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ACCP Report - September 2016

Highlights from the CMM Effectiveness and Implementation Grant: A Report from the Study Team


Each quarter, the ACCP Report features a column written by the CMM study team that provides ACCP members with highlights and learnings from the CMM project. The previous reports for January, March, and June 2016 can be found at www.accp.com/report/archives.aspx.

Starting with this report, we will provide an update on study progress as well as highlight a particular aspect of our work in the Research Insights section. Our goal is to share the key learnings emerging from our efforts.

Study Updates

To revisit the aims of the study, see the June 2016 ACCP Report at www.accp.com/docs/report/0616.pdf.

As a key component of aim 1, we launched a demographic and baseline CMM survey to all lead pharmacists within each of our sites. The pharmacists have now completed the baseline surveys, and we are analyzing the data. The survey findings will describe each site in greater detail as well as highlight the state of CMM within each practice. As a follow-up to the baseline survey, we will interview all sites in October to learn more about their CMM practice models, their capacity for CMM service development and refinement, and the practice management system that supports the delivery of CMM within the primary care practice. We will share the findings from the surveys and interviews later this year.

We continue to develop our plans to launch the rapid-cycle testing of CMM within the primary care medical practices, which is the focus of aims 2 and 3. This effort is being led in partnership with our colleagues at the National Implementation Research Network (NIRN). A key component of aims 2 and 3 is an assessment of the fidelity of CMM delivery (i.e., is CMM being delivered as defined and as intended), as well as site visits to learn more about how CMM is operationalized within each practice. For more insight into the implementation science frameworks and methodologies guiding our efforts, attend the programming session titled “Implementation Science: Application to CMM” at the upcoming ACCP Annual Meeting at 9:15 a.m. on Monday, October 24, 2016. Caryn Ward, Ph.D., senior implementation scientist at NIRN, will help lead this session.

We have confirmed the members of our two major stakeholder groups: the CMM Grant Steering Committee and the Payer and Policy Advisory Board. The CMM Grant Steering Committee will hold its first meeting at the University of North Carolina (UNC) Eshelman School of Pharmacy in Chapel Hill, North Carolina, on September 22 and 23, 2016. The Payer and Policy Advisory Board will convene in Washington, D.C., on Friday, October 7. Members of the CMM Grant Steering Committee are Amanda Brummel, Pharm.D.; Geoffrey Curran, Ph.D., M.A.; Grace Kuo, Pharm.D., MPH, Ph.D.; Mark Loafman, M.D., MPH; Marie Smith, Pharm.D.; and Ed Webb, Pharm.D., MPH. The Payer and Policy Advisory Board consists of two national payers, including representation from AHIP (America’s Health Insurance Plans), two regional health plans, and two representatives from provider-led accountable care organizations who are engaged in risk-based contracting with public and commercial payers. We look forward to sharing our efforts to date with the two groups and, importantly, to gathering their insight into shaping key aspects of the study moving forward. In early October, we will also share insights from the study at a Capitol Hill briefing, which has been arranged through the UNC Eshelman School of Pharmacy’s Center for Medication Optimization through Practice and Policy in collaboration with ACCP.

Jen Carroll, M.D., MPH, and Wilson Pace, M.D., with the American Academy of Family Physicians National Research Network and DARTNet Institute, respectively, have been instrumental in leading our efforts to formally evaluate the impact of CMM on important outcomes (aim 4 of the study). Our CMM Grant Steering Committee as well as our Payer and Policy Advisory Board will play a key role in reviewing and validating our approach to this aim. Our formal evaluation will take place in year 2 of the study.

Research Insights: Creating a Common Language for CMM

An instrumental area of emphasis at the start of our study was in developing a “common language document” for CMM. Our implementation science colleagues at NIRN advised us that an important first step in implementing and spreading an innovation is to describe the core activities that allow an intervention or program to be teachable, learnable, doable, and measurable in practice and to promote consistency across practitioners at the level of actual service delivery. Although existing resources and guidelines define and comprehensively describe CMM,1-5 none actually does so at the level of depth that meets the NIRN’s definition.

Thus, an important area of focus during the early part of our study was applying the NIRN’s principles and methodologies for defining a “usable innovation” by creating essential functions and operational definitions for CMM. For example, existing CMM resources outline that a critical step of the CMM patient care process is to “develop a care plan”; however, these resources do not establish specificity or operationally define the steps involved in developing a care plan to the degree necessary to replicate the intervention, measure its fidelity, or ensure that it is operationalized consistently.

Why is this level of detail necessary? The NIRN has discovered and observed throughout its decades of work that the lack of an adequately defined innovation (or intervention) is a major impediment to implementation, thereby limiting the ability to achieve desired outcomes. All too often, the innovation is not well defined, leading to an innovation that is inadequately implemented and desired outcomes that are not achieved. The systematic review and meta-analysis of medication therapy management in outpatient settings published in JAMA Internal Medicine in 2015 notes this as well.6 In this review, the authors concluded that most studies fail to sufficiently describe the medication therapy management intervention in a manner that allows for replication and scale, and when the intervention was discussed, it was limited in scope with considerable variation across studies. They concluded that “new research, regardless of specific focus, will likely continue to find inconsistent results until underlying sources of heterogeneity are accounted for.” Having a proper level of specificity for the innovation also provides an opportunity for us to measure fidelity and ensure that the innovation is implemented as intended. Without this, it would be difficult to draw any real meaning from studies assessing pharmacist impact on patient outcomes.

Using the methodology outlined by NIRN,7 our study team is completing the CMM common language document and validating its implementation across the sites enrolled in our study. We also anticipate that creating this common language will support many efforts to teach and spread CMM that extend well beyond this study. Our research team will present a poster at the ACCP Annual Meeting in October 2016 that describes the CMM common language and highlights the methodology used in creating the document. Please stop by our poster to learn more and to share your insights.

On behalf of the investigators and study personnel, we hope these highlights are informative. Please feel free to reach out to Mary Roth McClurg at mroth@unc.edu or Todd Sorensen at soren042@umn.edu at any time with questions or insights.

  1. American College of Clinical Pharmacy (ACCP). Standards of practice for clinical pharmacists. Pharmacotherapy 2014;34:794-7.
  2. American College of Clinical Pharmacy (ACCP). Comprehensive Medication Management in Team-Based Care. 2016. Available at https://www.accp.com/docs/positions/misc/CMM%20Brief.pdf. Accessed September 14, 2016.
  3. Patient-Centered Primary Care Collaborative (PCPCC). The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes Resource Guide, 2nd ed. Washington, DC: PCPCC, 2012. Available at www.pcpcc.org/sites/default/files/media/medmanagement.pdf. Accessed September 14, 2016.
  4. Joint Commission of Pharmacy Practitioners (JCPP). Pharmacists’ Patient Care Process. May 29, 2014. Available at https://www.pharmacist.com/sites/default/files/files/PatientCareProcess.pdf. Accessed September 14, 2016.
  5. Cipolle RJ, Strand L, Morley P. Pharmaceutical Care Practice: The Patient-Centered Approach to Medication Management, 3rd ed. New York: McGraw-Hill, 2012.
  6. Viswanathan M, Kahwati LC, Golin CE, et al. Medication therapy management interventions in outpatient settings: a systematic review and meta-analysis. JAMA Intern Med 2015;175:76-87.
  7. National Implementation Research Network (NIRN); Metz A. Practice Profiles: A Process for Capturing Evidence and Operationalizing Innovations. January 2016. Available at http://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/resources/NIRN-Metz-WhitePaper-PracticeProfiles.pdf. Accessed September 14, 2016.