Completion rates of comprehensive medication

reviews.
Avoidance/discontinuation of inappropriate
medications in elderly patients (i.e., Beers criteria).
CMS star ratings.
Patient quality of life.
HEDIS.
Pharmacy Quality Alliance (PQA) measures.
Hospital readmission rates.
Medication reconciliation measures.
Accountable care organization (ACO) quality

measures.
Some of these measures will be described in more detail in the

next section.
Opportunities for Pharmacists to Provide

MTM Services
Given the extent of their education and medication-related

expertise, pharmacists are ideally suited to provide MTM
services and are the leaders for providing these services.3 In
2007, APhA began conducting environmental scans of MTM
services, with resulting data providing a snapshot of the
provision of services throughout the country. Data indicate
that the majority of payers use pharmacists to provide services,
with the percentage of payers using nurses to provide MTM
services dropping from 29% in 2008 to 6% in 2013; some
payers used more than one type of provider.3 Data from CMS
indicate that 99.9% of Medicare Part D plans use pharmacists
to deliver MTM services.16
Quality Measures and MTM Opportunities
Many opportunities for pharmacists to provide MTM have

arisen from financial incentives that are linked to performance quality measures. Several initiatives are ongoing to
define, assess, and improve the quality of pharmacy services,
including MTM. PQA, a pharmacy quality alliance, has led
several of these initiatives to develop and test pharmacy
measures as well as to create report card systems for
communicating performance on quality measures. PQA
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Table 1-1. Examples of Pharmacy Quality Alliance Medication Use Quality Measures
Measure
Description
Proportion of days covered
The percentage of patients 18 years of age who met the proportion of days covered threshold of 80% during
the measurement period.
Diabetes medication dosing
The percentage of patients who were dispensed a dose higher than the daily recommended dose for the
following therapeutic categories of oral hypoglycemic agents: biguanides, sulfonylureas, thiazolidinediones,
and dipeptidyl peptidase4 inhibitors.
Appropriate treatment of
The percentage of patients who were dispensed a medication for diabetes and hypertension and who are
hypertension in patients with
receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, or direct renin inhibitor
diabetes
medication.
Medication therapy for persons
The percentage of patients with asthma who were dispensed >3 canisters of a short-acting 2-agonist inhaler
with asthma
over a 90-day period and who did not receive controller therapy during the same 90-day period. Two rates are
reported (i.e., suboptimal control and absence of controller therapy).
Use of high-risk medications in
The percentage of patients 65 years of age who received 2 prescription fills for a high-risk medication during
elderly patients
the measurement period.
Cholesterol management in
The percentage of adult patients diagnosed with coronary artery disease who received 1 prescription for a
coronary artery disease
3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (i.e., statin) medication during the measurement

period.
Completion rate for
The percentage of prescription drug plan members who met eligibility criteria for medication therapy
comprehensive medication review
management services and who received a comprehensive medication review during the eligibility period.
Antipsychotic use in persons with
The percentage of individuals 65 years of age with dementia who are receiving an antipsychotic medication
dementia
without evidence of a psychotic disorder or related condition.
Source: Reference 17.
develops medication-use measures in areas such as medication safety, medication adherence, and appropriateness.
Examples of PQA quality measures are shown in Table 1-1.17
PQA aims to report results on these measures in a way that is
meaningful to patients, pharmacists, employers, health plans,
and other stakeholders. The ultimate goal is to help patients
make informed choices about pharmacies, improve outcomes,
and develop new payment models. These measures are
being used by many stakeholders, including CMS. Community
pharmacy performance on PQA quality measures are
reported to the public in a report card format. However, initial
research suggests that the measures may need to be simplified
to assist patients in interpretation.18
The Electronic Quality Improvement Platform for Plans and
Pharmacies, known as EQuIPP, is a management information
systems service offered by Pharmacy Quality Solutions
(PQS) that provides standardized assessment of community
pharmacy performance on various quality measures including
the CMS star ratings. This system is intended to provide
consistency across plans to prevent the need for pharmacies
to manage multiple report card systems. Pharmacies have
access to performance dashboards that allow them to review

their scores on various quality measures.19 More information
about PQS and the EQuIPP system can be found at
www.pharmacyquality.com.
Expanding Opportunities in Medicare Part D
When Medicare Part D was implemented in 2006, coverage

for MTM was available only to a small proportion of beneficiaries and many plans offered limited services.20 Following
the initiation of MTM services, CMS conducted an exploratory investigation of the services, and released the results
in 2008.20 Based in part on the findings of this investigation,
CMS issued new requirements for improvements to MTM
programs that began in 2010 (available at www.cms.gov/
prescriptiondrugcovcontra/).21
Most of these requirements became law as part of the ACA.
According to the ACA, starting in 2013, Part D plan sponsors
must offer MTM services to targeted beneficiaries that include,
at a minimum, strategies to improve adherence to prescription
medications or other goals. Services and strategies must
include21:
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An annual comprehensive medication review

furnished person-to-person or using telehealth
technologies (e.g., telephones, videoconferences) by
a licensed pharmacist or other qualified provider.
The comprehensive medication review must include:

A review of the individuals medications.
This review may result in the creation

of a recommended medication action
plan or other actions in consultation with
the individual and with input from the
prescriber to the extent necessary and
practicable.
A written or printed summary of the results of the

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CMS, in consultation with relevant

stakeholders, has developed a
standardized format for the action plan
and the summary that must be used.
Follow-up interventions as warranted based on the

findings of the annual medication review or the
targeted medication enrollment and which may
be provided person-to-person or using telehealth
technologies.
Medicare Part D plan sponsors must have a process to21:
Assess, at least on a quarterly basis, the medication

use of individuals who are at risk but not enrolled in
the MTM program, including individuals who have
experienced a transition in care (e.g., a hospitalization or stay in a skilled nursing facility), if the
prescription drug plan sponsor has access to that
information.
Automatically enroll targeted beneficiaries, including

beneficiaries identified in the quarterly assessment.
Permit beneficiaries to opt out of enrollment in the

MTM program.
In 2010, an estimated 25% of Medicare Part D beneficiaries

were eligible for MTM services, compared with 10% to 12%
in previous years.16 Although eligibility does not necessarily
equate with receipt of services, many MTM providers reported
an increase in the number of patients receiving MTM services
in 2010.22 Pharmacists play a key role in marketing MTM
services to patients to help eligible patients take advantage of
the benefit provided by their plan.
Part D opportunities have continued to evolve since the implementation of the ACA. Each year in the spring, CMS publishes
a call letter for Medicare Part D plans that contains annual

adjustments and requirements that Part D plans must implement
for the following year. CMS efforts to improve and expand
the Part D MTM program and expand the number of patients
receiving these services were major themes in the 2014 call
letter. CMS encouraged plans to23:
Optimize their MTM programs for beneficiaries who

may achieve the greatest benefit.
Offer MTM services to an expanded population of

beneficiaries who do not meet eligibility criteria.
Use MTM to promote coordination of care.
Adopt standardized health information technology

for documentation of MTM services.
Promote beneficiary awareness about MTM.
In January 2014, CMS released a proposed rule that includes

a number of major changes to the Part D program that had
potential to create major shifts for participants in the Part D
program. However, the final rule did not include the provisions related to the expansion of the MTM program, noting
that the timeline for implementing the proposed changes
may be too aggressive and could negatively affect existing
MTM programs. While our goal was to increase eligibility
and access to MTM, we do not want to do it at the expense of
sacrificing any quality with existing programs. CMS noted that
they would continue to monitor Part D plans MTM programs,
with the goal of proposing other revisions to criteria in future
rulemaking that will help expand the program.24
CMS Star Ratings
CMS rates Medicare Part D plans using a star rating system,

from one star to five stars based on their performance and
quality. CMS rewards plans having higher ratings with higher
payments. In addition, Medicare Advantage and MA-PD
plans with a rating of four or more stars receive quality bonus
payments. In 2015, quality bonus payments will be based
on 2014 ratings, which were based on data from 2012 and
2013.
Star rating information serves an important role for marketing
to and enrolling patients. The information is available to
beneficiaries in the Medicare Prescription Drug Plan Finder.
Plans with five stars have a special icon to encourage
enrollment while poorly performing plans have a warning
symbol. Plans that receive five stars may market to and enroll
beneficiaries throughout the year (i.e., they are not limited to
the open enrollment period). Furthermore, after 2014, plans
with fewer than three stars for 3 consecutive years will not
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be permitted to enroll beneficiaries through the Medicare

website and they run the risk of being dropped from Medicare
altogether.25
party payers were represented.3 As Figure 1-1 shows, payment

opportunities are numerous.
Several factors are taken into account when determining the

star rating, including customer service measures, beneficiary
complaints, member experience with the plan, drug pricing,
and patient safety. Within the patient safety section of the
ratings, CMS considers PQA measures that can be influenced
by pharmacist provision of MTM services. Pharmacists can
make the strongest contributions to performance measures that
are weighted most heavily for medication use, adherence,
and chronic disease outcomes. The use of these measures
encourages Part D plans to provide robust MTM services
to enrolled beneficiaries. These factors include: (1) the
percentage of beneficiaries aged 65 years or older who
receive medications with a high risk of adverse effects in
elderly patients, and (2) the percentage of beneficiaries who
were dispensed a medication for diabetes and a medication
for hypertension who were receiving an angiotensin-converting
enzyme inhibitor or an angiotensin receptor blocker.25
Health Care Reform and MTM: Beyond Part D
In addition to star ratings, CMS uses display measures to

provide further information about plans quality. In 2013, the
display measures included three PQA-supported measures:
Drug-drug interactions.
Excessive doses of oral diabetes medications.
Completion rate of comprehensive medication

reviews; (this measure may become part of the star
ratings calculations in future years).
MTM Beyond Medicare
According to the core elements model of MTM, Any patient

who uses prescription and nonprescription medications,
herbal products, or other dietary supplements could potentially
benefit from the MTM core elements outlined in this model. As
part of the effort to effectively address the urgent public health
issue of medication-related morbidity and mortality, MTM
services should be considered for any patient with actual or
potential medication-related problems.7
Accordingly, the pool of patients who could benefit from MTM
is vast. While Medicare Part D acted as a catalyst for implementing MTM services, pharmacists have many opportunities
beyond the population of qualified Medicare beneficiaries. A
diverse set of third-party payers compensate pharmacists for
the provision of MTM services. In a 2013 environmental scan
of MTM service providers, more than a dozen types of third-
The ACA included many provisions that support MTM beyond

expanding requirements for Medicare Part D beneficiaries.
Among these provisions are the development of ACOs,
emphasis on patient-centered medical homes (PCMHs), establishment of the Center for Medicare and Medicaid Innovation
within CMS (also known as the CMS Innovation Center, which
will be testing MTM among other models), an Independence
at Home demonstration program, and a hospital preventable
readmissions reduction program that includes transition of
care activities (e.g., medication reconciliation, post-discharge
counseling, home visits).
MTM is an important element of many of these new initiatives.
For example, medication reconciliation is the comprehensive
evaluation of a patients medication regimen any time there is
a change of therapy or level of care and is intended to avoid
medication-related problems such as omissions, duplications,
dosing errors, or drug interactions. Pharmacists can consistently and effectively provide medication reconciliation by
using the framework of MTM services described in the core
elements document.
Additionally, one of the centerpieces of the ACA is an
emphasis on integrated care models to improve the quality of
care while managing costs. ACOs, medical homes, community
health teams, and home-based primary care teams (as well as
the use of bundled payments for acute and post-acute care)
are among these models. All of these models are structured
to compensate providers through Medicare Part B. However,
Medicare Part B does not currently cover pharmacists clinical
services.
The new care models created by the ACA provide financial
incentives to the health care organization providing care to
share cost savings and receive positive financial incentives for
achieving high results on quality metrics. Pharmacists generally
must negotiate compensation for their services directly from
medical homes and ACOs. Pharmacists who wish to contract
with these types of models can justify the cost of their services.
Transitions of Care Activities and Reducing Readmissions
Medication problems stemming from a lack of coordinated

