Pharmacist-led optimal medication management is achievable in a value-based care model
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In March 2020, a group of nephrology pharmacists met to discuss ways to help improve patient lives and keep the nephrologist at the center of the patient care team.
From those discussions the Advancing Kidney Health through Optimal Medication Management (AKHOMM) initiative was formed. The vision of AKHOMM is every person with kidney disease receives optimal medication management through team-based care, including a pharmacist, to ensure their medications are safe, effective and convenient.
Optimal medication management can be achieved by providing comprehensive medication management (CMM), the standard of care process that ensures each patient’s medications are individually assessed to determine whether these medications are appropriate for the patient, effective for the medical condition, safe given the patient’s comorbidities and other medications being taken, and that medications can be taken as intended.
Busy nephrologists or primary care practitioners who may be participating in new value-based kidney care or other value-based care models can benefit from a pharmacist who completes a full medication reconciliation, assists with medication access and patient education, optimizes medications for effectiveness and safety, and operates as an integral piece of the patient-chronic kidney disease care team.
This can result in improved patient activation and depression management, improved patient health prior to starting dialysis, increased use of medications proven to slow progression of CKD, proactive management of CKD complications and reduced hospitalizations and ED visits.
Medication therapy management
In the literature, there are several terms used interchangeably to describe pharmacists providing care to patients. The most common are medication therapy management (MTM) and CMM. MTM has an inconsistently defined process of care delivery, is focused more on disease management and is often delivered in professional silos and without full access to a patient’s medical records (such as in community pharmacies).
Most practitioners associate MTM with the Medicare Part D prescription program; these programs have had variable success. While MTM can be beneficial for patients, CMM provides more breadth and depth of care through its well-defined person- and clinical outcome-focused process that is conducted by pharmacists in collaboration with the nephrologist and other members of the patient’s health care team.
The benefits of CMM delivered by a pharmacist are well documented in primary care and are beginning to be reported in patients with kidney disease. A study by Pai and colleagues in 2009 showed reduced medication use, lower medication costs, fewer hospitalizations and shorter hospital stays for patients on hemodialysis who received standard of care plus medication management services when compared with patients who received standard of care alone.
Additionally, patients with diabetes and/or CKD who received medication management services had a statistically greater reduction in mean blood pressure and improved control at 9 months compared with those receiving usual care. Two recent studies were published comparing medication management delivered by a clinical pharmacist via a mobile health-based application to patients with a kidney transplant. When compared with the standard of care, the pharmacist-delivered medication management resulted in significant reductions in medication errors, adverse events and hospitalizations while demonstrating a 49% lower hospitalization charge and a return on investment of $4.30 for every $1 spent.
New therapies
There are new dynamics in nephrology health care today compared with a decade ago. The COVID-19 pandemic reduced the ranks of health care professionals across the board, decreasing the already beleaguered workforce in this specialty. Several new evidence-based therapies have been shown in large randomized clinical trials to reduce progression of CKD, in addition to angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB).
In a game-changing process, the American Heart Association published a presidential advisory, accompanying article and released a new online calculator to predict cardiovascular (CV) risk.
This is the first time that a CV risk calculator incorporated eGFR and urine-albumin creatinine ratio (UACR) as important risk factors for development of CVD.
These items lay the foundation for a new paradigm of care that integrates prevention, early detection and management of the cardiovascular-kidney-metabolic (CKM) syndrome. Recommendations contain an algorithm for management of patients with CKM syndrome, including ACEi/ARB, sodium glucose transporter-2 inhibitors (SGLT-2i), glucagon-like peptide receptor-1 agonists (GLP-1RAs) and mineralocorticoid receptor agonists.
The AHA Presidential Advisory is a paradigm shift in how individuals with metabolic, kidney and heart disease are managed. It lays the pathway for earlier detection and management of CKM syndrome which requires breaking down silos of specialty care, integration with primary care and a coordinated multidisciplinary care approach.
Medication management
Patients with CKM syndrome oftentimes take a multitude of medications to address this syndrome along with additional conditions. Currently, there are not enough nephrology practitioners to address kidney-focused medication management in patients with CKD, let alone address CKM syndrome.
One strategy to address the lack of nephrology practitioners is to integrate a clinical pharmacist into nephrology or primary care practices to focus on patient-centered guideline-directed medication therapy (GDMT) across conditions. Integration of clinical pharmacists into nephrology practices is one strategy that improves initiation and maintenance of GDMT.
