Medication Therapy Management (MTM) II

and
eCare Plans

Advanced Practice Management II

Spring

Jana Murry, PharmD, RPH

Nancy Stern, BA, BS, RPH
Department of Pharmacy Practice
MCPHS University – Boston
3.1.23
Objectives

Review MTM Case

Practice patient cases

eCare Plan
LAB 3: March 21 – March 30

o Integrated P3 (RPh) : P1 (Intern)

o APM student Team leader
o Medication Therapy Management (MTM)
o eCare Plan

o Endocrine Clinic Visit

o Clinical focus: Endocrine

o Estimated flow:
o 10 min. Overview & general instruction
o 60+/- min. Breakout P1:P3 teamwork MTM and eCare Plan
o 15 min. Endocrine Clinic Visit
o 10 min. Closing / wrap-up uploading submitting documents
MTM service depends on:

Patient’s needs
Pharmacist’s area of expertise

Third party payer coverage

Components of each service

Clinical Billing
 Review Core Elements of an MTM Service
Model in Pharmacy Practice
The MTM service model in pharmacy practice
includes the following five core elements:
• Medication therapy review (MTR)
• Personal medication record (PMR)
• Medication-related action plan (MAP)
• Intervention and/or referral (IAR)
• Documentation and follow-up (DOC)
Goals of a CMR

• Assess medication therapies to identify

medication related problems
• Identify and address problems or
concerns that the patient may have
• Improve patient’s knowledge of their
meds
• Empower patients to self manage their
meds and health
Adherence

https://www.cdc.gov/grand-rounds/pp/2017/20170221-presentation-medication-adherence-H.pdf
Case Study
Case Study

https://pubmed.ncbi.nlm.nih.gov/16602223
MTM and Technology
MTM and Technology
MTM Drug Therapy Worksheet
Case:
Identify drug therapy interventions from the case provided and
record the elements into the MTM platform:

Intervention #1:
Description of the intervention:
Action/What the patient should do:
Recommendation to MD:
On Scale of 1 (high severity) to 10 (low severity), what would
you rate this intervention?
MTM Drug Therapy Worksheet
MTM Case
Hyperlipidemia
FR is a 54-year-old male with BPH and
hyperlipidemia that gets his medications from
your pharmacy.
He reports that he was laid off from his job
several months ago, which has made it more
challenging to pay for his medications and
keep his current lifestyle.
He is in the pharmacy today to pick up an
antibiotic for a sinus infection. He also asked
you if there are cheaper medications that
would work for him or if you have any
coupons.
Past Medical History (PMH)
BPH
Hyperlipidemia
Allergies
Penicillins - Anaphylaxis
Recent Lab Results
Blood Pressure: 140/92 mm Hg Heart Rate: 112 bpm
Weight 198 lbs
Immunizations None
Social history
Drinks alcohol daily
Medication history
• Pravastatin 40mg 1 tablet by mouth daily
• Silodosin 8mg 1 capsule by mouth daily with food
• New prescription today: Amoxicillin 500mg every 12 hours for
10 days
Rx RX Fill Date NDC Drug Name Quantity Day Directions
Number Supply

567248 02.14.2023 33261-0868-00 Pravastatin 40mg 30 30 1QD

567248 01.08.2023 33261-0868-00 Pravastatin 40mg 30 30 1QD
567248 11.30.2022 33261-0868-00 Pravastatin 40mg 30 30 1QD
567248 10.24.2022 33261-0868-00 Pravastatin 40mg 30 30 1QD
567248 09.15.2022 33261-0868-00 Pravastatin 40mg 30 30 1QD
567248 08.05.2022 33261-0868-00 Pravastatin 40mg 30 30 1QD
594385 02.20.2023 68180-0740-02 Silodosin 8mg 30 30 1QD with food
594385 01.20.2023 68180-0740-02 Silodosin 8mg 30 30 1QD with food
594385 12.24.2022 68180-0740-02 Silodosin 8mg 30 30 1QD with food
594385 11.22.2022 68180-0740-02 Silodosin 8mg 30 30 1QD with food
594385 10.23.2022 68180-0740-02 Silodosin 8mg 30 30 1QD with food
594385 09.24.2022 68180-0740-02 Silodosin 8mg 30 30 1QD with food
Possible Claims:
1.The patient appears to be non-adherent to
pravastatin based on fill history.
2.Cost effective alternatives may exist for BPH therapy
depending on formulary preferences. Looking up the
formulary and making a prescriber recommendation
would be appropriate.
3.The patient has an allergy to penicillin that is potentially
life threatening. Another class of medications should be
recommended.
4.The pharmacist may document a Needs
Immunization claim for the influenza vaccine if the
pharmacist recommended the vaccination.
5. Patient’s Blood Pressure should be addressed
6. Patient’s weight, diet and exercise
7. Patient’s Heart rate
8. Patients alcohol consumption may need addressing
Issues Found Grade