care are a known reason for emergency hospitalizations,
especially in older adults.26 Medication reconciliation has
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medication reconciliation as part of a transitions of care

service bundle.31
The Success of MTM Programs Depends on

Advocacy From Pharmacists Like You
Several provisions of the ACA specifically list medication

reconciliation or activities that could include medication reconciliation provided by a pharmacist in an MTM framework.
For example, the Community-Based Care Transitions Program
provides funding for improved care transition services to
high-risk Medicare beneficiaries. Funds will be available to
hospitals with high readmission rates as well as communitybased organizations that provide care transition services
across a continuum of care. Care transition interventions
include those that can be performed by pharmacists, such as
conducting comprehensive medication reviews and medication
management (e.g., patient education, self-management
support).
It is unlikely that the legal and regulatory developments

described in this module would have occurred without
the efforts of pharmacists and pharmacy organizations to
educate decision makers about the value of pharmacists
services, such as MTM. Advocacy to develop and expand
MTM services remains crucial at federal, state, and local
levels. All pharmacists are encouraged to get involved.
Advocacy resources are available on APhAs website at
www.pharmacist.com/advocate.
been demonstrated to reduce medication errors, promote
patient adherence, and reduce hospital readmissions.27-29
For example, Project RED demonstrated that pharmacist
involvement in transitions of care activities can reduce
preventable readmission rates.30 Pharmacists often provide
MTM and medication reconciliation can play a crucial role in

reducing hospital readmission rates. Before the implementation
Figure 1-1. Insurance Types of Patient Populations Receiving Medication Therapy Management Services From Providers
Insurance Types of Patient Populations Receiving MTM Services

From Providers
Multiple Responses Allowed
Medicare Advantage plans
43
44
43
41
40
39
40
39
Medicare supplemental plans

Commercial health insurance
Stand-alone prescription drug plans
32
30
28
32
28
26
Self-paying (fee-for-service)
HMO/ managed care plans
Hospital discharge
23
State Medicaid program
36
36
35
26
27
26
34
21
21
PPO plans
25
21
25
20
23
21
Acute care
18
Self-insured health/ prescription benefit coverage
17
19
Specific employer benefit group
17
18
16
19
14
14
13
15
13
15
16
13
13
16
13
13
15
11
10
Long-term care/ assisted living
47
24
2013 (n=242)
2012 (n=198)
2010 (n=466)
14
Medicare SNPs
Patients as part of medical home
Health savings accounts
Traditional health indemnity plans
Home care
Medical home
Patients as part of accountable care organizations
11
5
5
10
10
Federal sector (DoD, PHS, VA)

Accountable care organizations
Other included: targeted patient populations, free clinic,

uninsured, indigent.
DoD = Department of Defense; HMO = health maintenance
organization; PHS = Public Health Service; PPO = preferred
provider organization; SNP = special needs plans; VA =
Veterans Administration
14
10
8
11
8
Other
10
20
30
40
Percent of Respondents
50
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of the ACA, approximately 19% of hospitalized Medicare

patients were readmitted to the hospital within 30 days of
discharge.32 Readmission rates following a nonsurgical hospitalization were higher for chronic conditions than for acute
conditions, suggesting that poor chronic care contributes to
readmission rates. Furthermore, post-discharge adverse events
attributed to medications are one of the most common reasons
for readmissions.33
The ACA creates a quality improvement program to help
hospitals improve their readmission rates. These provisions
have increased focus on robust discharge planning, including
post-discharge medication reconciliation and medication
management (e.g., patient assessment, providing patient
education) by pharmacists. The ACA also created penalties
for hospitals with excess readmissions. When then penalties
began in October 2012, they were calculated based on
all-cause 30-day readmission rates for patients with heart
failure, pneumonia, and acute myocardial infarction. In 2015,
the penalties will expand to include patients with chronic
obstructive pulmonary disease, coronary artery bypass graft,
percutaneous transluminal coronary angioplasty, and other
vascular procedures. Moving forward, the penalties will be
expanded to include more disease states.
Initial data indicate that the national readmission reduction
program is having a beneficial effect. The all-cause 30-day
hospital readmission rate among Medicare fee-for-service
beneficiaries held constant at 19% from 2007 to 2011. In
2012, when the penalties were first implemented, this rate
began to fall to 18.5%. Preliminary claims data show the
Medicare readmission rate averaged less than 18% over the
first 8 months of 2013.34 Pharmacists are involved in many of
the models focused on reducing readmissions and improving
transitions of care.
Patient-Centered Medical Homes
In 2007, the American Academy of Family Physicians,

American Academy of Pediatrics, American College of
Physicians, and American Osteopathic Association released
a joint statement describing the concept of the PCMH. In the
PCMH model, care is coordinated by primary care providers
across all elements of the health care system (e.g., specialty
care, hospitals, home health agencies, nursing homes) and
the patients community (e.g., family, public and private
community-based services). Care coordination among physically dispersed providers is facilitated by registries, information
technology, health information exchanges, and other means
to ensure that patients get the indicated care when and
where they need and want it in a culturally and linguistically

appropriate manner.35 In this model, providers are eligible to
receive additional compensation for care coordination.
The ACA included provisions designed to promote the
adoption of PCMH as a model for delivering primary care,
with additional payment for improved quality of care. The law
defined PCMH as a model of care that includes8:
A primary care provider.
Whole person orientation.
Coordinated and integrated care.
Safe and high-quality care (including evidencebased medicine, appropriate use of health
information technology, continuous quality
improvement).
Expanded access to care.
Payment that recognizes the added value of patientcentered care.
These programs are intended to help coordinate disease

prevention, health promotion, chronic disease management,
and transitions between health care providers and settings,
with priority given to preventive services.
Pharmacists can play integral roles in optimizing therapeutic
outcomes and promoting safe, cost-effective medication
use in PCMHs.36-39 For example, pharmacists can manage
medication therapies for selected patients with chronic conditions in a more cost-effective manner than physicians, and
pharmacists can discuss and help implement therapy recommendations with other care providers through the use of health
information systems. This type of model allows the primary
care practice to care for an increased number of patients by
using pharmacists as extenders of the primary care model
through collaborative relationships.
Prior to enactment of the ACA, pharmacists were already
working in roles in medical home settings, often focusing on
collaborative drug therapy.40,41 According to an article in
Health Affairs, Pharmacists should play key roles as team
members in medical homes....36 The ACA expands the roles
for pharmacists in the PCMH model. According to the ACA,
local primary care providers should be able to provide
access to pharmacist-delivered MTM services. Transitional
care programs must provide medication reconciliation upon
admission/discharge and ensure that post-discharge plans
include medication management. These programs include
higher reimbursement rates for services if requirements such
as medication reconciliation are completed, providing a
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Figure 1-2. Example of a Standard for PatientCentered Medical Homes From the National
Committee for Quality Assurance
The practice has a process for managing medications, and
systematically implements the process in the following ways:
1.
Reviews and reconciles medications for more than 50%

of patients received from care transitions. (CRITICAL
FACTOR)
2.
Reviews and reconciles medications with patients/families

for more than 80% of care transitions.
3.
Provides information about new prescriptions to more than
of the clinical and nonclinical staff regarding the utility of a

pharmacist in the practice disappeared within the first months
of pharmacist integration.13
Medical Home Quality Measures
The National Committee for Quality Assurance (NCQA)

accredits and certifies a wide range of health care organizations, including PCMHs. The NCQA 2014 standards and
guidelines for PCMHs include factors that can be impacted
by MTM. For example, within the care management and
support category, several factors affect the medication
management element (Figure 1-2).43
80% of patients/families/caregivers.
4.
Assesses understanding of medications for more than 50%

of patients/families/caregivers, and dates the assessment.
5.
Assesses response to medications and barriers to

adherence for more than 50% of patients, and dates the
assessment.
6.
Documents over-the-counter medications, herbal therapies,

and supplements for more than 50% of patients, and
dates the updates.
Accountable Care Organizations
An ACO is a health care model that provides greater

reimbursement or shared savings to coordinated groups of
health care providers who meet certain quality measures while
reducing the total cost of care for a specific population of
patients. (While ACOs and medical homes have similar goals,
an ACO is a financing model whereas a medical home is a
care delivery model. An ACO may include practices that have
organized themselves as PCMHs.)
financial incentive for primary care practices to collaborate

with pharmacists as well. There are a number of collaborative
opportunities for pharmacy services to be integrated into a
successful PCMH.
Services provided by pharmacists in medical homes have
included shared medical appointments with the physician and
pharmacist, providing MTM services, assisting with transitions
of care and medication reconciliation, diabetes services,
running anticoagulation and osteoporosis clinics, providing
interprofessional education, leading group patient education
classes, and participating in continuous quality improvement
initiatives.13,39,42
Providers in medical homes have reported experiencing
enhanced value from integrating pharmacists services.
In one survey of participants in a medical home model,
respondents reported that inclusion of a pharmacist in their
practice improved the quality of patient care, provided a
valuable drug information resource for all providers and
staff, and empowered patients. Furthermore, initial concerns
ACOs are accountable for the quality and cost of patient care.
They share financial risk as well as year-end savings if quality
and cost thresholds are met. ACO structures vary widely, often
reflecting the leading entity of the ACO (i.e., single or multiple
insurers, independent physician practices, health systems, or
pharmacy networks and/or providers). The ACA authorized
two Medicare ACO initiatives within CMSthe Pioneer ACO
demonstration and the Medicare Shared Savings Program.
The development of these ACOs has spurred the development
of many non-Medicare ACOs in the private sector in numerous
markets. In addition, a few state Medicaid programs have
developed ACOs and more are expected to follow suit.44
ACOs are instituting programs that increasingly engage
pharmacists in both population heath management and direct
patient care services. From a population health management
perspective, pharmacists review an ACOs entire patient panel
to identify those at risk for medication-related problems due
to gaps in care; assist in the development and management
of best practices to improve gaps in care; and help assess,
measure, and improve medication-related quality metrics.44
For direct patient care, ACOs are engaging pharmacists
to provide a variety of services focused on improving care
transitions, medication adherence, medication management,
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Learning Activity
Indicate whether each of the following statements about the ACA is true or false:
1. The law requires prescription drug plans to automatically enroll targeted beneficiaries in MTM services.
2. The law requires annual comprehensive medication reviews but does not address targeted reviews.
3. The law requires the development of a standardized format for the patient medication record and action plan that was
implemented in 2013.
Match each of the following models included in the ACA with the correct description:
4.
Patient-centered medical home
5.
Accountable care organizations
6.
Transition of care activities
a. A financing model in which entities (e.g., provider groups) are

accountable for the quality and cost of patient care.
b. A patient care model in which patient care is coordinated by
primary care providers across all elements of the health care
system.
c. Provisions intended to reduce hospital readmission rates
through strategies including medication reconciliation, patient
education, and medication adherence interventions.

