clinical pharmacy

1. Medication Therapy Management (MTM)
Definition of MTM Services
• Services provided by a pharmacist that improve treatment outcomes for individual patients
• A professional service to promote the safe and effective use of medications
• A way to provide better care for patients
● Promotes collaboration among the patient, the pharmacist, and the patient’s other health care providers.
Purpose of Medication Therapy Management Services (MTMS)
• To optimize therapeutic outcomes
• To decrease the likelihood of adverse events
• To enhance patient understanding and adherence
• To reduce overall healthcare spending
MTMS Activities
• Assess patients’ health status
• Devise medication treatment plan
• Select, modify and administer medications
• Review current medications and identify drug-related problems
• Communicate care to other providers
• Provide patient education
• Refer patients for broader disease management services
The Spectrum of Pharmacist-Provided MTMS
• Comprehensive or Targeted Medication Therapy Reviews
• Adherence Services
• Based on the number and/or type of medications
• Targeted Medication Intervention Programs
• High-alert and/or high-cost medications
• Targeted patient population (i.e. geriatrics, pediatrics)
• Disease State Management
• Interdisciplinary approach to achieve therapeutic goals
• Example disease states: Diabetes, Cholesterol, Asthma
• Health and Wellness Services
• Immunizations
• Wellness screenings
• Smoking cessation
• Weight management
Components of the MTMS Core Elements Service Model
• Medication Therapy Review (MTR)
• a review of all medications including prescription, nonprescription, herbal products, and other dietary
supplements
• Personal Medication Record (PMR) - self-management on medications
• Medication-Related Action Plan (MAP) for the patient
• Intervention and/or Referral
• Documentation and Follow-Up

2. 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 patient’s needs. Pharmacists provide medication therapy
management to help patients get the best benefits from their medications by actively managing drug therapy and
by identifying, preventing, and resolving medication-related problems.
MEDICATION THERAPY MANAGEMENT PROCESS
Pharmacist’s Communication with other Health Providers
⮚ MTM Pharmacists will communicate regularly with the patient’s primary care provider and other health care team
members as appropriate
• Describe assessment
• Describe and rationalize recommendations for medication changes
• Recommendations for follow-up
Medications Recommendations
⮚ MTM pharmacists may make recommendations in several ways:
• Directly to the patient
- Over-the-counter changes, general adherence tips, managing side effects
• Through the prescriber
- Changes in prescription medications
• Directly to the patient under collaborative practice agreements
- Allows pharmacists to make adjustments to prescription medications via protocol
Why is medication therapy management needed?
Medication-related problems and medication mismanagement are a massive public health problem in the United
States. Experts estimate that 1.5 million preventable adverse events occur each year that results in $177 billion
in injury and death.
Where is the medication therapy management provided?
Pharmacists provide medication therapy management services in all care settings in which patients take
medications. While pharmacists in different settings may provide different types of medication therapy
management services, the goal of all pharmacists providing medication therapy management is to make sure

3. that the medication is right for the patient and his or her health conditions and that the best possible outcomes
from treatment are achieved.
Who can benefit from medication therapy management?
Anyone who uses prescription medications, non-prescription medications, herbals, or other dietary supplements
may potentially benefit from medication therapy management services. People who may benefit the most
include those who use several medications, those who have several health conditions, those who have questions
or problems with their medications, those who are taking medications that require close monitoring, those who
have been hospitalized, and those who obtain their medications from more than one pharmacy.
Examples of Medication Management Services
Medication Therapy Reviews
The medication therapy review 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.
Pharmacotherapy Consults
A pharmacotherapy consult incorporates the pharmacist’s expertise in achieving desired therapeutic goals for
patients by promoting safe, appropriate, and cost-effective use of medications. Patients requiring
pharmacotherapy consults may have a single or multiple complex medical conditions that require medication
therapy to effectively manage.
Disease management coach/support
Disease management principles involve coordinated healthcare interventions for diseases in which patients must
assume some responsibility for their care. Pharmacists providing these medication therapy management services
address drug and non-drug therapy, as well as lifestyle modifications associated with these diseases integrate the
patient into programs that empower them to manage their disease and medications, and thereby reduce
healthcare costs and improve quality of life of patients.
Pharmacogenomics Applications

4. In various patient care settings from hospitals to community pharmacies, pharmacists are comparing
patient-specific treatments based on genetic markers, predicting patients’ response to therapy, dosing
medications based on genetic test results, predicting which patients will experience an adverse reaction to
selected therapies, and making informed recommendations to prescribers on the best treatments for that
individual patient that maximize effectiveness while minimizing risk.
Anticoagulation Management
Pharmacists providing anticoagulation management provide diverse services to patients who are taking oral
blood-thinning agents. Warfarin, the most prescribed oral medication agent for this purpose, must be
continuously monitored and managed to ensure patient safety and minimize risk. Pharmacists work with
educating many different types of patients on these therapies such as those with atrial fibrillation and at high
risk for stroke on the importance of oral anticoagulation adherence and attaining routine blood tests.
Medication Safety Surveillance
Pharmacists provide medication therapy management through medication safety surveillance programs, where
they serve an important role in the prevention of medication errors and adverse events. Improving the safety of
the medication use system as a whole is critical to achieving optimum therapeutic outcomes for individual
patients. From medication error and adverse event reporting to the collection of data and identification of
medication safety on an expanded scale, pharmacists are breaking new ground in ensuring medication-related
safety.
Health, Wellness, Public Health
Pharmacists provide a wide range of health, wellness, and public health services to improve care for individual
patients in the communities they serve. Examples of services include screening programs for common disease
states (e.ge. asthma, diabetes cardiovascular disease) nutritional planning, weight loss, smoking cessation
counseling.
Immunization
Pharmacists provide valuable immunization services and information for patients to improve vaccination rates
for vaccine-preventable illnesses. Pharmacists provide immunization medication management services through
the identification of patients based on disease states and medication therapies that could potentially benefit from
receiving various vaccines and by directly immunizing those patients or providing education on the benefits and
importance of vaccinations for preventable illness.
Other Clinical Services
As pharmacist-provided medication therapy management services continue to evolve, pharmacists' roles
continue to expand into new and emerging areas. These diverse clinical services all focus on optimizing
medication outcomes for the individual patient. Examples of other clinical services in medication therapy
management include employee health services & screening, travel medicine, nuclear pharmacy, veterinary
pharmacy, nutrition, and many others.