The DRIVE trial, involving patients with type 2 diabetes with increased CV or kidney risk, showed that a virtual multidisciplinary education program with simultaneous prescription of an SGLT-2i or GLP-1RA by a clinical pharmacist significantly increased initial prescriptions of these agents, as well as self-reported use at 6 months as compared with education first followed by prescription. This study showed that a pharmacist-driven program along with a patient navigator providing some care coordination could rapidly optimize GDMT.
The goal of AKHOMM is to assist nephrology and primary care practices in meeting value-based metrics by ensuring all patients’ medications are effective and safe, helping to empower patients to be partners in their medication management and overcoming their barriers to medication adherence including deprescribing unnecessary medications to reduce medication burden. In addition, incorporating pharmacists to focus on CMM will help decompress nephrologist workloads, allowing nephrologists to maintain their close patient relationship.
Challenges for CMM
There are two gaps that need to be addressed to provide patient-centered CMM within nephrology or primary care practices. First, there is a lack of trained pharmacists, nurses and physicians on medication management in persons with CKM syndrome. AKHOMM is addressing this first gap by developing an interprofessional curriculum on guideline-directed medication management and symptom management. Currently 18 modules that range from an introduction to CKD, transitioning to eGFR equations for medication-related decision-making, GDMT in CKD (ACE-I/ARB, SGLT-2i, GLP-1 RA and MRA) and working with Black patients with kidney disease using a patient-centered approach to address medication-related disparities.
These modules are accredited for physicians, nurse practitioners, physician assistants, nurses and pharmacists and are available free of charge. They are designed as 30- to 45-minute video-based activities, with embedded self-assessment questions and case-based application. The newest modules include a practical guide to medication dosage adjustment due to pharmacokinetic changes in non-dialysis CKD, management of depression and anxiety in patients with CKD, and pain management.
The second gap to overcome is clinical inertia, which has been exacerbated by reductions in the health care workforce. Although education is important, education alone is generally insufficient to transform practice. AKHOMM created a Learning and Action Collaborative (LAC) to assist nephrology and primary care practices in implementing a new (or expanded) pharmacist-provided CMM service. The LAC brings together a committed group of organizations, provides individualized implementation coaching and other resources, and allows for peer-to-peer sharing of effective practices and barriers faced with the goal of assisting these organizations in achieving their goal of a scalable and sustainable change in health care delivery. While each team will be striving towards the overall goal of implementing CMM, each team will also develop an individual aim specific to the needs of their organization. The first AKHOMM LAC cohort launched in July 2024 starting with a 4-month design phase followed by a 12-month implementation phase.
The kidney community has seen major advances in pharmacotherapy for patients with CKD. There is increasing hope that progression of this disease can be slowed, or even halted. Medication management directed by a pharmacist can provide medication reconciliation, assist with medication access and patient education, optimize medications for effectiveness and safety and operate as an integral piece of the patient-CKD care team.
- References:
- American Heart Association PREVENT Online Calculator. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator.
- Anderegg M, et al. Pharmacotherapy. 2018;doi:10.1002/phar.2083.
- Gonzales H, et al. Clin J Am Soc Nephrol. 2021;doi.org/10.2215/CJN.15911020.
- Khan SS, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001191.
- Ndumele CE, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001184.
- Pai A, et al. Pharmacotherapy. 2009;doi:10.1592/phco.29.12.1433.
- Palmer S, et al. Kidney Int. 2013;doi:10.1038/ki.2013.77.
- Patient-centered primary care collaborative: Comprehensive medication management to optimize patient outcomes. https://www.pcpcc.org/sites/default/files/media/medmanagement.pdf.
- Taber DJ, et al. Am J Transplant. 2021;doi:10.1111/ajt.16737.
- For more information:
- Rebecca Maxon, PharmD, is an associate clinical professor at Auburn University, Harrison College of Pharmacy and assistant director of the AKHOMM initiative. She can be reached at maxsora@auburn.edu.
- Calvin J. Meaney, PharmD, FCCP is clinical associate professor and interim division head, division of outcomes and practice management, department of pharmacy practice, School of Pharmacy, University at Buffalo and is an assistant director of the AKHOMM initiative. He can be reached at cjmeaney@buffalo.edu.
- Wendy L. St. Peter, PharmD, FASN, FNKF, FCCP, is a professor in the department of pharmaceutical care and health systems, College of Pharmacy, University of Minnesota, and director of the AKHOMM initiative. She can be reached at stpet002@umn.edu.
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