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Multidisciplinary views toward pharmacist-delivered medication therapy management services in dialysis facilities Wendy M. Parker, Soo Min Jang, Julia D. Muzzy, and Katie E. Cardone

Abstract Objective: To determine views of staff of dialysis centers toward pharmacist-delivered medication therapy management (MTM) services. Design: Focus group study. Setting: Three private, nonprofit, outpatient dialysis facilities. Participants: Multidisciplinary dialysis staff. Intervention: Two focus group sessions were conducted using a semistructured interview guide. Main outcome measures: Views of staff toward MTM services at a dialysis center. Results: A total of 13 staff members of dialysis centers participated in the study. Participants included nurses, patient care technicians, a social worker, dietitian, and administrative personnel. Key themes included: the need for access to MTM services in dialysis facilities exists; services should include medication reconciliation and patient education; services should be proactive, consistent, individualized, and covered by insurance; and that pharmacists are uniquely suited to provide MTM services. Conclusion: Dialysis staff support the integration of MTM services in facilities. Further research is needed to identify barriers and opportunities in the implementation process, including patient perspectives. J Am Pharm Assoc. 2015;55:390–397. doi: 10.1331/JAPhA.2015.14168

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Wendy M. Parker, PhD, Assistant Professor of Sociology, Albany College of Pharmacy and Health Sciences, Albany, NY Soo Min Jang, PharmD, Consultant Pharmacist, San Diego, CA; at time of project completion, Student Pharmacist, Albany College of Pharmacy and Health Sciences, Albany, NY Julia D. Muzzy, PharmD, PGY1 Pharmacy Resident, Kaleida Health: Women & Children’s Hospital of Buffalo, Buffalo, NY; at time of project completion, Student Pharmacist, Albany College of Pharmacy and Health Sciences, Albany, NY Katie E. Cardone, PharmD, BCACP, FNKF, FASN, Associate Professor of Pharmacy Practice, Albany Nephrology Pharmacy Group, Albany College of Pharmacy and Health Sciences, Albany, NY Correspondence: Katie E. Cardone, PharmD, BCACP, FNKF, FASN, Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave., Albany, NY 12208; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Previous publication: Poster presentation in part at the National Kidney Foundation 2013 Spring Clinical Meeting, Orlando, FL, April 2–6, 2013 Received July 28, 2014. Accepted for publication March 2, 2015. Published online in advance of print June 12, 2015.

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atients with end-stage renal disease represent a highly complex, expensive patient group and qualify for Medicare benefits regardless of age.1,2 Although they comprise only 1.3% of total Medicare beneficiaries, their costs equate to 7.5% of Medicare spending.1 Currently, approximately 70% of dialysis patients are enrolled in Medicare Part D plans.1 Based on their medical complexities and medication burden, it is likely that nearly all dialysis patients would qualify for Medicaresponsored medication therapy management (MTM) services, which are intended for patients with multiple chronic conditions and taking multiple medications that exceed a specific cost threshold.3,4 The Medicare Part D MTM benefit is aimed at reducing clinical problems and could potentially lead to overall health care savings in this patient population. It is unknown what proportion of eligible dialysis patients participate in MTM programs or what level of interest exists nationally. However, in the general Medicare population, MTM services are underused, with only 12% of eligible Part D beneficiaries receiving such services.5 Many patients have little knowledge of MTM services, despite feeling that a medication review by a pharmacist would be beneficial.6 Studies on pharmacist-led interventions in the dialysis population have demonstrated beneficial effects on clinical, economic, and humanistic outcomes including