and chronic disease management. For example, after patients
are identified (either through physician referral or population
health management targeting), ACOs utilize pharmacists to
deliver comprehensive medication reviews to identify and
resolve medication problems and then monitor patients over
multiple visits until medication-related goals are achieved.
Because chronic diseases are primarily managed through
appropriate medication use, pharmacists often concurrently
manage the patients chronic conditions in collaboration
with the health care team to achieve clinical care goals.
Collaborative practice agreements between pharmacists and
prescribers may be in place to facilitate efficient delivery of
these services.45
Increasingly, ACOs are involving pharmacists as part of
care transition teams that engage with patients from hospital
admission, throughout the stay, and continue to monitor them
at home after discharge. Pharmacists are also assisting ACOs
in identifying patients who are nonadherent or at risk of being
nonadherent to their medication regimen and implementing
services to improve patient medication adherence.44
pharmacist-provided services, as well as other measures that

can be influenced by pharmacists, such as health promotion
and education.
Commercial and Medicaid ACOs use a variety of quality
metrics with little standardization among them. Some
commercial payers require the ACOs with whom they contract
to be accredited. Currently, there are at least two accrediting agencies that offer ACO accreditation: URAC (formerly
known as the Utilization Review Accreditation Commission)
and NCQA. Both agencies include medication-related quality
metrics in their accreditation requirements. Table 1-2 summarizes medication-related quality measures evaluated by CMS
and the accrediting agencies. While these measures will have
the most direct influence on an ACOs approach to medication
use, nearly all quality measures contain, in one way or
another, a medication component.46
Other Pay-for-Performance Initiatives
In addition to ACOs and PCMHs, several other types of

models reward providers for delivering high-quality care.
ACO Quality Measures
Medicare ACOs (i.e., the Pioneer ACO and the Medicare

Shared Savings Program) share a common set of 33 quality
metrics, 12 of which are directly related to medications or

1. True; 2. False; 3. True; 4. b; 5. a; 6. c.
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Table 1-2. Medication-Related Quality Measures for Accountable Care Organizations

CMS (Medicare)
URAC (Commercial and Medicaid)
Ambulatory sensitive conditions admissions:
Medication reconciliation after discharge
Childhood immunization status
chronic obstructive pulmonary disease or
Drug education provided to patient/
Follow-up for children prescribed attention-
asthma in older adults
Ambulatory sensitive conditions admissions:

heart failure
Medication reconciliation
Influenza immunization
Pneumonia vaccination for patients 65

years of age
caregiver on all medications during episode

Influenza immunization
Controlling high blood pressure
Optimal diabetes care
Diabetes measure suite
Heart failure: -blocker therapy for left
Cholesterol management for patients with
ventricular systolic dysfunction
Chronic stable coronary artery disease:
Diabetes composite (includes A1C control,
Hypertension: controlling high blood

pressure
Ischemic vascular disease: use of aspirin or
other antithrombotic medication
cardiovascular disease
lipid control
and aspirin/antiplatelet use measures)
deficit/hyperactivity disorder medications
blood pressure control, tobacco non-use,
NCQA (Commercial and Medicaid)
Heart failure: -blocker therapy for left
asthma
Antidepressant medication management
Annual therapeutic monitoring for patients

on persistent medications
Coronary artery disease: lipid control
Coronary artery disease: angiotensin-
Disease-modifying antirheumatic drug use

for rheumatoid arthritis
Osteoporosis management
Monitoring harmful drug-disease interactions

in elderly adults
ventricular dysfunction
Appropriate medications for patients with
Use of high-risk medications in elderly adults
Medication reconciliation post discharge
converting enzyme inhibitor or angiotensin

receptor blocker therapy
CMS = Centers for Medicare and Medicaid Services; NCQA = National Committee for Quality Assurance; URAC = formerly the Utilization Review Accreditation
Commission.
Such models, often referred to as pay-for-performance (P4P)

models, are designed to offer financial incentives to health
care providers to meet defined quality, efficiency, or other
targets.47
Some P4P models include pharmacists provision of MTM
services. In such a model, reimbursement for MTM services
is tied to whether patients attain specified outcomes. In one
study, this model was associated with a 20% increase in
payment to pharmacists compared with a fee-for-service
model, with the potential for even greater reimbursement.48
The CMS Innovation Center has been a leader in the development of P4P programs in the public sector. In addition to
testing ACO models, the CMS Innovation Center is testing a
number of other models, such as bundled payments, for their
ability to improve care and lower costs. The CMS Innovation
Center is spending up to $1 billion for awards and evaluation
of projects from across the country that test new payment
and service delivery models for Medicare, Medicaid, and
Childrens Health Insurance Program (CHIP) enrollees.49

Pharmacists are playing key roles in several of these projects,
including working in collaborative practice models that
integrate pharmacists into team-based, patient-centered care
initiatives.50
MTM and Provider Status Efforts
To promote more system-wide implementation of pharmacists patient care services, a concerted push by national
pharmacy groups to advance provider status for pharmacists
began in 2013. (It is important to note that while the term
provider status often refers to the inclusion of pharmacists
in the list of providers who are paid for patient care services
by third-party payers such as Medicare Part B, the term has
alternate meanings in other situations and to various groups.)
From APhAs perspective, the pursuit of provider status for
pharmacists involves a multipronged strategy that targets many
different entities and includes many approaches at both the
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state and federal levels. APhA also believes provider status

advancement is critical to expanding the number of patients
who can benefit from pharmacists patient care services.
As part of its provider status efforts, APhA is a founding
member of the Patient Access to Pharmacists Care Coalition
(PAPCC). The PAPCC mission is to develop and help enact a
federal policy proposal that would enable patient access to,
and payment for, Medicare Part B services by state-licensed
pharmacists in medically underserved communities. Inclusion
of pharmacists as providers under Medicare Part B also would
position them for inclusion as critical members of team-based
care models.
In March 2014, H.R. 4190 was introduced in the House by
Representatives Brett Guthrie (R-KY), G.K. Butterfield (D-NC),
and Todd Young (R-IN). H.R. 4190 amends Title XVIII of the
Social Security Act to enable patient access to, and coverage
for, Medicare Part B services by state-licensed pharmacists in
medically underserved communities. Pharmacists should stay
apprised of legislative activity that can impact opportunities to
provide MTM and other patient care services. While it remains
to be seen whether this bill will progress through the legislative
process, it is one example of the many ongoing developments
in the push to obtain pharmacists provider status. All pharmacists are encouraged to stay apprised of ongoing developments and explore opportunities to advocate on behalf of their
profession.
Each state provides its own legislative and regulatory opportunities for advancing the pharmacy profession. Potential
strategies include seeking changes in Medicaid programs to
include coverage for pharmacist-provided services as well
as seeking the expansion of states scope of practice and the
services pharmacists can legally perform in each state. For
example, in 2013, California passed legislation (SB 493) that
provides new practice authorities for pharmacists in the state.
(While the new law specifically designates pharmacists as
health care providers, it does not address payment issues.)
Examples of the expanded authorities include: ordering and
interpreting tests to monitor and manage the efficacy and
toxicity of drug therapies, and initiating and administering
routine vaccinations. The law also creates a new practitioner
title for pharmacistsAdvanced Practice Pharmacist (APP)
and provides additional authorities to pharmacists who receive
the APP credential.51 The California Pharmacists Association
website provides a detailed summary of authorities granted
to pharmacists under the new the law.52 North Carolina and
New Mexico have similar practitioner titles with expanded
scope of practice for pharmacists.
Conclusion
MMA was a powerful catalyst for MTM services, triggering

the development of a profession-wide consensus definition
and model of care. The success of many of these programs at
both reducing costs and improving the quality of care has led
to a steady expansion of services, with continued growth in
opportunities expected over the next several years. Moreover,
the provision of MTM services on a larger scale is expected to
result in safer medication use for patients, greater professional
fulfillment for pharmacists, and national recognition of the
value of MTM services provided by pharmacists.
References
1.
IMS Health. IMS health study identifies $200+ billion annual

opportunity from using medicines more responsibly [press release].
June 19, 2013. Available at: http://www.imshealth.com/portal/site/
imshealth/menuitem.c76283e8bf81e98f53c753c71ad8c22a/?vgnexto
id=12531cf4cc75f310VgnVCM10000076192ca2RCRD&vgnextfmt=de
fault. Accessed April 16, 2014.
2.
U.S. Department of Health and Human Services. Healthy People 2020:

Topics and objectives index. Available at: http://healthypeople.gov/
2020/topicsobjectives2020/default.aspx. Accessed May 13, 2014.
3.
American Pharmacists Association. Medication Therapy Management

Digest. The Pursuit of Provider Status to Support the Growth and
Expansion of Pharmacists Patient Care Services. March 2014.
Available at: http://www.pharmacist.com/sites/default/files/MTM
%20Digest_2014%20FINAL.pdf. Accessed May 13, 2014.
4.
Giberson S, Yoder S, Lee MP. Improving Patient and Health System

Outcomes Through Advanced Pharmacy Practice. A Report to the U.S.
Surgeon General. Office of the Chief Pharmacist. U.S. Public Health
Service. December 2011.
5.
Rovers JP, Currie JE, Hagel HP, eds. A Practical Guide to Pharmaceutical
Care. 2nd ed. Washington, DC: American Pharmacists Association;
2003.
6.
Bluml BM. Definition of medication therapy management: development

of professionwide consensus. J Am Pharm Assoc. 2005;45:56672.
7.
American Pharmacists Association; National Association of Chain Drug

Stores Foundation. Medication Therapy Management in Pharmacy
Practice: Core Elements of an MTM Service Model. Version 2.0. March
2008. Available at: http://www.pharmacist.com/MTM. Accessed
September 20, 2011.
8.
Patient Protection and Affordable Care Act. H.R. 3590. Available

at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/
PLAW-111publ148.pdf. Accessed May 13, 2014.
9.
Centers for Medicare and Medicaid Services. Medicare Part D

Medication Therapy Management Program Standardized Format.
Available at: http://www.cms.gov/medicare/prescription-drugcoverage/prescriptiondrugcovcontra/downloads/mtm-programstandardized-format-english-and-spanish-instructions-samples-v032712.
pdf. Accessed May 13, 2014.
18
M EDI CA
TI
ICE
RV
T HERAPY M
D ELI
VE
NG
RI
NA
GEMENT
SE
10. Berger BA. Interacting with physicians. In: Berger BA, ed.
Communication Skills for Pharmacists: Building Relationships, Improving
Patient Care. 2nd ed. Washington, DC: American Pharmacists
Association; 2005:1319.
25. American Pharmacists Association; Academy of Managed Care

