The MTM case life cycle

The first stage in the MTM case life cycle is the Verification stage, in which the clinician or pharmacist verifies the patient or member through specific patient/member details that are required by HIPAA validation standards.  

The first step in the Verification stage is HIPAA validation of the patient/member, in which the patient verifies their private patient details to the clinician to identify themselves as the correct patient.

In the following figure, the clinician verifies the address, date of birth, and social security number of the patient:

These patient identifiers are configured on the Care Management configuration page on the Patient Identifiers tab, prior to implementation, as shown in the following figure: 

The Verification stage allows for one customizable rule and rule type, which is used to set the member context for the case: 

In the Review history stage, you assess allergies, medical history, and conditions that are associated with members. There are two steps:

• Assess allergies and medical history
• Assess conditions

In the Assess allergies and medical history step, users view the allergy history of the member and add any new allergies or update existing allergy details. The medical history shows details that have been identified through authorization, admissions, claims, and other sources, and users can also add more details. The Assess allergies and medical history step sources these sections directly from the Patient 360 profile and is updated when reviewed or edited in the MTM “Review History.” Once the user completes the review, they select the Reviewed allergies and medical history checkbox to acknowledge the review before moving to the next step.

In the Assess conditions step, users assess the overall conditions that are documented for the member and can add new conditions and edit or update existing conditions that are in the table. Once the user completes the review, they select the Reviewed allergies and medical history checkbox to acknowledge the review and complete the step stage. 

The following figure shows the first step in the Review history stage, in which the user reviews the patient's allergies and medical history and then moves on to the second step, Assess conditions, to review the patient's conditions:

In the Screening stage, the clinician delivers the Social Determinants of Health (SDOH) assessment to the patient or member. The assessment identifies the social determinant factors of the member, along with appropriate action items that the relevant healthcare professionals should take to assist the patient with, for example, 'barriers.' The social determinants of health are the economic and social conditions that influence individual and group differences in health status. 

The following figure shows an example of an SDOH assessment:

You assign the SDOH assessment in the MTM Configuration, in the Business Analyst Portal. The SDOH assessment is what users use to determine the barriers that can be identified during the MTM case life cycle.  

Medication adherence plays a large role in reducing the overall cost of care and improving clinical outcomes. Prescription medication might be ineffective if patients do not take it as prescribed. Improper use of medication can result in major health issues that lead to negative health outcomes, an increase in urgent care visits and hospital readmissions, and increased healthcare spending. The MTM program helps patients that struggle with patient compliance to follow proper medication use. 

Patients proceed through the following steps in the Medication adherence stage:

Late to refill medications

Users can review the patient's medication and obtain consent from them for refills.

If a patient opts to refill their medication, then the clinician or pharmacist can select the set of medications that the patient wants to refill.

If the Days late column for the selected medication has a value that is greater than zero, then in the Late reason column, the clinician uses the Select reason list to provide an explanation. 

Patients might choose to refill only a few medications at a time. For example, if a patient has five medications, they might want to refill three medications. For the remaining two, patients provide the reasons for not refilling on the next page.

If patients do not opt to refill their medication, the medications list is hidden, and the clinician or pharmacist enters the reason for not refilling the medication after they click Continue.

If the patient or member does request a refill of their medication, the clinician clicks Yes and completes the Late reason for each medication that is late to refill, as shown in the following figure:

Reason for not refilling

Medications that patients do not opt to refill are displayed on the Reason for not refilling page.

Each medication has a list in which patients select the reason for not refilling that medication, such as cost, significant side effects, or a change in condition. If a patient no longer uses a medication, there is an option to capture the date that they ceased using the medication, which is also then displayed in the patient profile.

Drug-Drug interactions

A drug-drug interaction is a change in the effect of a drug on a patient when the drug is taken together with a second drug. A drug-drug interaction can delay, decrease, or enhance absorption of either drug.

If a drug-to-drug interaction is indicated, the pharmacist or clinician must interact with and obtain details about the interaction from the patient or member.  

Pega Care Management offers drug-drug interactions through an online drug database. The following figure shows an example of a drug-drug interaction listed in Drug Bank:

Medication questions

The third and final step helps users to review a member's understanding of their medication and its side effects. For each medication, members must answer the following questions:

• “Do you understand this medication and its side effects?” − Yes/No
  • If No, then an additional question is displayed: “What do you understand about this medication?”
•  “Do you experience effects from this medication?” − Yes/No
  • If Yes, an additional question is displayed: “What side effects do you experience?”
•  When the user captures all of the answers, they click Finish to proceed to the next stage, Wrap up.

In the Wrap up stage, the Medication Action Plan (MAP) helps the user to document the action plan and create a follow-up plan for the patient/member. The pharmacist or clinician captures the following details: 

• What we talked about
• What does the member need to do
• What the member did, and when they did it

These details can be captured in a repeated structure for each medication listed in the MAP.  

Additionally, the pharmacist or clinician can enter a follow-up plan to share with the patient.

The following figure displays an example of a medication action plan that the pharmacist or clinician documents:

Barriers and interventions

System-identified barriers and interventions are displayed in the Barriers and Interventions sections. The information in this section comes from the patient response to the social determinant assessment. Additionally, clinical users can add new barriers and interventions that they learn about during their discussions with patients.

The following figure shows an example of the Barriers and Interventions sections:

MTM eligibility

If a patient is eligible for the MTM program, after the new barriers and interventions are entered, the following information about their eligibility criteria is displayed: 

• Coverage plan name
• Current medical expenses: Total amount paid for pharmacy claims within the current annual period, along with the percentage consumed out of the threshold amount configured.
• Medications: List of current medications.
• Conditions: List of member's chronic conditions

The member is then automatically enrolled in the program, and the medication action plan and MTM enrollment correspondence are sent to the member. The MTM program with the barriers and interventions is added to the member profile by the system. 

If a patient is ineligible for the MTM program, the ineligible notification is displayed to the clinician. The patient and team members still receive the medication action plan, and the system displays the barriers and interventions on the member profile. 

Patient Medication List 

The Patient Medication List (PML) lists the most recent medications that the patient is currently taking. The clinician can generate the list in the Patient 360, and then send the PML as correspondence to the patient. 

To send the PML, the user clicks Actions > New > Send PML, as shown in the following figure:

The clinician reviews the medication list after the PML is generated and adds any additional information as necessary. The following figure shows an example of a generated PML:

 Once the user clicks Submit, the system creates a PDF file of the PML with all of the required details. The PDF can be found in the Attachments section of the Patient 360 profile. Email correspondence is automatically generated with the PML attachment that the patient receives, as shown in the following figure:

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