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reductions in medication-related problems, maintained quality of life, and reduced hospital stays.7–15 However, unlike dietitians and social workers, pharmacists are not mandated to be part of the care team in U.S. dialysis facilities by the Centers for Medicare & Medicaid Services’ (CMS) Conditions for Coverage for ESRD Facilities.16 Pharmacist integration within dialysis care teams has therefore been limited in the U.S. Recently, innovations encouraged by Affordable Care Act (ACA) legislation have led to the exploration of pharmacist-delivered MTM services within some dialysis facilities.17,18 These innovations are expected to improve care coordination and patient engagement with the health care team. In the general population, physician support for MTM services is important to gain patient acceptance.19–21 Although care within dialysis facilities is directed by a nephrologist, it involves many other health care team members (e.g., nurses, dialysis technicians, dietitians, social workers, and other support personnel). Therefore, multidisciplinary staff are likely to influence dialysis patient behaviors and attitudes.22 This care team also oversees and manages patient medication records. Hence, dialysis staff have a direct interest in the successful delivery of MTM services, yet their views have not been studied previously.

Objectives

Background:

The objectives of this study were to determine views of dialysis staff toward MTM services and identify desirable components of an MTM service for dialysis patients.

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Methods

Key Points

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Pharmacist-led interventions in dialysis have demonstrated improvements in clinical, economic, and humanistic outcomes. However, pharmacists’ services are not mandated in U.S. dialysis facilities by the Centers for Medicare & Medicaid Services’ (CMS) Conditions for Coverage for ESRD Facilities. As public policies increasingly incentivize quality improvement, there is growing interest in implementing medication therapy management (MTM) services within dialysis facilities. This study aimed to identify the views of dialysis personnel on MTM services provided to patients on dialysis.

Findings: ❚❚ ❚❚

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Participants were supportive of integration of MTM services within dialysis facilities. Dialysis staff identified the widespread need for access to MTM services among their patients. Desirable components included medication reconciliation and patient education. Pharmacists were identified as ideal providers of MTM services.

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Study design A qualitative, focus group study was conducted involving staff from three affiliated, nonprofit, private outpatient dialysis centers in upstate New York. Focus groups have long been used in market research and provide a well-validated method for obtaining qualitative data.23 For this study, focus groups were used to learn about broad dialysis staff perspectives as an initial step toward understanding implementation barriers related to MTM services. The study was exempted by the Institutional Review Board at the Albany College of Pharmacy and Health Sciences. Study setting The study facilities care primarily for in-center hemodialysis patients but also serve patients on peritoneal dialysis and home hemodialysis. Pharmacist faculty and student pharmacists have played evolving roles at these dialysis centers for several years but formalized MTM services were not widely implemented at these sites at the time of this study.

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Study participants and recruitment Multidisciplinary dialysis staff members from study sites were invited to participate. Nonmanagerial staff who were at least 18 years old and who spoke and understood English were included. Management staff were excluded to prevent potential bias in respondents’ answers. No interested staff member was excluded. Recruitment techniques included the use of flyers hung in staff break rooms and onsite recruitment by investigators. Participants were given refreshments during sessions and an incentive worth $30. Focus group procedures Two focus group sessions were held with staff from all three sites at one centrally located facility during nonwork hours. This facility was chosen as it is centrally located approximately halfway between the other two sites, facilitating staff attendance from all three facilities. A nonpharmacist, experienced facilitator unknown to participants conducted sessions using a semistructured interview guide (see the online Appendix for interview questions, available on JAPhA.org in the Supplemental Content section). Study objectives were explained at each session. The facilitator identified discussion points requiring elaboration, and used probing questions to confirm findings. Participants completed a questionnaire regarding basic demographic information. Sessions were audiorecorded and notes were taken by the facilitator and an assistant. Audiorecordings were professionally transcribed verbatim. Transcripts were proofread and edited by the facilitator for accuracy. A final report of findings included a qualitative thematic analysis and selected deidentified quotations. Data analysis Data were coded using inductive coding techniques for each group and then compared across groups to find common themes.24 Primary coding was completed by the facilitator, a trained analyst, and compared to coding done by other investigators. Descriptive statistics were used for questionnaire responses.

