Medication Therapy Management in a Memory Care Clinic A Cornerstone for Care JoanThralow OTRL Dean S

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Medication Therapy Management in a Memory Care
Clinic - A Cornerstone for Care JoanThralow
OTR/LDean Schmiedt Pharm. D.Memory Care Clinic
St. Cloud, Minnesota
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MEMORY CARE CLINIC

• Began in 2004- Several agencies identified the
  need for early diagnosis
• Central Minnesota Council on Aging
• Alzheimers Association
• St. Benedicts Center
• Mid-Minnesota Clinic/Centra Care
• Health Partners
• Stearns, Benton, Sherburne, Wright Counties
• St Cloud Area Faith in Action

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The Importance of Early Identification

• GOAL
• Increase rates of diagnosis and treatment at
  earlier stages to enhance quality of care and
  caregiver support

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Memory Disorders

• Dementia the loss of cognitive function
  (cognition) due to changes in the brain caused by
  disease or trauma.
• Dementia is not a diagnosis.
• Cognition is the act or process of thinking,
  perceiving, and learning
• Cognitive functions that may be affected by
  dementia include the following

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Memory Disorders (cont.)

• Irreversible Dementia
• Alzheimers Disease
• Vascular Dementia
• Lewy Body Dementia
• Parkinsons disease
• Huntingtons Disease
• Frontotemporal Dementia
• AIDS Dementia Complex

• Reversible Dementia
• Major Depression
• Delirium
• Metabolic Disorder
• Infections
• Brain tumor and subdural hematoma

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MISSION
The Memory Care Clinic is a community partnership
committed to enhancing the lives of persons
affected by memory disorders through excellence
in care, treatment, support, and education.
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• Memory Care Clinic
• recent name change
• formerly
• Memory Disorders Clinic

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COLLABORATIVE CARE IN THE MEMORY CARE CLINIC
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MEMORY DISORDERS TEAM

• Medical Director
• Nurse Practitioner
• Social Worker
• Occupational Therapist
• Doctor of Pharmacology
• Office Manager
• Executive Director
• Accountant

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Memory Care Clinics Role in the Community

• Assess
• Assist
• Learn
• Teach

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Memory Care Clinic

• Partnership of many community agencies working to
  enhance the lives of persons affected by memory
  disorders and those who care for them.
• Three cornered assessment process

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The Memory Care Clinic assesses

• 3 Cornerstones for Assessment
• Medical assessment.
• Functional assessment.
• Psycho-social assessment.
• Also Assess the Caregiver
• Burden of the care giving.
• Social/emotional capability for caregiving.
• Knowledge about the condition of the patient.

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Memory Care Clinic Staff Assist

• The person with memory loss
• Recommendations resources
• The caregiver of the person with memory loss
• Support education, support groups, coaching
• Information referral
• The primary care physician
• Information recommendations

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Memory Care Clinic

• Provides
• Comprehensive assessment
• Collaboration in care with the patients primary
  physician
• Recommendations for treatment
• Education and caregiver support
• Community agency referral
• Case management

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MCC has a commitment to LEARN

• Regular review of research literature
• Opportunities for professional education
• Analysis of data gathered through our work.

MCC has a commitment to TEACH

• In-service education for health care
  professionals
• Internships for students in health professions
• Sharing our knowledge with caregivers

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Memory Care Clinic

• Is a Collaborative Care Model for Clients with
  Dementia and their families, serving a broad
  community.
• Partners with primary care physicians.
• Provides assessment, recommendations for
  treatment, education and support for care givers.
• Follow-up includes Education, Support Groups
  Caregiver Coaching
• Is a cooperative community project.

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THE MEMORY CARE CLINIC

• Accepts referrals from family members,
  physicians, social service community agencies.
• A few individuals self refer.
• Do not need a physician order to come to the
  clinic - primary care physician support helps
• Assessment is completed in two 2-hour
  appointments.
• Follow-up after Assessment is very important.

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Funding the MCC

• Start-up funding was provided by
• MN Dept. of Human Services CSSD Grants.
• MN Board on Aging Alzheimers Demo. Grants.
• Medicare, MA, health insurance fund part of
  Assessment costs.
• Older Americans Act Title III-E covers part of
  Caregiver support services.
• Board of Directors has fiduciary responsibility.
  