Pharmacy. Medicare star ratings: stakeholder proceedings on
community pharmacy and managed care partnerships in quality. J Am
Pharm Assoc. 2014;54:22840.
11. Zierler-Brown S, Brown TR, Chen D, Blackburn RW. Clinical

documentation for patient care: models, concepts, and liability
considerations for pharmacists. Am J Health Syst Pharm.
2007;64:18518.
26. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency

hospitalizations for adverse drug events in older Americans. N Engl J
Med. 2011;365:21;200212.
12. Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa
Medicaid pharmaceutical case management program. J Am Pharm
Assoc. 2004;44:33749.
13. Smith M, Giuliano MR, Starkowski MP. In Connecticut: improving
patient medication management in primary care. Health Aff.
2011;30:64654.
14. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic
outcomes of medication therapy management services: the Minnesota
experience. J Am Pharm Assoc. 2008;48:20311.
15. Health Resources and Services Administration. HRSAs Patient Safety
and Clinical Pharmacy Services Collaborative. Available at: http://
www.hrsa.gov/ruralhealth/media/508ehrincentive052609.pdf.
Accessed May 13, 2014.
16. Centers for Medicare and Medicaid Services. 2010 Medicare
Part D Medication Therapy Management (MTM) Programs.
Fact Sheet. June 8, 2010. Available at: https://www.cms.gov/
prescriptiondrugcovcontra/082_mtm.asp. Accessed October 12, 2011.
17. PQA Pharmacy Quality Alliance. PQA measures. Available at: http://
pqaalliance.org/measures/default.asp. Accessed May 13, 2014.
18. Shiyanbola OO, Mort JR, Lyons K. Advancing the use of community
pharmacy quality measures: a qualitative study. J Am Pharm Assoc.
2013;53:4007.
19. Pharmacy Quality Solutions. Available at: http://www.pharmacy
quality.com. Accessed May 13, 2014.
20. Abt Associates Inc. Final Report: Exploratory Research on Medication
Therapy Management. Cambridge, MA: Abt Associates Inc.; July 8,
2008.
21. Centers for Medicare and Medicaid Services. 2010 Combined
Call Letter. March 30, 2009. Available at: https://www.cms.gov/
prescriptiondrugcovcontra. Accessed July 13, 2011.
22. American Pharmacists Association. Medication Therapy Management
Digest. Tracking the Expansion of MTM in 2010: Exploring the
Consumer Perspective. March 2011. Available at: http://www.
pharmacist.com/AM/Template.cfm?Section=MTM&TEMPLATE=/CM/
ContentDisplay.cfm&CONTENTID=25712. Accessed May 27, 2014.
23. Centers for Medicare and Medicaid Services. Announcement of
Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and
Medicare Advantage and Part D Payment Policies and Final Call Letter.
April 1, 2013. Available at: http://www.cms.gov/Medicare/HealthPlans/MedicareAdvtgSpecRateStats/Downloads/Announcement2014.
pdf. Accessed May 13, 2014.
24. Centers for Medicare and Medicaid Services. Medicare Program;
Contract year 2015 policy and technical changes to the Medicare
Advantage and the Medicare Prescription Drug Benefit programs.
May 23, 2014. Federal Register. 2014;79:29844968. Available at:
http://www.gpo.gov/fdsys/pkg/FR-2014-05-23/pdf/2014-11734.pdf.
Accessed June 19, 2014.
27. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective
transitions of care at hospital discharge: a review of key issues for
hospitalists. J Hosp Med. 2007;2:31423.
28. Cua YM, Kripalani S. Medication use in the transition from hospital to
home. Ann Acad Med Singapore. 2008;37:1366.
29. American Pharmacists Association. Improving Care Transitions:
Optimizing Medication Reconciliation. March 2012. Available at:
http://www.pharmacist.com/sites/default/files/files/2012_improving_
care_transitions.pdf. Accessed June 11, 2014.
30. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital
discharge program to decrease rehospitalization. Ann Intern Med.
2009;150:17887.
31. Kwan JL, Lo L, Sampson M, Shjania K. Medication reconciliation during
transitions of care as a patient safety strategy: a systematic review. Ann
Inter Med. 2012;158(5 pt 2):397403.
32. Ventura T, Brown D, Archibald T, et al. Improving care transitions and
reducing hospital readmissions. Remington Report. January/February
2010. Available at: http://www.amedisys.com/images/news/care_
transition_article_remington_report_jan_2010. Accessed May 13,
2014.
33. Medicare Payment Advisory Commission. Report to the Congress:
Promoting Greater Efficiency in Medicare. June 2007. Available at:
http://www.medpac.gov/documents/jun07_entirereport.pdf. Accessed
May 13, 2014.
34. Centers for Medicare and Medicaid Services. The CMS Blog. New
data shows Affordable Care Act reforms are leading to lower hospital
readmission rates for Medicare beneficiaries. December 6, 2013.
Available at: http://blog.cms.gov/2013/12/06/new-data-showsaffordable-care-act-reforms-are-leading-to-lower-hospital-readmissionrates-for-medicare-beneficiaries. Accessed May 13, 2014.
35. American Academy of Family Physicians; American Academy of
Pediatrics; American College of Physicians; American Osteopathic
Association. Joint Principles of the Patient-Centered Medical Home.
February 2007. Available at: http://www.pcpcc.net/content/jointprinciples-patient-centered-medical-home. Accessed October 13, 2011.
36. Smith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists
belong in the medical home. Health Aff. 2010;29:90613.
37. American College of Clinical Pharmacy. Integration of Pharmacists
Clinical Services in the Patient-Centered Primary Care Medical Home.
March 2009. Available at: http://www.accp.com/docs/misc/pcmh_
services.pdf. Accessed October 13, 2011.
38. Scott MA, Hitch B, Ray L, Colvin G. Integration of pharmacists into a
patient-centered medical home. J Am Pharm Assoc. 2011;51:1616.
39. Moczygemba LR, Goode JV, Gatewood SB, et al. Integration of
collaborative medication therapy management in a safety net patientcentered medical home. J Am Pharm Assoc. 2011;51:16772.
40. Worth T. Tick tock, tick tock: clock running out on Capitol Hill.
Pharmacy Today. December 2009:134.
19
M EDI CA
TI
ICE
RV
T HERAPY M
D ELI
VE
NG
RI
NA
GEMENT
SE
41. Erickson S, Hambleton J. A pharmacys journey toward the patientcentered medical home. J Am Pharm Assoc. 2011;51:15660.
42. Kozminski M, Busby R, McGivney MS, et al. Pharmacist integration
into the medical home: qualitative analysis. J Am Pharm Assoc.
2011;51:17383.
43. National Committee for Quality Assurance. NCQA standards and
guidelines 2014. Available at: http://store.ncqa.org/index.php/
recognition/patient-centered-medical-home-pcmh/2014-pcmhstandards-and-guidelines-epub-single-user.html. Accessed June 19,
2014.
44. American Pharmacists Association. Issue Brief #8ACOs: Highlights
and Considerations for Pharmacists. March 2014. Available at: http://
www.pharmacist.com/apha-accountable-care-organization-aco-briefs.
Accessed April 21, 2014.
45. American Pharmacists Association. Issue Brief #6ACO Engagement
of Pharmacists. March 2014. Available at: http://www.pharmacist.
com/apha-accountable-care-organization-aco-briefs. Accessed April
21, 2014.
46. American Pharmacists Association. Issue Brief #5ACO Approaches
to Medication Use. February 2014. Available at: http://www.
pharmacist.com/apha-accountable-care-organization-aco-briefs.
Accessed April 21, 2014.
47. Agency for Healthcare Research and Quality. Pay for Performance
(P4P): AHRQ Resources. Available at: http://www.ahrq.gov/
professionals/quality-patient-safety/quality-resources/tools/pay4per/
index.html. Accessed May 13, 2014.
48. Lenz T, Monaghan MS. Pay-for-performance model of medication
therapy management in pharmacy practice. J Am Pharm Assoc.
2011;51:42531.
49. Centers for Medicare and Medicaid Services. Health Care Innovation
Awards Round Two. Available at: http://innovation.cms.gov/initiatives/
Health-Care-Innovation-Awards/Round-2.html. Accessed September 11,
2013.
50. Centers for Medicare and Medicaid Services. Health Care Innovation
Awards: Virginia. Available at: http://innovation.cms.gov/initiatives/
Health-Care-Innovation-Awards/Virginia.html. Accessed October 3,
2013.
51. Pharmacy practice. California Senate Bill 493, 469 (2013). Available
at: http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_
id=201320140SB493. Accessed May 27, 2014.
52. California Pharmacists Association. What does SB 493 mean for me?
Available at: http://www.cpha.com/Portals/45/Docs/CEO%20
Message%20Misc/SB493FactGuide.pdf. Accessed May 27, 2014.
20
Appendix A
Medication Therapy Management Services

Definition and Program Criteria
Medication Therapy Management is a distinct service or group of services that optimize therapeutic
outcomes for individual patients. Medication Therapy Management Services are independent of, but can
occur in conjunction with, the provision of a medication product.
Medication Therapy Management encompasses a broad range of professional activities and
responsibilities within the licensed pharmacists, or other qualified health care provider's, scope of
practice. These services include but are not limited to the following, according to the individual needs of
the patient:
a.
b.
c.
d.
Performing or obtaining necessary assessments of the patients health status;

Formulating a medication treatment plan;
Selecting, initiating, modifying, or administering medication therapy;
Monitoring and evaluating the patients response to therapy, including safety and
effectiveness;
e. Performing a comprehensive medication review to identify, resolve, and prevent medicationrelated problems, including adverse drug events;
f. Documenting the care delivered and communicating essential information to the patients
other primary care providers;
g. Providing verbal education and training designed to enhance patient understanding and
appropriate use of his/her medications;
h. Providing information, support services and resources designed to enhance patient adherence
with his/her therapeutic regimens;
i. Coordinating and integrating medication therapy management services within the broader
health care-management services being provided to the patient.
A program that provides coverage for Medication Therapy Management Services shall include:
a. Patient-specific and individualized services or sets of services provided directly by a
pharmacist to the patient*. These services are distinct from formulary development and use,
generalized patient education and information activities, and other population-focused quality
assurance measures for medication use.
b. Face-to-face interaction between the patient* and the pharmacist as the preferred method of
delivery. When patient-specific barriers to face-to-face communication exist, patients shall
have equal access to appropriate alternative delivery methods. Medication Therapy
Management programs shall include structures supporting the establishment and maintenance
of the patient*-pharmacist relationship.
c. Opportunities for pharmacists and other qualified health care providers to identify patients
who should receive medication therapy management services.
d. Payment for Medication Therapy Management Services consistent with contemporary
provider payment rates that are based on the time, clinical intensity, and resources required to
provide services (e.g., Medicare Part A and/or Part B for CPT & RBRVS).
e. Processes to improve continuity of care, outcomes, and outcome measures.
* In some situations, Medication Therapy Management Services may be provided to the caregiver or
other persons involved in the care of the patient.
Approved July 27, 2004 by the Academy of Managed Care Pharmacy, the American Association of Colleges of
Pharmacy, the American College of Apothecaries, the American College of Clinical Pharmacy, the American
Society of Consultant Pharmacists, the American Pharmacists Association, the American Society of Health-System
Pharmacists, the National Association of Boards of Pharmacy**, the National Association of Chain Drug Stores, the
National Community Pharmacists Association and the National Council of State Pharmacy Association Executives.
** Organization policy does not allow NABP to take a position on payment issues.
Appendix B
Medication Therapy
Management in
Pharmacy Practice
Core Elements of an
MTM Service Model
Version 2.0
March 2008
Version 2.0
A joint initiative of
the American Pharmacists Association and
the National Association of Chain Drug Stores Foundation
Acknowledgment
The American Pharmacists Association and the National Association of Chain Drug Stores Foundation
respectfully acknowledge the contributions of all individuals and organizations that participated in the
development of Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service
Model Version 2.0 document for application across the pharmacy profession.
This service model is supported by the following organizations:
Academy of Managed Care Pharmacy
American Association of Colleges of Pharmacy
American College of Apothecaries
American College of Clinical Pharmacy
American Society of Consultant Pharmacists
American Society of Health-System Pharmacists
National Alliance of State Pharmacy Associations
National Community Pharmacists Association
2008 American Pharmacists Association and National Association of Chain Drug Stores Foundation.
All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior permission of the American Pharmacists Association and the
National Association of Chain Drug Stores Foundation, with the sole exception that Appendices C and D may be reproduced,
stored, or transmitted without permission.
March 2008
Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0
Medication Therapy Management