> 8 issues 100

7 issues 85

6 issues 70

<5 50
Care planning has become an essential
part of the health care system in the
United States, as chronic diseases have
been linked to the majority of health care,
morbidity, and mortality expenditures
Chronic diseases are responsible for about 75% of the nation’s
aggregate health care spending, as well as 96% of Medicare
spending and 86% of Medicaid spending.
According to the National Association of Chronic Disease
Directors 45% of people in the United States suffer from at least
1 chronic disease, and more than two-thirds of all deaths are
cause by 1 or more of 5 chronic diseases:
• cancer
• chronic obstructive pulmonary disease
• diabetes
• heart disease
• stroke
Medication use is the predominant intervention for chronic
disease, according to the PeCP
Care planning and follow up are required for effective medication
use
Pharmacist eCare Plan (PeCP)
• Developed by the Pharmacy Health Information
Technology Collaborative (Pharmacy HIT)

• In conjunction with National Council for Prescription

Drug Programs (NCPDP)

• Based on the HL7 standard in conjunction with

National Council for Prescription Drug Programs
(NCPDP)
Why is the eCare Plan structures the
way it is
Standards
• Standards represents concepts unambiguously between an
sender and a received
• Examples of standards
o NCPDP.0
o ICD-10
o SNOMED-CT

• The eCare Plan uses SNOMED-CT to systematically capture data

and make them
o transferable
o universal
o ability to aggregate data
SNOMED Codes

• Comprehensive, multilingual clinical terminology in the world, encompassing

more than 300,000 concepts, along with terms, synonyms, and definitions
for human and non-human concepts.
• Designed to be a U.S. standard for electronic health information exchange.
• Enables consistent, processable representation of clinical content

https://www.wolterskluwer.com/en/expert-insights/snomed-ct-why-it-matters-to-you

https://www.youtube.com/watch?v=dfKNgIIumxo
Documentation with SNOMED-CT Codes

https://vimeo.com/413192554
 o A tool for community pharmacists to clinically
document patient care services
o Pharmacist-led patient care services, a key component to
advancing the profession of pharmacy
o Allows more efficient communication - a standard
for the way data sent from 1 health care provider or
system to another. It’s a way to leverage technology
What that can help every pharmacist be more
productive.
is an o Reinforces the Pharmacist Patient Care Process

eCare (PPCP) from the Joint Commission on Pharmacy

Practice (JCPP)

Plan? o Provides a standardized method of exchanging

information between pharmacy technology platforms,
clinically integrated networks such as CPESN
pharmacies, chain pharmacies, and electronic health
records.
o Longitudinal person centric coordination of care
dynamic plan
o Swiss Army Knife of healthcare informatics. It maintains
nearly all of the salient information needed to coordinate
care, with a payer section
https://www.pharmacytimes.com/resource-centers/reimbursement/pharmacy-ecare-plan-developed-as-a-valuable-tool https://www.ncpdp.org/NCPDP/media/pdf/Pharmacist-eCare-Plan.pdf
Pharmacists’ Patient Care Process. https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf.
 Used for tracking patient’s progress as part of the
Pharmacist’s Patient Care Process (PPCP)
1. Collect: Gather objective and subjective
information on a patient including medical
history, current prescriptions, lifestyle habits, and
other social determinants of health.

