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In Module 3, the MTM pharmacist collected patient information from a patient interview and a variety of other sources. This information will be used to decide a course of action, or "Therapeutic Action Plan," and to communicate the plan to the patient and healthcare providers. In addition to documenting the plan, follow-up is a key component to ensure that the desired outcomes are met or modifications can be made to the plan as necessary. 

Most MTM formats focus on the development of 2 key documents for the patient:

1. Personal medication list (PML)
2. Medication Action Plan (MAP)

CREATING A PERSONAL MEDICATION LIST (PML)

This document is known by several names, including Patient-Centered Medical Record (PMR), Patient-Centered Medication List, and Personal Medication List (PML). Its goal is to provide a user-friendly reference of all of the patient's current medications, to help patients clearly understand why and how to take their medications. 

The PML is different from the types of documents that most pharmacies are currently able to provide for the patient. Due to limitations of existing computer systems, most pharmacists are only able to print out transaction records and standard drug information handouts based on the package insert. The latter are often long, unwieldy documents that do not offer patient-specific information in an understandable format and are likely to be ignored by the patient. In most pharmacy settings, a personalized document that presents this information in a simple, individualized format would need to be generated through the MTM process.

A number of sample templates are available for generating an electronic PML. No one template is suitable for every pharmacy practice setting. A pharmacy chain or clinic may have its own template, or a pharmacist conducting MTM may create or adapt an existing document. If the pharmacist is working through a third-party service such as Outcomes MTM, specific templates may be provided. Some templates are proprietary and cannot be widely shared electronically across multiple platforms.

Pros and Cons of Existing PML Templates

Some of the commonly used PML templates have drawbacks, either by providing too much or too little information. The template provided by the Centers for Medicare and Medicaid Services (CMS) in its Standardized MTM Format, is shown in Figure 1.¹ This basic template provides key information needed in the PML, but lacks flexibility.

Figure 1. CMS Recommended Format for the Personal Medication List¹

In other examples, the PML may contain too much information. Some of these forms are generated by contracted MTM organizations, or even in discharge summaries patients receive after hospitalization. If the instructions for the patient are buried within an 8-page document filled with other instructions and fine print, it is likely to be ignored by the patient. 

A drawback of many PML formats used today is that they divide the Action Plan and the Personal Medication List into two separate documents. An alternative approach may be to develop one document that provides a brief review of current medications and also indicates any changes or actions that are decided during MTM. This way, patients will have a record of their existing medications and actionable items relating to those medications all in one place. A suggested template that may be adapted by the pharmacist is shown in Figure 2. 

Figure 2. Sample PML With Actionable Items

Ideally, the PML format should be flexible enough to fit the patient's primary needs. For example, type size may be increased for person with visual impairments. Some patients find it useful to be able to see the drug listing organized by indication (e.g., "On top are the medications I take for my heart condition"). Many people like to have the PML printed to organize the medications by the time of day they're taken. Having a grouping for morning, afternoon, and evening can help the person see at a glance what they'll need to be doing to prepare for and take medications correctly. Figure 3 summarizes the goals and elements of the PML.

Figure 3. Patient-Centered Medication List (PML)

HOW DO PATIENTS USE THE PML? WHAT IS REALISTIC?

To be effective, MTM documents must be realistic with regard to how the patient is willing and able to use them. Ideally, the goal is to develop documents and tools that allow patients to manage their health conditions with less effort. 

Documentation steps suggested by CMS may not be completely realistic. CMS documents suggest that a patient on Medicare Part D who participates in MTM be requested to carry out the steps listed below, but this probably cannot be expected from most patients.

CMS directives to MTM patients for updating the PML:¹

• Have your action plan and medication list with you when you talk with your doctors, pharmacists, and other health care providers. 
• Ask your doctors, pharmacists, and other healthcare providers to update them at every visit. 
• Take your medication list with you if you go to the hospital or emergency room. 
• Give a copy of the action plan and medication list to your family or caregivers.
• Use blank rows to add new medications. Then fill in the dates you started using them. 
• Cross out medications when you no longer use them. Then write the date and why you stopped using them. 

CMS directives to MTM patients regarding the Medication Action Plan:¹

1. Read "What we talked about" (on the Action Plan)
2. Take the steps in the "What I need to do" boxes
3. Fill in "What I did and when I did it"
4. Fill in "My follow-up plan and Questions I want to ask"

The latter list might appear to be reasonable, but can become unrealistic for patients who have multiple chronic conditions. Patients can quickly become confused when keeping up with blood tests, radiologic assessments, physician appointments and/or therapy appointments, and complex daily medication regimens. In many situations, patients will require family or caregiver support to effectively manage their medications. 

When developing the PML, the pharmacist conducting MTM should set realistic expectations and be cognizant of individual differences. Starting out with a few basic steps that can be integrated successfully is more effective than giving a patient a long list that will be put in a drawer and forgotten.

OVERVIEW OF THE THERAPEUTIC ACTION PLAN

The Medication Action Plan (MAP) is the plan developed through MTM that helps patients to resolve problems related to their medical care and/or to meet specific health goals. This plan can also encompass nonpharmacologic aspects of healthcare such as screening assessments, lifestyle, and behavioral issues. The MAP (also called Therapeutic Action Plan in some settings) is a key part of the pharmacist's strategy in MTM.

The MAP will be different for every patient, but some common elements should be considered during the patient interview. These are summarized in Table 1. This checklist, modified for the patient's specific health conditions, can serve as a basis for identifying medication-related problems, adherence problems, and potential health safety issues or behavioral risks.