Results

Participant characteristics A total of 13 staff members participated in the two sessions, accounting for 14% of nonmanagerial staff at participating centers. Demographic information for study participants is provided in Table 1. Participants were representative of staff composition across the facilities. Nearly three-quarters of participants reported working in direct patient care (69%). Within their specified roles, 38% of participants were directly involved with updating patients’ medication records, 77% reported having been asked questions pertaining to patients’ medications, and nearly one-half (46%) had been asked about prescription drug coverage by patients. Some partici392 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5

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Table 1. Demographics of study participants (n = 13) Characteristics Gender Women

No. (%) 12 (92)

Age Younger than 30 years 30–49 years 50 years or older

3 (23) 4 (31) 6 (46)

Race White, non-Hispanic

13 (100)

Education Some college or less Associate’s degree Bachelor’s degree or more

6 (46) 3 (23) 4 (31)

Length of time working in dialysis Less than 5 years 5–10 years More than 10 years

4 (31) 3 (23) 6 (46)

Role at dialysis center Administrative Patient care technician Nursing staff Social worker Dietitian

3 (23) 4 (31) 4 (31) 1 (8) 1 (8)

pants had seen or worked with pharmacy students peripherally during introductory or advanced pharmacy practice experiences. Findings Each focus group session lasted approximately 1 hour. Three key themes were identified and were consistent across sessions: 1. A need exists for MTM services in dialysis, given the complex web of care, services, and medication use in this patient population. 2. MTM services should be provided within the dialysis facility, consist of timely medication reconciliation and patient education, be individualized, and be covered by insurance. 3. MTM providers should be highly accessible and part of the dialysis team. They should exhibit cultural sensitivity and have a broad knowledge of medications. Pharmacy professionals are uniquely suited to provide these services. Theme 1. A need exists for MTM services in dialysis, given the complex web of care, services, and medication use in this patient population. Multiple medications, limited patient knowledge, and literacy contribute to medication problems. Participants identified that it was commonplace for dialysis patients to be prescribed 10 or more self-managed medications, with additional medications administered at dialysis. They noted that most patients see multiple prescribers. A general lack of Journal of the American Pharmacists Association

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patient medication knowledge was discussed. Staff felt that patients, particularly the elderly, tended to not ask many questions of the health care team, which limited their understanding of their conditions and treatments. “Most of the older patients don’t question anything. They’ll just bring in new medications and… have no idea what they’re taking or what it was for, and most of ‘em have like 20 meds, I mean. They don’t know why they’re taking it.” Participants discussed that many dialysis patients have poor literacy, making medication reviews and counseling difficult. “Well we have a few patients that don’t read either, and they come from families that don’t read.” Problems during transitions in care. Frequent hospitalizations, care transitions, and numerous prescribers often lead to patient confusion regarding medications. Medication-related problems at hospital discharge were identified as a major area for improvement. “And I know as patients too, when they come into the unit, they’re like ‘I don’t know what I’m taking. Here, here is my paperwork. I don’t know what this is,’ and they’re just lost…” Medication nonadherence is common. Poor adherence was a concern of staff, as many patients do not have prescribed medications filled. Participants noted that this was due to financial constraints, forgetfulness, and patients’ lack of understanding. “… they’ll forget and then, you know, they were intended to [fill their prescriptions] and then like a week later, they’re still not taking whatever it is.” “I’ve had patients who like to decrease their [phosphate] binders just because they want to wait ‘cause they can’t afford ‘em and so they’ll take less so it’s not as effective.” Current MTM practices are inadequate. Staff noted limitations of the current dialysis workflow requiring many primary tasks for nurses and other staff, leading to medication reviews being of lower priority. “…I mean as nurses you try, but we have so many other things going on and so many patients and you never know what’s gonna happen out there. And you know you may not get a chance in the whole day to go over to sit down and talk 15 minutes with a patient.” “And from a social work perspective,… I don’t have time to call on every single patient to figure out what type of medication plan they have until it comes up that they need a prior authorization. Most of the patients have no idea what their prescription coverage is or where it comes from….” Medication management provided outside the dialysis facility during care transitions appears inadequate. It was perceived that clinical staff were not adequately involved at hospital discharges when patients would be going home and resuming outpatient dialysis. “[Discharge planners] tend to be administrative personnel, because they assume that a doctor or some other health care provider had a conversation with you prior to the actual moment of discharge.” Journal of the American Pharmacists Association