in Pharmacy Practice:
Core Elements of an MTM
Service Model
Preface
Eleven national pharmacy organizations achieved consensus on a definition of medication therapy management (MTM)
in July 2004 (Appendix A). Building on the consensus definition, the American Pharmacists Association and the National
Association of Chain Drug Stores Foundation developed a model framework for implementing effective MTM services in a
community pharmacy setting by publishing Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Version 1.0. The original version 1.0 document described the foundational or core elements of
MTM services that could be provided by pharmacists across the spectrum of community pharmacy.1
Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 is an
evolutionary document that focuses on the provision of MTM services in settings where patients* or their caregivers can
be actively involved in managing their medications. This service model was developed with the input of an advisory panel
of pharmacy leaders representing diverse pharmacy practice settings (listed in Addendum). While adoption of this model
is voluntary, it is important to note that this model is crafted to maximize both effectiveness and efficiency of MTM service
delivery across pharmacy practice settings in an effort to improve continuity of care and patient outcomes.
*In this document, the term patient refers to the patient, the caregiver, or other persons involved in the care of the patient.
Notice: The materials in this service model are provided only for general informational purposes and do not constitute business or legal
advice. The National Association of Chain Drug Stores Foundation and the American Pharmacists Association assume no responsibility for
the accuracy or timeliness of any information provided herein. The reader should not under any circumstances solely rely on, or act on the
basis of, the materials in this service model. These materials and information are not a substitute for obtaining business or legal advice in the
appropriate jurisdiction or state.
The materials in this service model do not represent a standard of care or standard business practices. This service model may not be
appropriate for all pharmacists or pharmacies. Service programs should be designed based on unique needs and circumstances and model
examples should be modified as appropriate.
Nothing contained in this service model shall be construed as an express or implicit invitation to engage in any illegal or anticompetitive
activity. Nothing contained in this service model shall, or should be, construed as an endorsement of any particular method of treatment or
pharmacy practice in general.
MTM services,* as described in this model, are distinct from

medication dispensing and focus on a patient-centered,
rather than an individual product-centered, process of
care.4 MTM services encompass the assessment and evaluation of the patients complete medication therapy regimen,
rather than focusing on an individual medication product.
This model framework describes core elements of MTM
service delivery in pharmacy practice and does not
represent a specific minimum or maximum level of all
services that could be delivered by pharmacists.5
Medication-related problems are a significant public health
issue within the healthcare system. Incidence estimates
suggest that more than 1.5 million preventable medicationrelated adverse events occur each year in the United
States, accounting for an excess of $177 billion in terms of
medication-related morbidity and mortality.6,7 The Institute
of Medicine advocates that healthcare should be safe,
effective, patient-centered, timely, efficient, and effective to
meet patients needs and that patients should be active
participants in the healthcare process to prevent medication-related problems.3,7
MTM services, as described in this service model, may help
address the urgent public health need for the prevention of
medication-related morbidity and mortality.3 MTM services
may contribute to medication error prevention, result in
improved reliability of healthcare delivery, and enable
patients to take an active role in medication and healthcare
self-management.7 The MTM services outlined in this model
are aligned with the Centers for Medicare & Medicaid
MTM programs are demonstrating positive clinical,

economic, and humanistic outcomes across diverse patient
populations in various patient care settings.915 MTM
services are currently being delivered in both the public and
private sectors. In the public sector, some state Medicaid
and Medicare Part D plans have focused on a comprehensive medication therapy review as the foundation of their
MTM programs. Pharmacists participating in these
programs often provide patients with an initial comprehensive assessment and ongoing follow-up assessments to
identify and resolve medication-related problems.11, 1620
In the private sector, MTM programs are beginning to
emerge nationwide, offering MTM services to traditional
insured groups, managed-care populations, self-insured
employers, and self-paying individual patients.9,10,12
Any patient who uses prescription and nonprescription
medications, herbal products, or other dietary supplements could potentially benefit from the MTM core elements
outlined in this model. As part of the effort to effectively
address the urgent public health issue of medication-related
morbidity and mortality, MTM services should be considered
for any patient with actual or potential medication-related
problems, regardless of the number of medications they
use, their specific disease states, or their health plan coverage. Although MTM program structure and the needs of
individual patients may vary, the use of a consistent
and recognizable framework for core MTM services, as
described in this model, will enhance their efficient delivery
and effective quality measurement. As new opportunities
arise, pharmacists in all practice settings must share a
common vision for patient-centered MTM services that
improve medication therapy outcomes and provide value
within our nations healthcare system.
*MTM services are built upon the philosophy and process of pharmaceutical care that was first implemented in pharmacy practice in
the early 1990s. As pharmacy education, training, and practice continue to evolve to a primarily clinical patient-centered focus,
pharmacists are gaining recognition from other healthcare professionals and the public as medication therapy experts. Recognizing
the pharmacists role as the medication therapy expert, the pharmacy profession has developed a consensus definition for medication
therapy management and is increasingly using this term to describe the services provided by pharmacists to patients.
March 2008
Medication Therapy Management in Pharmacy Practice:

Core Elements of an MTM Service Model Version 2.0 is
designed to improve collaboration among pharmacists,
physicians, and other healthcare professionals; enhance
communication between patients and their healthcare
team; and optimize medication use for improved patient
outcomes. The medication therapy management (MTM)
services described in this model empower patients to take
an active role in managing their medications. The services
are dependent upon pharmacists working collaboratively
with physicians and other healthcare professionals to
optimize medication use in accordance with evidencebased guidelines.2,3
Services expectations, as stated in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003,
that MTM services will enhance patients understanding of
appropriate drug use, increase adherence to medication
therapy, and improve detection of adverse drug events.8
Introduction
Framework for Pharmacist-Provided

MTM Services
This framework for MTM service delivery in pharmacy
practice is designed to facilitate collaboration among the
pharmacist, patient, physician, and other healthcare professionals to promote safe and effective medication use and
achieve optimal patient outcomes. MTM services in all patient
care settings should include structures supporting the establishment and maintenance of the patientpharmacist
relationship.
Providing MTM Services in Various Patient
Care Settings
Patients with a potential need for MTM services can be identified by the pharmacist, the physician or other healthcare
professionals, the health plan, or the patients themselves
when medication-related problems are suspected. Appendix
B provides considerations for identification of patients who
may benefit from MTM services. Patients may be especially
vulnerable to medication-related problems during transitions
of care* such as when their healthcare setting changes,
when they change physicians, or when their payer status
changes. These transitions of care often result in medication
therapy changes that may be due to changes in the patients
needs or resources, the patients health status or condition,
or formulary requirements. It is important that systems be
established so that pharmacist-provided MTM services can
focus on reconciling the patients medications and ensuring
the provision of appropriate medication management during transitions of care.
For ambulatory patients, MTM services typically are offered
by appointment but may be provided on a walk-in basis.
MTM services should be delivered in a private or semiprivate area, as required by the Health Insurance Portability
and Accountability Act, by a pharmacist whose time can be
devoted to the patient during this service.21 In other patient
care settings (e.g., acute care, long-term care, home care,
managed care), the environment in which MTM services are
delivered may differ because of variability in structure and
facilities design. Even so, to the extent MTM core elements
are implemented, a consistent approach to their delivery
should be maintained.
The Delivery of MTM Services

by the Pharmacist
Within the MTM core elements service model, the patient
receives an annual comprehensive medication therapy
review and additional medication therapy reviews according to the patients needs. The patient may require ongoing
monitoring by the pharmacist to address new or recurring
medication-related problems.
The total number of reviews required to successfully manage
a patients therapy will vary from patient to patient and will
be ultimately determined by the complexity of the individual
patients medication-related problems. The extent of health
plan benefits or other limitations imposed by the patients
payer may affect coverage for MTM services; however, this
would not preclude additional services provided by the pharmacist for which the patient pays on a fee-for-service basis.
To perform the most comprehensive assessment of a
patient, personal interaction with direct contact between
a healthcare professional and a patient is optimal. A
face-to-face interaction optimizes the pharmacists ability
to observe signs of and visual cues to the patients health
problems (e.g., adverse reactions to medications, lethargy,
alopecia, extrapyramidal symptoms, jaundice, disorientation)
and can enhance the patientpharmacist relationship.22 The
pharmacists observations may result in early detection of
medication-related problems and thus have the potential to
reduce inappropriate medication use, emergency department visits, and hospitalizations. It is recognized, however,
that alternative methods of patient contact and interaction
such as telephonic may be necessary for those patients
for whom a face-to-face interaction is not possible or not
desired (e.g., homebound patients) or in pharmacy practice settings in which the pharmacist serves in a consultative
role on the healthcare team. Irrespective of whether the
MTM service is provided by the pharmacist to the patient
face-to-face or by alternative means, the service is intended
to support the establishment and maintenance of the
patientpharmacist relationship.
*Examples of transitions of care may include but are not limited to changes in healthcare setting (e.g., hospital admission, hospital to
home, hospital to long-term care facility, home to long-term care facility), changes in healthcare professionals and/or level of care
(e.g., treatment by a specialist), or changes in payer status (e.g., change or loss of health plan benefits/insurance).
The MTM service model in pharmacy practice includes the

following five core elements:
In a comprehensive MTR, ideally the patient presents all

current medications to the pharmacist, including all
prescription and nonprescription medications, herbal
products, and other dietary supplements. The pharmacist
then assesses the patients medications for the presence of
any medication-related problems, including adherence, and
works with the patient, the physician, or other healthcare
professionals to determine appropriate options for resolving
identified problems. In addition, the pharmacist supplies
the patient with education and information to improve the
patients self-management of his or her medications.
Medication therapy review (MTR)

Personal medication record (PMR)
Medication-related action plan (MAP)
Intervention and/or referral
Documentation and follow-up
These five core elements form a framework for the delivery

of MTM services in pharmacy practice. Every core element
is integral to the provision of MTM; however, the sequence
and delivery of the core elements may be modified to meet
an individual patients needs.
Medication Therapy Review: The

medication therapy review (MTR) is a
systematic process of collecting patient-specific
information, assessing medication therapies to
identify medication-related problems, developing a prioritized list of medication-related
problems, and creating a plan to resolve them.
An MTR is conducted between the patient and the pharmacist.
Pharmacist-provided MTR and consultation in various
settings has resulted in reductions in physician visits,
emergency department visits, hospital days, and overall
healthcare costs.9,10,12,14,20,2325 In addition, pharmacists have
been shown to obtain accurate and efficient medicationrelated information from patients.10,26,27 The MTR is designed
to improve patients knowledge of their medications,
address problems or concerns that patients may have,
and empower patients to self-manage their medications
and their health condition(s).
The MTR can be comprehensive or targeted to an actual or
potential medication-related problem. Regardless of whether the MTR is comprehensive or targeted, patients may be
identified as requiring this service in a variety of ways.
Commonly, patients may be referred to a pharmacist by
their health plan, another pharmacist, physician, or other
healthcare professionals. Patients may also request an MTR
independent of any referral. Additional opportunities for
providing an MTR include when a patient is experiencing
Targeted MTRs are used to address an actual or potential

medication-related problem. Ideally, targeted MTRs are
performed for patients who have received a comprehensive
MTR. Whether for a new problem or subsequent monitoring,
the pharmacist assesses the specific therapy problem in the
context of the patients complete medical and medication
history. Following assessment, the pharmacist intervenes
and provides education and information to the patient, the
physician or other healthcare professionals, or both, as
appropriate. The MTR is tailored to the individual needs of
the patient at each encounter.
Depending on its scope, the MTR may
include the following:
Interviewing the patient to gather data including
demographic information, general health and activity
status, medical history, medication history, immunization
history, and patients thoughts or feelings about their
conditions and medication use28
Assessing, on the basis of all relevant clinical
information available to the pharmacist, the patients
physical and overall health status, including current
and previous diseases or conditions
Assessing the patients values, preferences, quality of
life, and goals of therapy
Assessing cultural issues, education level, language
barriers, literacy level, and other characteristics of
the patients communication abilities that could affect
outcomes
Evaluating the patient to detect symptoms that could
be attributed to adverse events caused by any of his or
her current medications
Interpreting, monitoring, and assessing patients
laboratory results
March 2008
a transition of care, when actual or potential medicationrelated problems are identified, or if the patient is suspected
to be at higher risk for medication-related problems.
Core Elements of an MTM Service