• Is now a 501(c)(3) Charitable Organization.
• Private donations and other grants.

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2009 Funding Sources for The Memory Care Clinic

• Government Grants 35
• Insurance Co-pays 18
• In-Kind Contributions 22
• Donations Private Grants 24
• Other Income 1

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Why involve a pharmacist?

• Frequent medication related questions from
  caregivers and patients.
• Clinic survey identified that approximately 1 out
  of 3 patients or their caregivers desired more
  assistance with medication issues.
• Perception of unidentified medication related
  issues.
• Medication Therapy Management (MTM) has been
  found to be valuable
• Insurers may cover MTM under Medicare D and by
  the state for MA patients.

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Pharmacists

• Jody Ellingson, Pharm. D.
• Dean Schmiedt, Pharm. D.
• Our background is long term care consulting,
  providing medication therapy reviews for a large
  number of nursing facilities in central
  Minnesota.
• We have no role in dispensing medications to
  patients.

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Barriers

• The only true barrier to implementation has been
  funding and insurance reimbursement for the
  program.
• The clinic received assistance with funding for
  one year via a CS/SD grant.

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Memory Care Clinic Staff

• Have been extremely open, supportive, and helpful
  with our integration into the clinic.
• We highly value their insights on patients and
  caregivers medication related issues.
• Clinic staff have been helpful in encouraging
  pharmacist reviews for patients felt to be in
  need of MTM.

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Integration / Orientation Process

• Orientation to clinics processes and
  documentation requirements
• Federal and State Provider numbers
• Credentialing with insurance companies
• Followed patients/caregivers through the clinics
  assessment process.
• Developed pharmacist assessment documentation
  process.
• Orientation for the clinic staff of our proposed
  assessment process and services.

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Pharmacist Integration Into Assessment Process

• Discussion with staff about what approaches would
  work best?
• Early, late, or after the assessment process?
• Targeted or referred patients or all?
• Paper chart review vs direct meeting with patient
  and/or caregiver.
• We chose to be flexible and provide pharmacist
  services on an as desired/ as needed basis.

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Scheduling

• Decision was made to be flexible to see what
  worked best.
• Best model for efficiency and cost-effectiveness.
• We have a lot of flexibility in our scheduling.

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Our Goals This First Year

• Clinic integration
• Develop pharmacist assessment process
• Provide both chart and in-person MTM reviews.
• Identify the types of issues identified during
  MTM review and their significance.
• Document pharmacist findings in clinic chart,
  letter to primary physician, and to the
  patient/caregiver.
• Be an educational resource to caregivers,
  patients, and clinic staff.

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Caregiver and Patient Education/Support

• Presentations were made to the clinics
  Caregivers Support Group twice.
• Well attended, primarily caregivers.
• Lots and lots of questions!
• Many caregivers are well read on medications used
  for memory loss.
• We emphasize realistic expectations from
  medications such as cognitive enhancing drugs.

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Caregiver Support Group Interests

• High level of interest and questions relating to
• Medications that may cause memory impairment.
• Cognitive enhancing medications
• When is it appropriate to terminate cognitive
  enhancing medications?
• New or experimental treatments.
• Non-traditional / alternative treatments such as
  herbal, nutritional, or vitamin products.
• Medication adverse reactions
• Behavior, mood, or sleep inducing medications.

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Assessment ProcessIn-Person Review
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In-Person Assessment Process

• Comprehensive review covering all aspects of
  medication use.
• MTM reviews not limited to memory loss issues.
• Caregivers and patients have been very clearthey
  want a total medication review.
• Initially, they may have one or two very specific
  primary questions or issues.
• Often more issues are identified.