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MTM programs could improve care. The concept of MTM was mostly unknown to participants. Once defined by the facilitator, staff welcomed the idea of having a professional dedicated to conducting medication reviews within the dialysis center. MTM services were seen as important, a way of improving communication, and useful to educate patients about medications and overall health, something current resources are unable to maintain. This becomes a key way to empower patients to better engage in their health care. Theme 2. MTM services should be provided within the dialysis facility, should consist of timely medication reconciliation and patient education, be individualized, and be covered by insurance. Scheduling of medication reviews. Participants felt that medication reviews should be conducted during dialysis sessions. Face-to-face interaction, as opposed to telephonic, was preferred among participants. “…they’re seen here more regularly here than, you know, if they go to their pharmacy once a month, if they even go. “I can block you out over the phone. You can talk away and I’ll say ‘okay, yeah, alright, bye.’” Staff felt that medication reviews should be conducted within the first month of dialysis, with monthly to quarterly follow-up scheduled proactively based on patient needs. Although duration of medication reviews was not specifically discussed, it was agreed that enough time should be allotted for patients to receive necessary education and ask questions, and for reinforcement of good adherence practices. “They might like that because wherever else you go today, you’re being rushed in the doctor’s office. You only got 10 or 15 minutes, so maybe that’s one thing.” Focus of the MTM session. Staff identified medication reconciliation and education as the most important interventions for dialysis patients, and were not fully aware of other roles for MTM services. Participants highlighted the importance of individualized, personal care. In many cases, patient caregivers need to be involved in the MTM sessions. Participants stated that patient education requires adaptation to specific patient needs and engagement with the patient at their level. “I think the younger patients need to, you know, take a hold of their own visits, but the education again still I mean, I know a young patient that stopped taking her meds and ended up back on dialysis and their transplant rejected. You know, again it’s the education, because did she have the whole mindset, ‘oh it’s not gonna happen to me’? You know and at that younger age, that’s what they all, you know, nothing’s ever gonna happen to you.” Payment for services. Staff did not think patients should pay out-of-pocket for MTM services; rather, insurance should cover the costs. “That’s no different in the insurance as you’re doing pharmacy education as it is a smoking education. You go to classes, insurance pays for that. You know there’s classes out j apha.org