Model in Pharmacy Practice
Assessing, identifying, and prioritizing medicationrelated problems related to

The clinical appropriateness of each medication
being taken by the patient, including benefit
versus risk
The appropriateness of the dose and dosing
regimen of each medication, including consideration of indications, contraindications,
potential adverse effects, and potential
problems with concomitant medications
Therapeutic duplication or other unnecessary
medications
Adherence to the therapy
Untreated diseases or conditions
Medication cost considerations
Healthcare/medication access considerations
Developing a plan for resolving each medicationrelated problem identified
Providing education and training on the appropriate
use of medications and monitoring devices and the
importance of medication adherence and
understanding treatment goals
Coaching patients to be empowered to manage

their medications
Monitoring and evaluating the patients response to
therapy, including safety and effectiveness
Communicating appropriate information to the
physician or other healthcare professionals, including
consultation on the selection of medications, suggestions to address identified medication problems,
updates on the patients progress, and recommended
follow-up care29
In this service model, a patient would receive an annual
comprehensive MTR and additional targeted MTRs to
address new or ongoing medication-related problem(s).
Significant events such as important changes in the patients
medication therapy, changes in the patients needs or resources, changes in the patients health status or condition,
a hospital admission or discharge, an emergency department visit, or an admission or discharge from a long-term
care or assisted-living facility could necessitate additional
comprehensive MTRs.
Within the MTM core elements service model, the patient

receives a comprehensive record of his or her medications (prescription and nonprescription medications, herbal
products, and other dietary supplements) that has been
completed either by the patient with the assistance of the
pharmacist or by the pharmacist, or the patients existing
PMR is updated. Ideally, the patients PMR would be generated electronically, but it also may be produced manually.
Whether the pharmacist provides the PMR manually or
electronically, the information should be written at a literacy
level that is appropriate for and easily understood by the
patient. In institutional settings, the PMR may be created
at discharge from the medication administration record or
patient chart for use by the patient in the outpatient setting.
The PMR contains information to assist the patient in his or
her overall medication therapy self-management. A sample
PMR is included in Appendix C.
The PMR, which is intended for use by the patient, may
include the following information:30
Patient name
Patient birth date
Patient phone number
Emergency contact information
(Name, relationship, phone number)
Primary care physician
(Name and phone number)
Pharmacy/pharmacist
(Name and phone number)
Allergies (e.g., What allergies do I have? What
happened when I had the allergy or reaction?)
Other medication-related problems (e.g., What
medication caused the problem? What was the
problem I had?)
Potential questions for patients to ask about their
medications (e.g., When you are prescribed a new
drug, ask your doctor or pharmacist...)
Date last updated
Each time the patient receives a new medication; has a

current medication discontinued; has an instruction change;
begins using a new prescription or nonprescription medication, herbal product, or other dietary supplement; or has
any other changes to the medication regimen, the patient
should update the PMR to help ensure a current and
accurate record. Ideally, the pharmacist, physician, and
other healthcare professionals can actively assist the patient
with the PMR revision process.
Pharmacists may use the PMR to communicate and collaborate with physicians and other healthcare professionals to
achieve optimal patient outcomes. Widespread use of the
PMR will support uniformity of information provided to all
healthcare professionals and enhance the continuity of care
provided to patients while facilitating flexibility to account
for pharmacy- or institution-specific variations.
March 2008
Date last reviewed by the pharmacist, physician, or

other healthcare professional
Patients signature
Healthcare providers signature
For each medication, inclusion of the following:
Medication (e.g., drug name and dose)
Indication (e.g., Take for)
Instructions for use (e.g., When do I take it?)
Start date
Stop date
Ordering prescriber/contact information
(e.g., doctor)
Special instructions
The PMR is intended for patients to use in medication
self-management. The maintenance of the PMR is a collaborative effort among the patient, pharmacist, physician,
and other healthcare professionals. Patients should be
encouraged to maintain and update this perpetual document. Patients should be educated to carry the PMR with
them at all times and share it at all healthcare visits and at
all admissions to or discharges from institutional settings to
help ensure that all healthcare professionals are aware of
their current medication regimen.
Personal Medication Record: The personal

medication record (PMR) is a comprehensive
record of the patients medications (prescription
and nonprescription medications, herbal
products, and other dietary supplements).
Medication-Related Action Plan:

The medication-related action plan (MAP) is
a patient-centric document containing a list of
actions for the patient to use in tracking progress
for self-management.
A care plan is the health professionals course of action
for helping a patient achieve specific health goals.31 The
care plan is an important component of the documentation
core element outlined in this service model. In addition to
the care plan, which is developed by the pharmacist and
used in the collaborative care of the patient, the patient
receives an individualized MAP for use in medication selfmanagement. Completion of the MAP is a collaborative
effort between the patient and the pharmacist. The patient
MAP includes only items that the patient can act on that are
within the pharmacists scope of practice or that have been
agreed to by relevant members of the healthcare team. The
MAP should not include outstanding action items that still
require physician or other healthcare professional review
or approval. The patient can use the MAP as a simple
guide to track his or her progress. The Institute of Medicine
has advocated the need for a patient-centered model of
healthcare.7 The patient MAP, coupled with education, is an
essential element for incorporating the patient-centered approach into the MTM service model. The MAP reinforces a
sense of patient empowerment and encourages the patients
active participation in his or her medication-adherence

behavior and overall MTM. A sample MAP is included in
Appendix D.
The MAP, which is intended for use by the patient, may
include the following information:
Patient name
Primary care physician
(Doctors name and phone number)
Pharmacy/pharmacist
(Pharmacy name/pharmacist name and
phone number)
Date of MAP creation (Date prepared)
Action steps for the patient: What I need to do...
Notes for the patient: What I did and when I did it...
Appointment information for follow-up with
pharmacist, if applicable
Specific items that require intervention and that have been
approved by other members of the healthcare team and
any new items within the pharmacists scope of practice
should be included on a MAP distributed to the patient on
a follow-up visit. In institutional settings the MAP could be
established at the time the patient is discharged for use by
the patient in medication self-management.
During the course of an MTM encounter, medication-related

problems may be identified that require the pharmacist to
intervene on the patients behalf. Interventions may include
collaborating with physicians or other healthcare professionals to resolve existing or potential medication-related
problems or working with the patient directly. The communication of appropriate information to the physician or
other healthcare professional, including consultation on the
selection of medications, suggestions to address medication
problems, and recommended follow-up care, is integral to
the intervention component of the MTM service model.29
Examples of circumstances that may require referral include

the following:
The positive impact of pharmacist interventions on outcomes

related to medication-related problems has been demonstrated in numerous studies.3237 Appropriate resolution of
medication-related problems involves collaboration and
communication between the patient, the pharmacist, and
the patients physician or other healthcare
professionals.
A patient may exhibit potential problems discovered

during the MTR that may necessitate referral for evaluation and diagnosis
A patient may require disease management education
to help him or her manage chronic diseases such as
diabetes
A patient may require monitoring for high-risk
medications (e.g., warfarin, phenytoin,
methotrexate)
The intent of intervention and/or referral is to optimize
medication use, enhance continuity of care, and encourage
patients to avail themselves of healthcare services to prevent
future adverse outcomes.
March 2008
Some patients medical conditions or medication therapy

may be highly specialized or complex and the patients
needs may extend beyond the core elements of MTM
service delivery. In such cases, pharmacists may provide
additional services according to their expertise or refer the
patient to a physician, another pharmacist, or other
healthcare professional.
Intervention and/or Referral: The pharmacist provides consultative services and intervenes
to address medication-related problems; when
necessary, the pharmacist refers the patient to a
physician or other healthcare professional.
Documentation and Follow-up: MTM

services are documented in a consistent manner,
and a follow-up MTM visit is scheduled based
on the patients medication-related needs, or the
patient is transitioned from one care setting to
another.
Documentation is an essential element of the MTM
service model. The pharmacist documents services and
intervention(s) performed in a manner appropriate for
evaluating patient progress and sufficient for billing
purposes.
Proper documentation of MTM services may serve several
purposes including, but not limited, to the following:
Facilitating communication between the pharmacist
and the patients other healthcare professionals regarding recommendations intended to resolve or monitor
actual or potential medication-related problems
Improving patient care and outcomes
Enhancing the continuity of patient care among
providers and care settings
Ensuring compliance with laws and regulations
for the maintenance of patient records
Protecting against professional liability

Capturing services provided for justification of
billing or reimbursement (e.g., payer audits)
Demonstrating the value of pharmacist-provided
MTM services
Demonstrating clinical, economic, and
humanistic outcomes
MTM documentation includes creating and maintaining an
ongoing patient-specific record that contains, in chronological order, a record of all provided care in an established
standard healthcare professional format (e.g., the SOAP
[subjective observations, objective observations, assessment,
and plan] note38).
Ideally, documentation will be completed electronically or
alternatively on paper. The inclusion of resources such as a
PMR, a MAP, and other practice-specific forms will assist the
pharmacist in maintaining consistent professional documentation. The use of consistent documentation will help facilitate collaboration among members of the healthcare team
while accommodating practitioner, facility, organizational,
or regional variations.
Documentation elements for the patient record may include, but are not limited to, the following:22,29,3840
10
Documentation category
Examples
Patient demographics
Basic information: address, phone, e-mail, gender, age, ethnicity, education status,
patients special needs, health plan benefit/insurance coverage
Subjective observations
Pertinent patient-reported information: previous medical history, family history,

social history, chief complaints, allergies, previous adverse drug reactions
Objective observations
Known allergies, diseases, conditions, laboratory results, vital signs, diagnostic

signs, physical exam results, review of systems
Assessment
Problem list, assessment of medication-related problems
Plan
A care plan is the healthcare professionals course of action for helping a patient
achieve specific health goals
Education
Goal setting and instruction provided to the patient with verification of understanding
Collaboration
Communication with other healthcare professionals: recommendations, referrals, and

correspondence with other professionals (cover letter, SOAP note)
PMR
A record of all medications, including prescription and nonprescription medications,

herbal products, and other dietary supplements
MAP
Patient-centric document containing a list of actions to use in tracking progress