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Assessment ProcessHistory Review

• Review past medical history, medication lists,
  labs, cognitive testing, plus any relevant
  assessments or background information available
  in the clinic chart.
• Done prior to visit.
• Provides insight about the patient
• Identifies potential issues for review

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Examples of Common Medication Related Problems

• Appropriate Indication
• Medication Effectiveness
• Dose
• Adverse Effects
• Drug Interactions including with food
• Compliance/Adherence/Administration
• Potentially Unnecessary or Inappropriate
  medication
• Potentially untreated or under-treated
  conditions.
• Undisclosed medications, herbals, or relevant
  nutritional products.
• Medication Errors
• Lab Monitoring/Assessment

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Assessment ProcessMedications

• Complete list of medications from
  chart/historical information is compared with the
  caregivers or patients list.
• Frequently, medication regimens have changed from
  information provided to the clinic.
• Many patients are taking undisclosed
  medicationsincluding prescription, OTC, herbal
  and nutritional supplements.
• Eight of eighteen (44) patients seen in-person
  had undisclosed medications, herbals, vitamins,
  or supplements.

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Assessment Process Caregiver or Patient Concerns

• We always inquire early in the process if the
  caregiver or patient has any specific concerns?
• Most common concerns
• Are all these medications needed?
• Could any medications cause memory loss?
• Do these medications work together or could they
  interfere with each other?
• Specific adverse effect related questions

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Areas for review/assessment

• Does the caregiver/patient
• Understand the indications and goals for each
  medication?
• Understand medication directions
• Take medications properly
• Indicate any issues with adherence or compliance
• Express concerns over medication effectiveness.

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Adverse Reaction Review

• Potential adverse reactions specifically
  reviewed
• Unintended weight loss or gain.
• Dizziness
• Confusion/Memory Loss
• Recent or multiple falls
• Sleeping issues
• Abnormal body movements or tremors
• Urinary incontinence or bowel issues
• GI symptoms such as unusual or persistent nausea,
  heartburn, or vomiting
• Behavioral or Mood issues
• Other

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Ability to pay for medications

• We check if there are any issues relating to
  paying for medications.
• Medicare D has reduced payment issues.

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Reassurance

• Caregivers and patients often desire reassurance
  that
• All medications are necessary.
• Medications go together.
• Medications are not the cause of memory loss or
  other significant adverse effects.
• They are doing the right thing with medications.

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Documentation Process

• Post Visit Documentation for In-Person Includes
• Clinic chart documentation
• Letter with recommendations to physician (s)
• Letter with recommendations to patient / caregiver

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Patients Oct 08 June 09

• Grant goal, initially, was 24 patients / reviews
• We did not see patients until October 08.
• Actual 27 patients/reviews in 9 months
• 9 chart reviews
• 18 in person reviews.
• Could have been higher
• Weather
• Cancellations
• Insurance refusal to cover

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Reason Given At Start of Visit for Seeing
Pharmacist (N18)
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Chart Reviews

• Chart reviews were done on 9 patients.
• Chart reviews were requested by clinic staff if
  they were concerned about potential medication
  related issues.

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Chart Review Process

• Complete review of relevant medication related
  material.
• Often resulted in discussion with staff that
  requested review.
• Review and recommendations documented in the
  chart for assessment team review.

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Chart Review vs. In-Person

• In-person visits result in significantly higher
  issue identification.

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Chart Paper Patient Review

• Chart Paper Patient Review ( 9 patients)
• 32 issues/recommendations
• Average per patient 3.22
• Range 2 to 5
• Potentially Significant Issues 13
• Average per patient 1.44
• Insignificant per patient 1.78
• Range 0 to 2
• Potential Issues Involving Memory 14
• Average per patient 1.56
• Average per patient sig 0.67

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In-Person

• In-person review ( 18 patients)
• 115 issues/recommendations
• Average per patient 6.39
• Range 1 to 10
• Potential Issues Involving Memory 33
• Average per patient involving memory 1.83
• Average per patient significant/memory 1.28
• Potentially Significant Issues 50
• Average per patient 2.78
• Range 0 to 6

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Issues From In-Person
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Issues From In-Person
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Issues From Chart Review
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Examples Significant Potential Adverse Drug
Reactions

• Amitriptyline for fibromyalgia
• c/o dry mouth, constipation, dizziness upon
  arising. Dizziness significantly interfering with
  the quality of her life. Patient states she
  becomes dizzy to the point of almost blacking out
  at least 5 to 10 times upon standing up while at
  church.
• Patient states his blood pressure control is not
  good.
• Takes Effexor for depression
• Effexor may be associated with increased blood
  pressure especially at higher doses. Using
  337.5mg daily.