SUMMARIZING THE MAP FOR THE PATIENT

The Therapeutic Action Plan will list steps that are recommended for implementation by the patient, a caregiver, or the physician. The physician may need to approve or review some changes before an Action Plan can be distributed to the patient. The Goals of the MAP can be explained to the patient using the elements in Figure 4.

Figure 4. Summarizing MAP Goals to the Patient

The MAP should be provided to the patient in writing, either as a separate document or integrated with the PML. Newer formats may allow patients to access and manage this information via "apps" on their smartphones or other electronic devices. These may include symptom diaries and enable patients to log medication dosage or adverse effects (but patients should be aware of privacy issues when using such apps.) Some MTM services can be set up to print the PML and MAP in multiple formats, such as an abbreviated wallet card version plus a standard sized sheet to post on a bulletin board or refrigerator. 

To simplify the goals for the patient, many Therapeutic Action Plans present the information to the patient in the following format: 

• What we talked about (during MTM)
• What I need to do
• What I did, when I did it

A sample of the CMS action plan (called the Medication Action Plan, or MAP) format is shown in Figure 5. More information can be found in the Medicare Part D Medication Therapy Management Program Standardized Format Form CMS-10396 (08/17), available online.

Figure 5. CMS Medication-Related Action Plan Template

THE MAP: WHAT'S REALISTIC?

A potential pitfall of the MAP is identifying too many changes and attempting to implement all of them at once. It's important to identify and document all of the issues during an MTM session. Then, they should be prioritized according to importance. A plan that is too lengthy or complicated is apt to fail. Instead, start with a goal of 2 or 3 items that can be implemented realistically, and then follow up on their progress before proceeding down the list.

Levels of priority may be determined by the circumstances. Some information uncovered in MTM may warrant an immediate phone call to the physician's office if it involves an aspect of patient safety or medication efficacy. These issues are clearly at the top of the priority list. 

Keep in mind that the best therapy for the patient is often the one the patient will take. This issue is covered in more detail in Module 7, Adherence. This also applies to whether the patient can afford the medications. Changing to a more affordable drug is a better alternative if a patient is likely to miss or stretch out doses due to cost.

FOLLOWING UP ON THE MAP

MTM should not be a one-time process. Continuity of care is especially needed for the management of chronic diseases that affect much of the population. Giving the person "homework" that helps to engage him or her in a positive way may encourage that person to come back for a follow-up visit. A person who feels that he or she has accomplished a goal will want to share this news and start on the next steps. However, if the patient is not engaged and does not believe that he or she has gained any benefit from MTM, that person is unlikely to return for a follow-up session. 

In order to prepare for successful follow-up, the pharmacist should:

• Set achievable goals for the patient to accomplish before the next follow-up
• Communicate clearly to the patient the plan and time of the follow-up appointment
• Keep clear, updated records
• Communicate/collaborate with physician/healthcare providers when appropriate (see Module 5, Communication Essentials)

DOCUMENTATION STEPS

Documentation is essential in MTM. In addition to providing information for the patient, records of the MTM process must be generated for the pharmacy and for other healthcare providers. A common error in medical record keeping is a failure to document the absence of a particular sign or symptom, such as a medication side effect. This has the potential to create confusion or repetition for future healthcare providers, who might think this issue was overlooked rather than simply absent. When a normal result is not documented, screening steps or lab tests may be repeated unnecessarily. There is an old adage, "If it's not documented, it didn't happen." In the future, as MTM reimbursement programs become further developed, documentation will be the basis of payment, regardless of whether the assessment findings were normal or unchanged.

MTM encounters are often documented using software provided by the pharmacy. In an ideal world, this documentation would automatically be transferred to the patient's EMR. In many settings this technology is not available, so communication with the provider is often done via fax. There are also initiatives to develop secure email systems so MTM documents can be sent directly to providers electronically.

With the move toward provider status for pharmacists, documentation styles should be in alignment with national standards for other healthcare providers. Typically, the requirements of CMS are also integrated into the requirements of insurance payers as well. Thus, it is important for MTM providers to be aware of current documentation requirements and changes. Some valuable resources include:

• CMS.gov
• Pharmacy Quality Alliance (pqaalliance.org)
• Professional organizations such as APhA, ASCP, and ASHP

Attention to appropriate documentation is a high priority in developing a successful MTM program, and the MAP is where many outcomes measures are developed and generated. 

SUMMARY AND CONCLUSIONS

The PML and the MAP are standard documents that are part of most MTM systems. Generating printed lists with a lot of information and handing them over to the patient is unlikely to achieve the overall goals of MTM. The information should be presented in a way that is clear, concise, and easily used by the patient. Recommended steps need to be practical and manageable. Sometimes, steps should be broken down into several phases to avoid trying to make too many changes at one time. Follow-up with healthcare providers and documentation of the MTM session is vital to the process of health information exchange among providers. The next section, Module 5, covers Communication Essentials: which includes patient communication and interviewing tips, as well as successful communication with healthcare providers. 

References

1. Centers for Medicare & Medicaid Services (CMS). Medicare Part D Medication Therapy Management Program Standardized Format. Form CMS-10396 (08/17). Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html
2. Stebbins MR, Cutler TW, Parker PL. Assessment of Therapy and Medication Therapy Management. In: Alldredge BK, Corelli RL, Ernst ME, et al. Koda-Kimble and Youngs Applied Therapeutics: The Clinical Use of Drugs. 10th Ed. Baltimore: Wolters Kluwer/Lippincott Williams & Wilkins; 2013.
3. American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. 2008. 
4. Patient-Centered Primary Care Collaborative. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Resource Guide, 2nd ed. June 2012. Available at: http://www.pcpcc.org/sites/default/files/media/medmanagement.pdf. 

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