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there insurance pays for, so why not just add this.” Theme 3. MTM providers should be highly accessible and part of the dialysis team. They should exhibit cultural sensitivity and have a broad knowledge of medications. Pharmacy professionals are uniquely suited to provide these services. Necessary skills of the MTM provider. Participants raised the importance of cultural competency of MTM providers since patients have diverse ethnic backgrounds, speak different languages, differ in age and have varying literacy levels. Staff mentioned their own familiarity with dialysis-specific medications, however the MTM provider should possess a broad awareness of medications beyond those used in dialysis. MTM provider access. Participants felt that the MTM provider should be part of the dialysis team and be highly accessible. Patients should have a way to reach the provider by either phone or email. The importance of relationship-building was noted. “… just this a familiar face continuing with the same person they can establish some sort of relationship.” MTM provider familiarity with dialysis operations. The MTM provider must be familiar with dialysis, and services should be integrated into existing workflow to avoid disruptions in other dialysis processes. Services should complement medication reviews done by nursing staff, and should coincide with monthly patient care conferences (PCCs) involving the multidisciplinary team. “Oh, I think it’s essential because you know at PCCs every month, the doctor is reviewing their meds and if there needs to be changes or if there’s you know if they wanna prescribe something new, they’re gonna need an updated list in order to say officially interactions….” “Well it can be kinda chaotic on the floor sometimes, so the timing would be a minor issue. I mean you definitely don’t wanna be out there during a changeover trying to counsel somebody.” Pharmacists are suited to provide MTM services in dialysis. There was a perceived need for pharmacists’ services in dialysis facilities. Other dialysis staff may not have the resources or time to answer medication questions. Pharmacists possess the requisite expertise to perform quality medication reviews. Patients trust pharmacists’ recommendations surrounding medication use, and to a greater extent compared with other health care providers. “…And I think a pharmacist or a pharmacy student has the most, you know, specific education in that area to answer those questions. I mean we can answer, you know, renal answers as far as educations but when they start asking us all different medications that we’re not familiar with we gotta look it up you know. But there should be somebody I think that you know helps them out before they get sent on their way. “ [on if it matters that a pharmacist is involved.] “I think it does for the patients. I do. I mean we go over their meds, we 394 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5

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talk to ‘em each one. But I think they feel a little more confident having a pharmacist there to you know… and just kind of look over their stuff again. I think that they appreciate it.” When discussing their personal experiences with medication reviews, many participants reported that those conducted by pharmacists were the most informative. “It was the pharmacist, they sent a pharmacist over to explain a new med to me and he just described more of what the side effects and what to watch for when I took the new med to see if I had any reactions. I found it very informative and I appreciated it.” In summary, MTM services are seen as important to the complex care and medication needs of dialysis patients. Dialysis staff value the participation of pharmacy professionals in the delivery of services.

Discussion Patients on dialysis are among those at highest risk for medication-related problems, suggesting that many may benefit from MTM services. The average patient on dialysis has multiple health conditions requiring 10 to 12 self-managed medications.3,25 Patients on dialysis are frequently hospitalized and medications contribute to nearly one-half of these hospitalizations.1,26 In the outpatient setting, patients on dialysis see multiple providers and receive medications from various sources, commonly leading to inaccurate medication lists, dosing concerns, poor patient adherence, and confusion.13,27–30 Despite an unmet need for improved medication management, pharmacists are not currently part of most dialysis care teams, largely due to the lack of a sustainable compensation mechanism. Several existing federal health policies seek to improve medication use in highrisk individuals, including patients on dialysis.4,18 Not only is MTM a required service for high-risk Medicare Part D beneficiaries, but medication management is also an expected component of CMS-sponsored end-stage renal disease seamless care organizations (ESCOs), which will operate similarly to accountable care organizations (ACOs) for general Medicare beneficiaries.4,18 However, these existing opportunities have limited reach for patients on dialysis. Only 14% of Part D plans chose to target patients with end-stage renal disease for MTM services in 2014.31 ESCO models will be tested in selected facilities, but will not be universally implemented, at least in the short-term.18 Identifying barriers to MTM delivery is an important step as new services are contemplated. Because facility staff are integral in delivering care to dialysis patients on a routine basis and their support may influence patient decision-making, identifying staff attitudes and views on MTM services is important as services are developed. Our results show that staff were generally supportive of MTM services and envisioned a focus on patient education and medication reconciliation. Staff noted that serJournal of the American Pharmacists Association