for self-management
Follow-up
Transition plan or scheduling of next follow-up visit
Billing
Amount of time spent on patient care, level of complexity, amount charged
Follow-up
When a patients care setting changes (e.g., hospital admission, hospital to home, hospital to long-term care facility,
home to long-term care facility), the pharmacist transitions the patient to another pharmacist in the patients new
care setting to facilitate continued MTM services. In these
situations, the initial pharmacist providing MTM services
participates cooperatively with the patients new pharmacist
provider to facilitate the coordinated transition of the
patient, including the transfer of relevant medication and
other health-related information.
If the patient will be remaining in the same care setting,
the pharmacist should arrange for consistent follow-up
MTM services in accordance with the patients unique
medication-related needs. All follow-up evaluations and
interactions with the patient and his or her other healthcare
professional(s) should be included in MTM documentation.
The MTM core elements, as presented in this document,

are intended to be applicable to patients in all care settings where the patients or their caregivers can be actively
involved with managing their medication therapy, taking full
advantage of the pharmacists role as the medication therapy expert.A flow chart of the core elements of an MTM
service model contained in this document can be found in
Appendix E. As the core elements service model continues
to evolve to meet diverse patient needs, pharmacists are
encouraged to make the most of the framework provided to
improve patient outcomes and medication use.
March 2008
Following documentation of the MTM encounter, appropriate external communication should be provided or sent to
key audiences, including patients, physicians, and payers.
Providing the patient with applicable documentation that
he or she can easily understand is vital to facilitating active
involvement in the care process. Documentation provided
to the patient at the MTM encounter may include the PMR,
MAP, and additional education materials. Documentation to
physicians and other healthcare professionals may include
a cover letter, the patients PMR, the SOAP note, and care
plan. Communicating with payers and providing appropriate billing information may also be necessary and could
include the name of the pharmacist or pharmacy and
appropriate identifier, services provided, time spent on
patient care, and appropriate billing codes.
Conclusion
External Communication of
MTM Documentation
11
References
1.
AmericanPharmacistsAssociation,NationalAssociationofChainDrug
StoresFoundation.Medicationtherapymanagementincommunitypharmacy practice: core elements of an MTM service (version 1.0).
J Am Pharm Assoc. 2005;45:573-9.
2.
WagnerEH.Chronicdiseasemanagement:Whatwillittaketoimprovecare
for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.
3.
Institute of Medicine. Crossing the Quality Chasm: A New Health System

for the 21st Century. Washington, DC: Institute of Medicine; 2001.
4.
Cipolle RJ. Strand LM, Morley PC. Pharmaceutical Care Practice:

The Clinicians Guide. New York: McGraw Hill; 2004.
5.
McGivney MS, Meyer SM, Duncan-Hewitt W, et al. Medication therapy

management:itsrelationshiptopatientcounseling,diseasemanagement,
and pharmaceutical care. J Am Pharm Assoc. 2007;45:620-8.
6.
Ernst FR,Grizzle AJ.Drug-related morbidity and mortality:updating the

cost-of-illness model. J Am Pharm Assoc. 2001;41:192-9.
7.
Institute of Medicine. Report Brief: Preventing Medication Errors.

Washington,DC:Institute of Medicine;July 2006.http://www.iom.edu/
Object.File/Master/35/943/medication%20errors%20new.pdf.Accessed
September 1, 2007.
8.
9.
21. Rovers J, Currie J, Hagel H, et al. Re-engineering the pharmacy layout.

In: A Practical Guide to Pharmaceutical Care. 2nd ed. Washington, DC:
American Pharmacists Association; 2003:261-6.
22. Rovers J, Currie J, Hagel H, et al. Patient data collection. In: A Practical
Guide to Pharmaceutical Care. 2nd ed.Washington, DC: American Pharmacists Association; 2003:26-51.
23. Borgsdorf LR, Miano JS, Knapp KK. Pharmacist-managed medication
review in a managed care system. Am J Hosp Pharm. 1994;51:772-7.
24. BondCA,RaehlCL,FrankeT.Clinicalpharmacyservices,pharmacystaffing,
and the total cost of care in the United States hospitals.
Pharmacotherapy. 2000;20:609-21.
25. Christensen D, Trygstad T, Sullivan R, et al. A pharmacy management
interventionforoptimizingdrugtherapyfornursinghomepatients.AmJ
Geriatr Pharmacother. 2004;2:248-56.
26. Gurwich EL. Comparison of medication histories acquired by
pharmacists and physicians. Am J Hosp Pharm. 1983;40:1541-2.
Centers for Medicare & Medicaid Services.Medicare Prescription Drug

Benefit Final Rule: 42 CFR Parts 400, 403, 411, 417, and 423 Medicare
Program. Federal Register, vol. 70, no. 18. January 28, 2005. http://
a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.
gov/2005/pdf/05-1321.pdf. Accessed September 1, 2007.
27. NesterTM,HaleLS.Effectivenessofapharmacist-acquiredmedicationhistory in promoting patient safety. Am J Health Syst Pharm. 2003;3-14.
Garrett D,Bluml B.Patient self-management program for diabetes:firstyear clinical, humanistic, and economic outcomes. J Am Pharm Assoc.
2005;45:130-7.
29. Berger BA. Interacting with physicians. In: Communication Skills for
Pharmacists. 2nd ed. Washington, DC: American Pharmacists
Association; 2005:131-9.
10. CranorCW,BuntingBA,ChristensenDB.TheAshevilleProject:long-term
clinicalandeconomicoutcomesofacommunitypharmacydiabetescare
program. J Am Pharm Assoc. 2003;43:173-90.
11. Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa
Medicaid pharmaceutical case management program.
J Am Pharm Assoc. 2004;44:337-49.
12. BuntingBA,CranorCW.TheAshevilleProject:long-termclinical,humanistic, and economic outcomes of a community-based
medication therapy management program for asthma.
J Am Pharm Assoc. 2003;46:133-47.
13. JamesonJ,VanNoordG,VanderwouldK.Theimpactofapharmacotherapy
consultation on the cost and outcome of medical therapy.
J Fam Pract. 1995;41(5):469-72.
14. Lipton HL, Bero LA, Bird JA, et al. The impact of clinical pharmacists
consultations on physicians geriatric drug prescribing.
Med Care. 1992;30:646-58.
15. SchumockGT,ButlerMG,MeekPD,etal.Evidenceoftheeconomicbenefit
of clinical pharmacy services: 19962000.
Pharmacotherapy. 2003;23:113-132.
16. MinnesotaDepartmentofHumanServices.MHCPenrolledprofessionals:
medicationtherapymanagementservices.http://www.dhs.state.mn.us/
main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelection
Method=LatestReleased&dDocName=id_055325#P116_7762.Accessed
February 5, 2007.
12
20. Galt KA. Cost avoidance, acceptance, and outcomes associated with
apharmacotherapyconsultclinicinaVeteransAffairsmedicalcenter.Pharmacotherapy. 1998;18:1103-11.
28. Rovers J, Currie J, Hagel H, et al. The case for pharmaceutical care. In: A
Practical Guide to Pharmaceutical Care. 2nd ed.Washington, DC: American Pharmacists Association, 2003:3-4.
30. Executive summary of the American Society of Health System

Pharmacists (ASHP) and ASHP Research and Education
Foundation Continuity of Care in Medication Use Summit.
Am J Health Syst Pharm. In press.
31. Rovers J,Currie J,Hagel H,et al.Patient care plan development.In:A Practical Guide to Pharmaceutical Care. 2nd ed. Washington, DC: American
Pharmacists Association, 2003:69.
32. Rupp MT. Value of the community pharmacists interventions to
correct prescribing errors. Ann Pharmacother. 1992;26:1580-4.
33. McMullin ST, Hennenfent JA, Ritchie D, et al. A prospective
randomizedtrialtoassessthecostimpactofpharmacist-initiatedinterventions. Arch Intern Med. 1999;159:2306-9.
34. KnappKK,KatzmanH,HambrightJS,etal.Communitypharmacistintervention in a capitated pharmacy benefit contract.
Am J Health Syst Pharm. 1998;55:1141-5.
35. Dobie RL, Rascati KL. Documenting the value of pharmacist
interventions. Am Pharm. 1994;NS34(5):50-4.
36. Hepler CD, Strand LM. Opportunities and responsibilities in
pharmaceutical care. Am J Hosp Pharm. 1990;47:533-43.
37. Bootman JL, Harrison DL, Cox E. The healthcare cost of
drug-related morbidity and mortality in nursing facilities.
Arch Intern Med. 1997;157:2089-96.
17. TraynorK.Wyomingprogrambringspharmacistconsultationshome.AmJ
Health Syst Pharm. 2004;61:760.
38. Zierler-Brown S, Brown TR, Chen D, et al. Clinical documentation

forpatientcare:models,concepts,andliabilityconsiderationsforpharmacists. Am J Health Syst Pharm. 2007;64:1851-8.
18. North Carolina Department of Health and Human Services. North

Carolina Medicaid: Medication Therapy Management Program (MTMP).
August 2006. http://www.dhhs.state.nc.us/dma/Forms/
mtmpinstructions.pdf. Accessed September 1, 2007.
39. Currie JD, Doucette WR, Kuhle J, et al. Identification of essential

elements in documentation of pharmacist-provided care.
J Am Pharm Assoc. 2003;43:41-9.
19. Touchette DR,Burns AL,Bough MA,et al.Survey of medication therapy

management programs under Medicare part D. J Am Pharm Assoc.
2006;46:683-91.
40. Culhane N, Brooks A, Cohen V, et al. Medication therapy management

services:Applicationofthecoreelementsinambulatorysettings.American
College of Clinical Pharmacy. March 14, 2007.
Medication Therapy Management encompasses a broad

range of professional activities and responsibilities within
the licensed pharmacists, or other qualified healthcare
providers, scope of practice. These services include but
are not limited to the following, according to the individual
needs of the patient:
a. Performing or obtaining necessary assessments of the
patients health status
b. Formulating a medication treatment plan
c. Selecting, initiating, modifying, or administering
medication therapy
d. Monitoring and evaluating the patients response to
therapy, including safety and effectiveness
e. Performing a comprehensive medication review to
identify, resolve, and prevent medication-related problems, including adverse drug events
f. Documenting the care delivered and communicating
essential information to the patients other primary
care providers
g. Providing verbal education and training designed to
enhance patient understanding and appropriate use of
his/her medications
h. Providing information, support services, and resources
designed to enhance patient adherence with his/her
therapeutic regimens
i. Coordinating and integrating medication therapy
management services within the broader healthcare
management services being provided to the patient
A program that provides coverage for Medication Therapy

Management services shall include:
a. Patient-specific and individualized services or sets
of services provided directly by a pharmacist to the
patient.* These services are distinct from formulary development and use, generalized patient education and
information activities, and other population-focused
quality-assurance measures for medication use
b. Face-to-face interaction between the patient* and the
pharmacist as the preferred method of delivery. When
patient-specific barriers to face-to-face communication
exist, patients shall have equal access to appropriate alternative delivery methods. Medication Therapy
Management programs shall include structures supporting the establishment and maintenance of the
patient*pharmacist relationship
c. Opportunities for pharmacists and other qualified
healthcare providers to identify patients who should
receive medication therapy management services
d. Payment for medication therapy management services consistent with contemporary provider payment
rates that are based on the time, clinical intensity, and
resources required to provide services (e.g., Medicare
Part A and/or Part B for CPT and RBRVS)
e. Processes to improve continuity of care, outcomes, and
outcome measures
Approved July 27, 2004, by the Academy of Managed
Care Pharmacy, the American Association of Colleges
of Pharmacy, the American College of Apothecaries, the
American College of Clinical Pharmacy, the American Society of Consultant Pharmacists, the American Pharmacists
Association, the American Society of Health-System Pharmacists, the National Association of Boards of Pharmacy,**
the National Association of Chain Drug Stores, the National
Community Pharmacists Association, and the National
Council of State Pharmacy Association Executives.
* In some situations, medication therapy management services may be provided to the caregiver or
other persons involved in the care of the patient.
** Organization policy does not allow NABP to take a position on payment issues.
Bluml BM. Definition of medication therapy management: development of profession wide consensus.
J Am Pharm Assoc. 2005;45:56672.
March 2008
Medication Therapy Management is a distinct service or

group of services that optimize therapeutic outcomes for individual patients. Medication Therapy Management services
are independent of, but can occur in conjunction with, the
provision of a medication product.
Appendix A. Definition of Medication Therapy Management (MTM)
13
Appendix B. Considerations for Identification of Patients Who