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Compliance

• Caregiver
• Caregiver presented appearing sedated, slow to
  find words, slurred speech, and was slow to
  respond.
• Indicated she took four Vicodin shortly before
  driving her husband to the clinic.
• Stated she had extreme anxiety during the night,
  taking up to three Klonopin at one time which
  differs from her prescription of one tablet 3 to
  4 x daily.
• Of note, she was taking 18.25 mg of Ambien and
  trazadone 200mg every night

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Compliance

• Patient lives alone and sets up her own
  medications. Stated she has no problems setting
  up her meds. Indicated a little trouble
  remembering taking her vitamins.
• Has a form she checks off when she sets up her
  meds. After going to get a glass of water to take
  her meds. Cannot always remember if the check
  means she took med.
• Orders for Tylenol with Codeine No. 3 Three tabs
  4 X day and Vicodin 5/500 one or two tabs every 4
  to 6 hours as needed. States she NEVER takes more
  than the maximum amount allowed of either pain
  med.
• Discussion indicated she was likely using both T3
  and Vicodin at or near their maximum daily doses.
  This could have contributed to her memory
  impairment plus puts her at risk of excessive
  acetaminophen intake. Her T-3 alone put her at
  the daily acetaminophen maximum of 4000mg daily.
• Taking her Actonel with food and other
  medications at times. Actonel must be taken on an
  empty stomach first thing in the morning with
  nothing but plain water before, with, or for ½
  hour afterward.

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Potential Indication w/o Treatment

• Historical information in patients chart showed
  a past diagnosis of B-12 deficiency. No B-12 was
  noted on her medication list or evidence of a
  B-12 level.
• B-12 deficiency can cause memory loss.
• During our visit, she stated she had been on
  Vitamin B-12 in the past. She did not know why
  she wasnt receiving it now and had not had any
  for many years.
• Recommendation made to check B-12 level and
  consider B-12 treatment, if indicated.

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Compliance / Dose

• Reason for requesting to see pharmacist
• Why was there a recall for isosorbide
  mononitrate?
• More to it than the initial questionhis real
  question and reason was how long do I have to be
  off isosorbide mononitrate before I can take
  Viagra?
• He had been reducing as isosorbide mononitrate
  dose without his physicians knowledge.

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Potentially Significant Drug Interaction

• Patient taking gemfibrozil and verapamil with
  simvastatin 80mg daily.
• Recommended maximum daily simvastatin doses when
  on
• Verapamil is 20mg daily
• Gemfibrozil is 10mg daily
• Lower simvastatin dose is recommended due to
  significantly increased risk of myopathy and
  rhabdomyolysis ( condition where muscle cells
  break down that can lead to muscle breakdown and
  kidney failure)

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Lessons Learned

• Pharmacist MTM and educational services are
  beneficial.
• Potentially significant medication related issues
  are common.
• In-Person reviews yield more potential and
  significant issues than chart reviews.
• Caregivers and patients want complete medication
  regimen reviews covering all medications and
  aspects of medication use.

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Lessons Learned

• Caregivers and patients have many medication
  related questions/issues they want to discuss.
• Reimbursement for pharmacist MTM services is a
  challenging issue.
• Scheduling flexibility is necessary for both the
  clinic and pharmacists.
• Documentation time is significant.

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What Would We Do Differently?

• The process in setting up MTM services worked
  well and no significant changes would be made.
• Contacting insurance companies prior to providing
  MTM services to see if they will cover MTM via
  the clinic.
• Consider expanding educational opportunities.
• Consider outcomes follow-up

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Sustainability

• We hope to increase the number of patients seen
  at the clinic.
• Sustainability is dependent on insurance
  coverage, private reimbursement or alternative
  funding sources.
• The as needed model allows for pharmacist
  availability without significant ongoing fixed
  costs to the clinic.
• Medicare D MTM insurance coverage is increasing.