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vices should be proactive, consistent, and personalized to the patient, and be offered while the patient received dialysis at no out-of-pocket cost. These ideas are in line with existing federal initiatives directed by the ACA.32,17 A key provision of the ACA is a focus on prevention and the sharing of appropriate health care information to coordinate care and avoid duplicative treatment.32 The ACA also renews a focus on patient-centered care and engagement as strategies to reduce costs and achieve better outcomes.32,17 As a result, Medicare-sponsored MTM services already focus on education and medication reconciliation, and now require providers to supply patients with standardized personal medication lists and medication action plans that include steps to improve self-management.33 MTM services offered within dialysis facilities may be more valuable than typical Part D MTM services due to better patient engagement, integration with other providers, and availability of real-time patient data. Participants in this study acknowledged the importance of services provided inside dialysis facilities, namely patient education and medication reconciliation. However several valuable MTM elements were not cited by participants, including addressing dosing problems, medication scheduling, identifying unwarranted medication use or need for additional medications, optimizing drug selection, and staff education. This may be due to participants’ lack of familiarity with the breadth of pharmacist-delivered services, which is commonly identified in studies of pharmacists working on teams.34,35 A study by Maracle and colleagues showed that other health care team members, even those with extensive working relationships with pharmacists, struggled to define MTM services or how to describe benefits to patients.35 This underscores the need for improved communication by pharmacists regarding their educational background and capabilities in patient care settings. Our findings add to the literature that support pharmacist integration in dialysis facilities. However, opportunities for pharmacist services, like MTM, are limited within U.S. dialysis facilities, principally due to the lack of a viable payment model.13 The current Medicare reimbursement structure for dialysis, the ESRD Prospective Payment System, bundles costs of the dialysis procedure, associated supplies, certain medications, and laboratory services.36 The dialysis care team is dictated by CMS’ Conditions for Coverage for ESRD Facilities, and must include physicians, nurses, dietitians, and social workers, but does not mandate pharmacist involvement.16 Given the unclear financial implications of including a nonmandated provider under a bundled payment model, widespread pharmacist integration into the current dialysis paradigm is unlikely. Pai et al. demonstrated reduced hospitalizations and medication use in patients receiving pharmacist-led care compared with standard care in a 2-year study.7 While Journal of the American Pharmacists Association

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these findings are expected to reduce total health care costs, the financial impact at the dialysis facility level is unknown. Return on investment for individual dialysis facilities for such services would likely require longterm investment and would be highly dependent on the individual facility’s payer mix (i.e., proportion of private payers versus Medicare), as private payers reimburse at higher rates and for unbundled services. At the same time, quality improvement initiatives across settings are becoming increasingly important in the health care system. The ESRD Quality Incentive Program (QIP) is the first federally funded pay-for-performance program and affects all U.S. dialysis facilities.37 Starting in 2017, a QIP performance measure about hospital readmissions will be included.38 Together with the existing Hospital Readmission Reduction program, the QIP will encourage improvements in care transitions.38,39 Pharmacistdelivered services have the potential to reduce hospital readmission rates, leading to financial benefits for both dialysis centers and hospitals, and were supported by a recent editorial.40 Models that support shared savings across health care settings are likely to benefit from pharmacist services.

Limitations While our results suggest that MTM services in a dialysis center would fulfill an unmet need that could be filled by pharmacists, this perspective may not apply to all dialysis centers or staff. The sizes of the focus groups were typical, but are limited to the dialysis centers and staff we approached and those who volunteered, reducing our ability to generalize and potentially skewing to those with strong opinions about MTM. Across the two focus groups, themes were largely consistent and supported. However, there was not enough representation from each discipline to draw conclusions specific to each role within the dialysis team. Some participants in this study were familiar with pharmacy personnel, which could have affected responses. This study was limited to regional, private dialysis facilities. Thus, findings may not be generalizable to dialysis facilities outside this locale.

Conclusion The study findings support the idea that MTM services, specifically medication reconciliation and patient education, are needed within dialysis facilities and endorse a role for pharmacists in their delivery. Future research should expand to other members of the dialysis team, including management, physicians, pharmacists, patients, and caregivers. Although a number of studies support pharmacist integration into the dialysis care team, continued advocacy for MTM services is needed, particularly surrounding compensation issues.