Purpose of 2. Assess: Analyze the information to determine the

effectiveness of any current medications and
an eCare identify any gaps in patient care, such as
opportunities for vaccination or other preventative
Plan? health services.
3. Plan: Create a personalized plan of action by
outlining a detailed list of Care Goals for the
patient.
4. Implement: Take concrete steps to work
towards achieving the patient’s goals and
document all Care Actions that are taken.
5. Follow-Up: Monitor and evaluate the
effectiveness of the plan and modify it as
needed.
https://www.pharmacytimes.com/resource-centers/reimbursement/pharmacy-ecare-plan-developed-as-a-valuable-tool
Pharmacist eCare Plan (PeCP)
eCare plan essentially allows pharmacies to receive and
share information about active patient goals
o health concerns
o active medication lists
o drug therapy issues
o laboratory results
o vitals
o payer information
o billing for services
Traditional Care Plan Pharmacist Care Plan
o Health Concerns o Health Concerns
o Identified health or risk o Add documentation of
concerns such as problems, medication therapy problems
allergies, or social issue, etc.
o Interventions o Interventions
o Includes active medication o Add more medication history
list, medication o Prescription fill history may
administered, and planner be added
medications
o Goals o Goals
o Includes patient goals o Emphasis on goals of
therapy
o Health Status Evaluation & o Health Status Evaluation &
Outcomes Outcomes
o Includes disposition and o Emphasis on sections
outcomes related to medications
o Laboratory Results and Vitals o Laboratory Results and Vitals
o Payer Section
o Longitudinal plan
/
https://www.ecareplaninitiative.com
What it is What it is Not

o It is a repository for clinical o It is not a platform

data for a patient o It is not vendor –specific
o Active medication list (can work with any system
o Drug therapy problems that has adopted it
o Lab results o It is not a construct of
o Vital signs CPESN
o Health concerns o It is not a SOAP not that you
o It is an interoperable print or fax
transmission standard
o It is an open industry
standard in which any
system can adopt
https://vimeo.com/413192554
 o Utilizing care goals and care actions in a
pharmacy provides a holistic, personalized level
of care.
o Pharmacies who submit eCare Plans to CPESN
can be reimbursed for their value- based clinical
services.
Benefits of o Properly documenting and tracking all the
steps to reach a patient’s health goals
an eCare demonstrates the value of the additional
services provided.
Plan? o Standardized data
o Each eCare Plan includes a payer section that
acts as a means of claims submission for the
pharmacy.
o Benefits of implementing eCare Plans are
valuable for both the patient and the pharmacy
o Expanding the use of eCare Plans will help to
improve patient outcomes and reimburse
independent pharmacists for practicing value-
based care

https://www.pharmacytimes.com/resource-centers/reimbursement/pharmacy-ecare-plan-developed-as-a-valuable-tool
Documentation

https://vimeo.com/413192554
CPESN eCare Plan Practice
French fry case – Flip the pharmacy

https://medium.com/docstation/the-pharmacist-ecare-plan-8ad744093767
 eCare Plans on PioneerRx

Will be using software Adding clinical Use critical thinking

that is already familiar knowledge to fill in skills to develop a
to the pharmacist the missing complete eCare plan
information provided
by the patient case

https://www.ajpe.org/content/ajpe/84/10/ajpe8396.full.pdf
 eCare plan Case

AK is a 71-year-old female who presents today

with the following conditions. She has Type 2
diabetes, a history of hypertension.
She reports that 5 years ago she had a MI. AK also
has had COPD,
She mentions that she has had GERD for awhile
that is exacerbated after she takes her glyburide.
AK has also developed peripheral neuropathy.
She complains that she “has to take so many
medications now”, and admits to forgetting
doses occasionally.
PMH
DM2 COPD
Hypertension GERD
Peripheral neuropathy History MI ( 5 years
ago)
Allergies
NKA
Mild rash resulting from glyburide

Recent Lab Results

Blood Pressure: 139/96 mmHg
LDL is above 190 mg/dL

Immunizations
Influenza – at age 62
Social history
Occasionally drinks alcohol
 Current Medications
(per pharmacy records / patient interview)