May Benefit From MTM Services
Any patients using prescription and nonprescription

medications, herbal products, and other dietary supplements could potentially benefit from the medication therapy
management (MTM) services described in the core elements
outlined in this service model, especially if medicationrelated problems or issues are discovered or suspected.
Patients may be evaluated for MTM services regardless of
the number of medications they use, their specific disease
state(s), or their health plan coverage.
Opportunities for the identification of patients targeted for
MTM services may result from many sources including, but
not limited to, pharmacist identification, physician referral,
patient self-referral, and health plan or other payer referral.
Pharmacists may wish to notify physicians or other healthcare professionals in their community or physicians within
their facility, if applicable, of their MTM services, so that
physicians may refer patients for MTM services.
To provide assistance in prioritizing who may benefit most
from MTM services, pharmacists, health plans, physicians,
other healthcare professionals, and health systems may
consider using one or more of the following factors to target
patients who are likely to benefit most from MTM services:
Patient has experienced a transition of care, and his or
her regimen has changed
Patient is receiving care from more than one prescriber
Patient is taking five or more chronic medications
(including prescription and nonprescription medications, herbal products, and other dietary supplements)
Patient has at least one chronic disease or chronic
health condition (e.g., heart failure, diabetes,
hypertension, hyperlipidemia, asthma, osteoporosis,
depression, osteoarthritis, chronic obstructive
pulmonary disease)
14
Patient has laboratory values outside the normal range

that could be caused by or may be improved with
medication therapy
Patient has demonstrated nonadherence (including
underuse and overuse) to a medication regimen
Patient has limited health literacy or cultural
differences, requiring special communication
strategies to optimize care
Patient wants or needs to reduce out-of-pocket
medication costs
Patient has experienced a loss or significant change in
health plan benefit or insurance coverage
Patient has recently experienced an adverse event
(medication or non-medication-related) while
receiving care
Patient is taking high-risk medication(s), including
narrow therapeutic index drugs (e.g., warfarin,
phenytoin, methotrexate)
Patient self-identifies and presents with perceived need
for MTM services
Patients, professionals, payers, and health information technology system vendors are encouraged to develop a format that
meets individual needs, collecting elements such as those in the sample personal medication record (PMR).
March 2008
Appendix C. Sample Personal Medication Record

(Note: Sample PMR is two pages or one page front and back)
LOGO
Name:________________________________________________________________ Birth date: _______________________________

Include
onon
thisthis
record:
prescription
medications,
nonprescription
medications,
herbal herbal
products,
and other
dietary
Includeall
allofofyour
yourmedications
medications
reord:
prescription
medications,
nonprescription
medications,
products,
and
other supplements.
dietary supplements.
Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.
Drug
Name
Dose
5mg
Morning
Diabetes
Noon
Evening
Start Date Stop Date
Doctor
Special Instructions
Bedtime
1/15/08
Johnson (000-0000)
Take with food
08-029
Glyburide
When do I take it?
Take for...
This sample Personal Medical Record (PMR) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient
(or other user) should not, under any circumstances, solely rely on, or act on the basis of, the PMR or the information therein. If he or she does so, then he or she does so at his or her
own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the PMR is not a substitute for obtaining professional healthcare
advice or treatment. This PMR may not be appropriate for all patients (or other users). The National Association of Chain Drug Stores Foundation and the American Pharmacists
Association assume no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.
APhA and the NACDS Foundation encourage the use of this document in a manner and form that serves the individual needs of practitioners.
All reproductions, including modified forms, should include the following statement: This form is based on forms developed by the
American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Reproduced with permission from APhA
and NACDS Foundation.
side 1
My Medication record
15
side 2
My Medication record
Name: ____________________________________ Birth date: _______________ Phone:_______________________

Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.
Emergency Contact Information

Name
Relationship
Phone Number
Primary Care Physician
Name
Phone Number
Pharmacy/Pharmacist
Name
Phone Number
Allergies
What allergies do I have? (Medicines, food, other)
What happened when I had the allergy or reaction?
Other Medicine Problems

Name of medicine that caused problem
What was the problem I had with the medicine?
When you are prescribed a new drug, ask your doctor or pharmacist:
What am I taking?
What is it for?
When do I take it?
Are there any side effects?
Are there any special instructions?
What if I miss a dose?
Notes:
16
Healthcare Providers Signature
Date last reviewed by

healthcare provider
08-029
Date last updated
Patients Signature
Patients, healthcare professionals, payers, and health information technology system vendors are encouraged to
develop a format that meets individual and customer needs, collecting elements such as those included on the sample
medication-related action plan (MAP) below.
March 2008
Appendix D. Sample Medication-Related Action Plan (for the Patient)
My Medication-related action Plan
Doctor (Phone):
Pharmacy/Pharmacist (Phone):
Date Prepared:
The list below has important Action Steps to help you get the most from your medications.
Follow the checklist to help you work with your pharmacist and doctor to manage your medications
AND make notes of your actions next to each item on your list.
Action Steps
What I need to do
Notes
What I did and when I did it
AM PM
08-029
My Next Appointment with My Pharmacist is on:__________________(date) at __________
Patient:
17
Appendix E. Flow Chart of a Medication Therapy Management Service Model
18
Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 was
developed with the input of an advisory panel of pharmacy leaders representing diverse pharmacy practice settings.
The pharmacy practice setting areas represented by members of the advisory panel included ambulatory care, community,
government technical support services, hospital, long-term care, managed care health systems, managed care organization
plan administration, and outpatient clinics.
March 2008
Addendum
Marialice S. Bennett, RPh, FAPhA

The Ohio State University
Macary Weck Marciniak, PharmD, BCPS

Albany College of Pharmacy
Rebecca W. Chater, RPh, MPH, FAPhA

Kerr Drug, Inc.
Randy P. McDonough, PharmD, MS, CGP, BCPS

Towncrest and Medical Plaza Pharmacies
Kimberly Sasser Croley, PharmD, CGP, FASCP

Knox County Hospital
Melissa Somma McGivney, PharmD, CDE

University of Pittsburgh School of Pharmacy
Rachael Deck, PharmD

Walgreen Co.
Rick Mohall, PharmD

Rite Aid Corporation
Jeffrey C. Delafuente, MS, FCCP, FASCP

Virginia Commonwealth University School of Pharmacy
Anthony Provenzano, PharmD, CDE

SUPERVALU Pharmacies, Inc.
Susan L. Downard, RPh

Kaiser Permanente of the Mid-Atlantic States, Inc
Michael Sherry, RPh

CVS Caremark
Margherita Giuliano, RPh

Connecticut Pharmacists Association
Steven T. Simenson, RPh, FAPhA

Goodrich Pharmacies
Zandra Glenn, PharmD

HRSA Pharmacy Services Support Center
Donna S. Wall, RPh, PharmD, BCPS, FASHP

Clarian Healthcare Partners, Indiana University Hospital
Melinda C. Joyce, PharmD, FAPhA, FACHE

The Medical Center
Winston Wong, PharmD

CareFirst BCBS
Sandra Leal, PharmD, CDE

El Rio Community Health Center
Staff
Ben Bluml, RPh
American Pharmacists Association Foundation
Crystal Lennartz, PharmD, MBA

National Association of Chain Drug Stores
Anne Burns, RPh

American Pharmacists Association
James Owen, PharmD

American Pharmacists Association
Ronna Hauser, PharmD

Afton Yurkon, PharmD

Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 advisory panel members
provided expert advice. The content of this document does not necessarily represent all of their opinions or those of their affiliated organizations.
MTM Core Elements Service Model Version 2.0 Advisory Panel Members
19
NOTES
To request a single print copy of the publication, click on the following link:
http://fs6.formsite.com/APhA-NACDS/print_request/index.html
To provide comments and/or feedback on this publication, click on the following link:
http://fs6.formsite.com/APhA-NACDS/core_elements_feedback/index.html
To obtain a copy of a slide presentation explaining the MTM Core Elements Service
Model or to submit a request for a presentation to your organization or group, click on
the following link: http://fs6.formsite.com/APhA-NACDS/presentation_request/index.html
Medication Therapy Management in Pharmacy Practice

Core Elements of an MTM Service Model
08-323
Version 2.0

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M EDI CA

APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES

APhA DELIVERING MEDICATION THERAPY

A National Certificate Training Program

Module 1. The Current Landscape for MTM Services

2014, American Pharmacists Association. All rights reserved.

APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES

After completing this module of the self-study activity,

Explain the key components of medication therapy

Define the five core elements of the MTM service

Discuss the MTM provisions of the Medicare Part D

List opportunities for providing MTM services

Cite data that describe the current status of MTM

Discuss quality measures that can be impacted by

Describe economic and clinical outcomes that

Increase the proportion of adults with hypertension

Reduce emergency department visits for common,

Module 1. The Current Landscape for MTM Services

Medication therapy management (MTM) is designed to allow

The History of MTM

Pharmacists have provided individualized patient care services

The Medicare Prescription Drug Benefit: Part D

Prior to January 2006, the Medicare program consisted

MTM encompasses a broad range of health care services

Module 1. The Current Landscape for MTM Services

APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES

Disease management programs and MTM services also are

Core Elements of an MTM Service

APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES

a. A brief, medication-centered discussion about a specific

Answers are located at the bottom of the page.

promotes ongoing evaluation of the patients medication

Medication therapy review (MTR).

Personal medication record (PMR).

Medication-related action plan (MAP).

Intervention and/or referral.

Documentation and follow-up.

The following descriptions summarize each of these elements.

Learning Activity Answer Key

Core Elements of an MTM Service Model

Medication Therapy Management in Pharmacy Practice:

Medication Therapy Review

The MTR is a systematic process in which the pharmacist

Module 1. The Current Landscape for MTM Services

APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES

The MTR is tailored to the individual needs of the patient at

Personal Medication Record

Medication-Related Action Plan

The document known as the MAP is typically provided to the

related issues, the person responsible for action, and other

MTM Documentation for Medicare Part D

The Affordable Care Act of 2010 directed CMS to develop

Module 1. The Current Landscape for MTM Services

APhA DELIVERING MEDICATION THERAPY MANAGEMENT SERVICES

Intervention and/or Referral

The intent of providing intervention and/or referral is to

Evaluation of a new problem discovered during the

Advanced education to help the patient manage a

Monitoring of high-risk medications (e.g., warfarin,

Laboratory monitoring (e.g., cholesterol panel,

Medication therapy dose adjustments or changes.

Communication of timely and appropriate information to

Documentation and Follow-Up

Documentation and follow-up are essential elements of the