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References 1. United States renal data systems, USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes, Digestive, and Kidney Diseases, Bethesda, MD, 2013. 2. Centers for Medicare & Medicaid Services. Medicare coverage of kidney dialysis and kidney transplant services. 2012. http:// www.medicare.gov/Pubs/pdf/10128.pdf. Accessed July 28, 2014. 3. Cardone KE, Bacchus S, Assimon MM, et al. Medication-related problems in CKD. Adv Chronic Kidney Dis. 2010;17(5):404– 412. 4. Centers for Medicare & Medicaid Services. Medicare program, Medicare prescription drug benefit. Final rule. 2005. http://edocket.access.gpo.gov/2005/05-1321.htm. Accessed July 28, 2014. 5. Shoemaker S, Hassol A. Understanding the landscape of MTM programs for Medicare Part D: results from a study for the Centers for Medicare & Medicaid Services. J Am Pharm Assoc. 2011;51(4):520–526. 6. Truong HA, Layson-Wolf C, de Bittner MR, et al. Perceptions of patients on Medicare Part D medication therapy management services. J Am Pharm Assoc. 2009;49(3):392–398. 7. Pai AB, Boyd A, Depczynski J, et  al. Reduced drug use and hospitalization rates in patients undergoing hemodialysis who received pharmaceutical care: a 2-year, randomized, controlled study. Pharmacotherapy. 2009;29(12):1433–1440. 8. Pai AB, Boyd A, Chavez A, Manley HJ. Health-related quality of life is maintained in hemodialysis patients receiving pharmaceutical care: a 2-year randomized, controlled study. Hemodial Int. 2009;13(1):72–79. 9. Chisholm-Burns MA, Graff Zivin JS, Lee JK, et al. Economic effects of pharmacists on health outcomes in the United States: a systematic review. Am J Health Syst Pharm. 2010;67(19):1624– 1634. 10. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. U.S. pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923–933. 11. Graabæk T, Kjeldsen LJ. Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review. Basic Clin Pharmacol Toxicol. 2013;112(6):359– 373. 12. 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. 2011.

15. Arbor Research Collaborative for Health. End-stage renal disease (ESRD) disease management demonstration evaluation report: findings from 2006–2008, the first three years of a five-year demonstration. Prepared for the Centers of Medicare & Medicaid Services, 2010. http://www.cms.gov%2FResearchStatistics-Data-and-Systems%2FStatistics-Trends-and-Rep orts%2FReports%2Fdownloads%2FArbor_ESRD_EvalReport_2010.pdf&ei=3rAwUtujHurj4AO4q4HIDQ&usg=AFQjCN Fobb6WUkcZGwSsevQ9EFfT5pcd-w&sig2=jPrQ0QtdpimMjk uzOCoDKg. Accessed July 28, 2014. 16. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs, conditions for coverage for end-stage renal disease facilities. Final rule. Fed Reg. 2008;73(73):20370–20484. 17. Center for Medicare and Medicaid Innovation. 42 USC 1315a (2010). http://www.gpo.gov/fdsys/granule/USCODE-2010-title42/USCODE-2010-title42-chap7-subchapXI-partA-sec1315a. Accessed July 28, 2014. 18. Centers for Medicare & Medicaid Services. Comprehensive ESRD care initiative 2014. http://innovation.cms.gov/initiatives/ comprehensive-esrd-care./ Accessed July 28, 2014. 19. McGrath SH, Snyder ME, Duenas GG, et al. Physician perceptions of pharmacist-provided medication therapy management: qualitative analysis. J Am Pharm Assoc. 2010;50(1):67–71. 20. Tallian KB, Hirsch JD, Kuo GM, et al. Development of a pharmacist-psychiatrist collaborative medication therapy management clinic. J Am Pharm Assoc. 2012;52(6):e252–e258. 21. American Pharmacists Association. Medication therapy management digest. APhA, Washington DC, 2013. www.pharmacist.com/2013-mtm-digest. Accessed July 28, 2014. 22. Zrinyi M. The influence of staff-patient interactions on adherence behaviours. EDTNA ERCA J. 2001;27(1):13–16. 23. Reutzel TJ, Gray DeFalco P, Hogan M, Vatanka Kazerooni P. Evaluation of a pharmaceutical care education series for chain pharmacists using the focus group method. J Am Pharm Assoc. 1999;39:226–234. 24. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758–1772. 25. Manley HJ, Garvin CG, Drayer DK, et al. Medication prescribing patterns in ambulatory haemodialysis patients: comparisons of USRDS to a large not-for-profit dialysis provider. Nephrol Dial Transplant. 2004;19(7):1842–1848. 26. Harchowal JT. Drug-related problems on a renal unit. Br J Renal Med. 1997;2:22–24. 27. Flauto RP, Leon JB, Sehgal AR. The provision and outcomes of diabetic care of hemodialysis patients. Am J Kidney Dis. 2003;41(1):125–131.