Medication Instructions

Metformin ER 1000mg 2T PO with evening meals

Glyburide 5mg 1T PO BID with breakfast and
supper
Lisinopril 10mg 1T PO daily
Ventolin HFA 2 puffs q 4-6h PRN
Dexilant 30mg 1 C PO daily
Hydrocodone / APAP 1T PO BID
5mg / 325mg
Rx RX Fill NDC Drug Name Quantit Day Directions
Number Date y Suppl
y
117467 02.17.2023 70010-0065-05 Metformin ER 1000mg 60 30 2T PO with evening meals
117467 01.07.2023 70010-0065-05 Metformin ER 1000mg 60 30 2T PO with evening meals
117467 11.30.2022 70010-0065-05 Metformin ER 1000mg 60 30 2T PO with evening meals
117467 10.15.2022 70010-0065-05 Metformin ER 1000mg 60 30 2T PO with evening meals
117467 09.05.2022 70010-0065-05 Metformin ER 1000mg 60 30 2T PO with evening meals
117467 07.29.2022 70010-0065-05 Metformin ER 1000mg 60 30 2T PO with evening meals
117468 02.18.2023 00093-8344-01 Glyburide 5mg 60 30 1T PO BID with breakfast and supper
117468 01.08.2023 00093-8344-01 Glyburide 5mg 60 30 1T PO BID with breakfast and supper
104812 01.30.2023 68180-0980-01 Lisinopril 10mg 30 30 1T PO daily
104812 12.15.2022 68180-0980-01 Lisinopril 10mg 30 30 1T PO daily
104812 11.02.2022 68180-0980-01 Lisinopril 10mg 30 30 1T PO daily
104812 09.25.2022 68180-0980-01 Lisinopril 10mg 30 30 1T PO daily
117466 02.11.2023 00173-0682-20 Ventolin HFA 18g 16 2 puffs q 4-6h PRN
117466 01.20.2023 00173-0682-20 Ventolin HFA 18g 16 2 puffs q 4-6h PRN
117466 12.30.2022 00173-0682-20 Ventolin HFA 18g 16 2 puffs q 4-6h PRN
117467 02.11.2023 64764-0171-30 Dexilant 30mg 30 30 1 C PO daily
117467 01.10.2022 64764-0171-30 Dexilant 30mg 30 30 1 C PO daily
117467 12.09.2022 64764-0171-30 Dexilant 30mg 30 30 1 C PO daily
117463 12.17.2022 67296-0016-20 Hydrocodone/ APAP 7 14 1T PO BID
5mg / 325mg
117463 11.30.2022 67296-0016-20 Hydrocodone/ APAP 7 14 1T PO BID
5mg / 325mg
Glyburide:
adverse drug reaction, recommend changing medication
Lisinopril:
nonadherence, provide education, enroll in med sync program , utilization adherence packaging

Ventolin HFA:
overuse of medication, provide medication education
Dexilant:
cost effective alternative, recommend changing medication
$469.36 for 30, 60MG Capsule Delayed Release. However, SingleCare's lowest price of Dexilant is
$89.05 for 30
Hydrocodone / APAP:
ineffective medication for peripheral neuropathy, needs additional drug terhapy, recommend changing
medication

Statin omission:
needs additional drug therapy, recommend a new medication
Aspirin indicated:
needs additional drug therapy, recommend new medication

Vaccinations:
Influenza immunization indicated
Shingles vaccination indicated
Covid-vaccine indicated
SNOMed Codes (example) CPESN Codes

Glyburide – adverse drug reaction, recommend changing medication

o 448178009: Adverse medication interaction with medication
o 394696007: Discussed with doctor
o 395085009: Discussed with patient
o 428711000124105: Recommend to change medication
Lisinopril – nonadherence, provide education,
enroll in med sync (Medication synchronization occurs when pharmacists
provide a patient with all their medication doses for the month, in only one
visit), utilize adherence packaging (put all the drugs a patient takes in one
package—either blister packs or pouches—to help them be adherent to
their drug regimen)
o 129834002: Noncompliance with medication regimen
o 410123007: Medication regimen compliance education / Education
about medication regimen
o 415693003: Synchronization of repeat medication
o 713116003: Monitoring of adherence to medication regimen
o 394696007: Discussed with doctor
o 395085009: Discussed with patient
Ventolin HFA – overuse of medication, provide education
o 429611000124105: Medication overuse
o 967006: Medication education
o 386465007: Prescribed medication education
o 395085009: Discussed with patient

