Comprehensive Medication Management: Landmark Study's Findings and Future Directions

ACCP and the ACCP Foundation funded the Comprehensive Medication Management (CMM) in Primary Care Study, a multi-year effort launched in 2016. Drs. Mary Roth McClurg and Todd Sorensen, primary investigators from the study’s research team, presented results and current applications during the 2020 Annual Meeting Town Hall. An executive summary and list of study deliverables have been released and are available for download.

CMM is a patient-centered approach to optimizing medication use and improving health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers. Pockets of strong evidence to support the positive impact of CMM on patient outcomes, health care costs, and patient and clinician experience exist. However, lack of fidelity in the implementation, magnitude, and precision of CMM can result in inconsistent clinical impact.^1,2 Therefore, the overarching goal of the CMM in Primary Care Study was to establish the necessary foundations to enable the replication and scale of CMM services in primary care. The study had two general areas of focus: (1) implementation – studying how to effectively and efficiently implement CMM with fidelity and (2) impact – measuring the impact of CMM on clinical and economic outcomes.

The implementation arm of the study established a shared philosophy of practice for CMM, explicitly defined and operationalized the intervention, and framed the core foundational elements of managing CMM practice in primary care. The study team identified and engaged with 35 mature CMM practices with embedded clinical pharmacists across the country to identify best practices and achieve these aims. In July 2018, The Patient Care Process for Delivering CMM was released.³ This seminal publication explicitly defined CMM as an intervention and clearly articulated CMM’s philosophy of practice, five essential functions, operational definitions, and a process for practitioner assessment of fidelity. Establishing a clear definition of CMM as an intervention served as a critical foundation to ensure a standardized approach to medication optimization in team-based care.

This work has produced numerous publications that detail CMM fidelity assessment,⁴ the philosophy of practice for CMM,⁵ and practice management assessment.⁶ A comprehensive list of the study’s deliverables to date can be found here. An interactive website scheduled for release in 2021 will serve as the culmination of the implementation work and will include a stepwise system designed to facilitate initial CMM service development, initiation, and evaluation as well as ongoing service improvement for mature CMM practices. The system will include important guidance resources as well as two dynamic tools: one for assessing fidelity to the CMM patient care process and another for assessing practice management supports. These tools will allow users to input information and obtain reports on their own practices.

A secondary goal of the study was to evaluate the impact of CMM on all components of the Quadruple Aim: clinical quality metrics, health care costs, the patient experience, and the clinician experience. These evaluations were limited by the retrospective design required for the implementation arm of the study. Compared with both internal and external controls, the CMM intervention demonstrated a significant positive impact on clinical quality metrics, including evidence-based prescribing for heart failure, diabetes, and cardiovascular disease. Because of the study’s lack of access to claims data, the study team was unable to complete a robust evaluation of the impact of CMM on costs, though decision analytic modeling supported an overall reduction in cost. CMM positively affected both the patient experience and the clinician experience.^7,8 Patient responses indicated a high degree of satisfaction, value, and trust associated with CMM.⁷ Primary care providers (PCPs) identified the clinical pharmacist’s provision of CMM as a collaborative partner with an added skill set.⁸ A positive relationship between CMM and PCP stressors and burnout was observed and attributed to multiple factors, including decreased workload, decreased mental exhaustion, enhanced professional learning, and increased patient access. The findings of the impact arm of the study confirmed the results observed in smaller studies and added strength to prior findings due to the number of clinics and diversity of organizations and practitioners represented. Overall, the study adds substantial evidence supporting the value proposition for CMM.

Although the implementation and outcomes research described was conducted within the primary care environment, products of the work can be applied to aid implementation or optimization of CMM services within varied practice settings. The study team recommends future directions focused on incorporation of the CMM process of care into professional education and training, adoption of CMM implementation supports and consistent terminology in clinical pharmacy practice, and research focused on fidelity assessment to support outcomes and return-on-investment evaluation at the local/single-payer level.

ACCP’s 2020 Strategic Plan includes a continued focus on implementation of CMM as a fundamental mechanism for achieving medication optimization. Specific initiatives include support for the inclusion of CMM as the core process of care in professional degree curricula and PGY1 residency training, promotion of CMM implementation resources, development of new resources to facilitate implementation of CMM across the care continuum, communication and dissemination of the value of clinical pharmacists in achieving medication optimization, and achievement of CMM value recognition by a national payer. Much of this work will be carried out through ongoing intra- and interprofessional collaborations, including the College’s work with the Get the Medications Right Institute. In addition, ACCP and the ACCP Foundation will continue to seek opportunities for future funding of medication optimization research.

ACCP Executive Director Michael Maddux commented on the study’s success. “ACCP and the Foundation knew they were funding a study seeking to better define contemporary clinical pharmacy practice and enhance the consistency and effectiveness of its implementation. This comprehensive, foundational work has achieved those goals, setting the stage for future advancements in clinical practice, education, and training. Although probably not surprising to many clinicians, the data demonstrating positive effects on physician work-life and the patient experience were an unexpected bonus. Indeed, this study provides new and important data that articulate exactly how and why clinical pharmacists contribute so positively to team-based practice – findings that will substantially enhance the College’s future advocacy efforts with policy makers, other health professionals, and payers.”

References

1. GTMRx Institute. The Outcomes of Implementing and Integrating Comprehensive Medication Management in Team-Based Care: A Review of the Evidence on Quality, Access and Costs, June 2020. Available at https://gtmr.org/wp-content/uploads/2020/07/GTMR-evidence-document-07312020-1.pdf. Accessed November 11, 2020.
2. Viswanathan M, Kahwati LC, Golin CE, Blalock SJ, Coker-Schwimmer E, Posey R, Lohr KN. Medication therapy management interventions in outpatient settings: a systematic review and meta-analysis. JAMA Intern Med 2015;175:76-87. Available at https://doi.org/10.1001/jamainternmed.2014.5841. Accessed November 11, 2020.
3. CMM in Primary Care Research Team. The Patient Care Process for Delivering Comprehensive Medication Management (CMM): Optimizing Medication Use in Patient-Centered, Team-Based Care Settings. July 2018. Available at www.accp.com/docs/positions/misc/CMM_Care_Process.pdf. Accessed November 11, 2020.
4. Livet M, Blanchard C, Frail C, Sorensen T, McClurg MR. Ensuring effective implementation: a fidelity assessment system for CMM. J Am Coll Clin Pharm 2020;3:57-67.
5. Pestka DL, Sorge LA, McClurg MR, Sorensen TD. The philosophy of practice for CMM: evaluating its meaning and application by practitioners. Pharmacotherapy 2018;38:69-79.
6. Pestka DL, Frail CK, Sorge LA, Funk KA, Janke KK, Roth McClurg MT, Sorensen TD. Development of the comprehensive medication management practice management assessment tool: a resource to assess and prioritize areas for practice improvement. J Am Coll Clin Pharm 2019. Available at https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1002/jac5.1182. Accessed November 11, 2020.
7. Blanchard C, Xu J, Roth McClurg M, Livet M. Reliability and validity of a patient responsiveness survey for comprehensive medication management. J Am Coll Clin Pharm 2018. Manuscript publication pending.
8. Funk KA, Pestka DL, Roth McClurg MT, Carroll JK, Sorensen TD. Primary care providers believe that comprehensive medication management improves their work-life. J Am Board Fam Med 2019;32:462-73.