13. Pai AB, Cardone KE, Manley HJ, et al. Medication reconciliation and therapy management in dialysis-dependent patients: need for a systematic approach. Clin J Am Soc Nephrol. 2013;8(11):1988–1999.

28. Manley HJ, Drayer DK, McClaran M, et al. Drug record discrepancies in an outpatient electronic medical record: frequency, type, and potential impact on patient care at a hemodialysis center. Pharmacotherapy. 2003;23(2):231–239.

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30. Rifkin DE, Laws MB, Rao M, et al. Medication adherence behavior and priorities among older adults with CKD: a semistructured interview study. Am J Kidney Dis. 2010;56(3):439–446. Journal of the American Pharmacists Association

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31. Centers for Medicare & Medicaid Services. 2014 Medicare Part D medication therapy management (MTM) programs fact sheet. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2014-MTMFact-Sheet.pdf. Accessed December 18, 2014. 32. U.S. Department of Health and Human Services. National strategy for quality improvement in health care. Report to Congress. 2011. http://www.ahrq.gov/workingforquality./ Accessed July 28, 2014. 33. Centers for Medicare & Medicaid Services. 2013 Medicare Part D medication therapy management (MTM) programs fact sheet. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2013-MTMFact-Sheet.pdf. Accessed July 28, 2014. 34. Patterson BJ, Solimeo SL, Stewart KR, et  al. Perceptions of pharmacists’ integration into patient-centered medical home teams. Res Social Adm Pharm. 2015;11:85–95. 35. Maracle HL, Ramalho de Oliveira D, Brummel A. Primary care providers’ experiences with pharmaceutical care-based medication therapy management services. Innovations Pharm. 2012;3(1):Article 72,1–12.

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36. Centers for Medicare & Medicaid Services. End-stage renal disease prospective payment system. Final rule. Regulation CMS1418-F. Fed Regist. 2010;75(155):49029–49214. 37. Centers for Medicare & Medicaid Services. End-stage renal disease quality incentive program. Final rule. Regulation CMS3206-F. Fed Regist. 2011;76(3):628–646. 38. Centers for Medicare & Medicaid Services. Technical specifications for ESRD QIP measures. http://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/061_TechnicalSpecifications.html. Accessed December 18, 2014. 39. Centers for Medicare & Medicaid Services. Readmissions reduction program. http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/AcuteInpatientPPS/ReadmissionsReduction-Program.html. Accessed July 28, 2014. 40. Hakim RM, Collins AJ. Reducing avoidable rehospitalizations in ESRD: a shared accountability. J Am Soc Nephrol. 2014;25:1891–1893.

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Journal of the American Pharmacists Association

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JU L/A U G 2015 | 55:4 |

10/1/201 19

JAPhA 397

Multidisciplinary views toward pharmacist-delivered medication therapy management services in dialysis facilities.

To determine views of staff of dialysis centers toward pharmacist-delivered medication therapy management (MTM) services...
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