Medication Therapy Management (MTM) Sessions

Patient Assessment and Medication Reconciliation

• Patients should be asked to bring all medications, including prescription medications, over-the-counter medications, dietary or herbal supplements, and traditional and complementary medicines, to visits, according to the Mayo Clinic Proceedings 1
• Verification of medication details, such as name, strength, and dosing schedule, is crucial, as recommended by the Journal of Clinical Oncology 2
• Patients should be asked about recent changes to their medications and if they are using multiple prescribers or pharmacies, as suggested by the Mayo Clinic Proceedings 1
• Assessing patient knowledge by asking questions like "What do you understand about why you're taking each medication?" and "How do you take your medication?" is recommended by the American College of Clinical Oncology 2

Adherence Assessment and Support

• Direct adherence questions, such as "Have you missed any doses in the past week?" and "What specific challenges do you face taking your medications as prescribed?", should be asked, as recommended by the Journal of Clinical Oncology 2
• Financial concerns, such as difficulty affording medications and awareness of assistance programs, should be addressed, according to the Journal of Clinical Oncology 2
• Patients should be asked about their daily habits, including tobacco, alcohol, or recreational drug use, as suggested by Clinical Infectious Diseases 3
• Assessing diet and specific dietary patterns is recommended by the American Academy of Family Physicians, as published in the American Family Physician 4

Health Monitoring and Support System

• Patients should be asked about their support system, including who helps them manage their medications, as recommended by Clinical Infectious Diseases 3
• Asking about reliable transportation to pick up medications and storage of medications at home is suggested by the Journal of Clinical Oncology 2
• Recent changes in living situation that affect medication taking and concerns about medication safety at home should be addressed, according to Clinical Infectious Diseases 3 and the Journal of Clinical Oncology 2

Medication Safety and Potential Interactions

• Failing to verify all current medications can lead to potential drug interactions, and using at least two patient identifiers when reviewing medications is recommended, as published in the Journal of Clinical Oncology 2
• Actively reviewing drug interactions at each encounter by asking about all medications, including OTC and supplements, is crucial, according to the Journal of Clinical Oncology 2
• Patients should be asked about difficulty opening medication containers, recent falls, and memory concerns that affect taking medications, as suggested by the Mayo Clinic Proceedings 1
• Assessing for cognitive impairment, fall risk, frailty, and family support, including both cardiovascular and non-cardiovascular problems, is recommended by the American College of Cardiology 5
• The following table summarizes potential risks and recommendations for various medication classes:

Special Populations

• For dialysis patients: Perform medication reconciliation at least monthly, with particular attention to altered pharmacokinetics, to ensure safe and effective medication use, as recommended by the Journal of Clinical Oncology 6
• For older adults: Assess for anticholinergic burden, fall risk medications, and inappropriate medications based on kidney function, and prioritize medications for deprescribing, targeting those with unfavorable risk-benefit profiles, as recommended by the American College of Physicians and the American Geriatrics Society 7, 8
• For patients with multiple chronic conditions: Involve patients in expressing their personal values and treatment priorities to provide patient-centered care, and use a sequenced approach to medication simplification, making one change at a time and allowing 2-3 weeks between changes, as recommended by the Mayo Clinic Proceedings and other authorities 9, 7, 10

Patient Education and Adherence

• Providing written educational materials explaining the purpose of each medication, administration instructions, common side effects, potential drug interactions, and when to contact the healthcare provider is essential for patient education and adherence 2, 11, 9
• Establishing a structured plan for assessing adherence at each clinical encounter can help identify potential barriers to adherence, using questions such as "Have you missed any doses in the past 3 days?" and "What specific challenges do you face taking your medications as prescribed?" 2, 11
• The "Ask, Tell, Ask" method can be used to educate patients about their medications, including asking what the patient already knows, telling them new information, and asking them to repeat back what they understood, as recommended by the American College of Cardiology 5

Monitoring and Follow-up

• Regular laboratory monitoring, including renal function for medications cleared by kidneys and liver function for hepatically metabolized drugs, is crucial for patients on multiple medications 2
• Therapeutic drug monitoring for narrow therapeutic index drugs, such as digoxin, is necessary to minimize risks and optimize outcomes, according to the American College of Cardiology 12
• Screening for high-risk medications (anticholinergics, NSAIDs, sulfonylureas) that may worsen existing conditions, and monitoring drug toxicity, laboratory tests, and medication changes can help ensure safe and effective medication use, as recommended by the American College of Physicians and the American Geriatrics Society 7, 8