Dexilant – cost effect alternative, recommend changing

medication
o 448151007: Cost effect medication alternatives available
o 428711000124105: Recommend to change medication
o 394696007: Discussed with doctor
o 395085009: Discussed with patient
Hydrocodone / APAP – ineffective medication use for Peripheral
neuropathy, needs additional drug therapy recommend
changing medication
o 435501000124106: Medication not effective
o 436071000124104: New medication needed for condition
o 428711000124105: Recommend to change medication
o 394696007: Discussed with doctor
o 395085009: Discussed with patient

Statin omission – needs additional drug therapy recommend

new medication
o 42898100012401: Additional medication therapy required
o 428821000124109: Recommendation to start prescription
medication
o 394696007: Discussed with doctor
o 395085009: Discussed with patient
Aspirin indicated – needs additional drug therapy recommend
new medication
o 42898100012401: Additional medication therapy required
o 428821000124109: Recommendation to start prescription
medication
o 394696007: Discussed with doctor
o 395085009: Discussed with patient

Influenza immunization indicated – needs additional drug

therapy, administer immunization
o 171259000: Not up to date with immunizations
o 86198006: Influenza vaccination
o 128660066: Pneumococcal vaccination
o 268558004: Immunization status screening
MTM Case

CHF
LB is a 71-year-old male who presents today for
a CMR. He had a STEMI 3 years ago, and
subsequently developed worsening heart
failure. He also developed atrial fibrillation
within the past 2 years that did not respond to
chemical cardioversion and was not maintained
after direct current cardioversion.
He says he is frustrated he “has to take so
many medications now”, and admits to
forgetting doses occasionally.
PMH
STEMI CHF
Hypertension Hyperlipidemia
Atrial fibrillation (chronic, rate controlled)
Allergies
Ciprofloxacin – hives
Recent Lab Results
Blood Pressure: 139/96 mmHg
Immunizations Influenza – Current
Zostavax – At age 67
Social history
Former smoker (quit 3 years ago) Occasionally drinks
alcohol
Medication history
• Metoprolol tartrate 50 mg ; 1 tablet by mouth twice daily
• Bumetanide 2 mg ; 1 tablet by mouth daily
• Spironolactone 25 mg ; 1 tablet by mouth daily
• Atorvastatin 80 mg ; 1 tablet by mouth daily
Rx RX Fill Date NDC Drug Name Quantity Day Directions
Number Supply
117467 02.17.2023 54868-4352-01 Bumetanide 2mg 30 30 1 QD
117467 01.07.2023 54868-4352-01 Bumetanide 2mg 30 30 1 QD
117467 11.21.2022 54868-4352-01 Bumetanide 2mg 30 30 1 QD
117467 10.05.2022 54868-4352-01 Bumetanide 2mg 30 30 1 QD
117467 08.29.2022 54868-4352-01 Bumetanide 2mg 30 30 1 QD
117467 07.29.2022 54868-4352-01 Bumetanide 2mg 30 30 1 QD
117468 02.18.2023 49999-0010-60 Metoprolol tartrate 50mg 60 30 1 BID
117468 01.18.2023 49999-0010-60 Metoprolol tartrate 50mg 60 30 1 BID
117468 12.20.2022 49999-0010-60 Metoprolol tartrate 50mg 60 30 1 BID
117468 11.20.2022 49999-0010-60 Metoprolol tartrate 50mg 60 30 1 BID
117468 10.23.2022 49999-0010-60 Metoprolol tartrate 50mg 60 30 1 BID
117468 09.26.2022 49999-0010-60 Metoprolol tartrate 50mg 60 30 1 BID
104812 02.17.2023 60505-2671-08 Atorvastatin 80mg 30 30 1 QD
104812 01.18.2023 60505-2671-08 Atorvastatin 80mg 30 30 1 QD
104812 12.20.2022 60505-2671-08 Atorvastatin 80mg 30 30 1 QD
104812 11.20.2022 60505-2671-08 Atorvastatin 80mg 30 30 1 QD
104812 10.24.2022 60505-2671-08 Atorvastatin 80mg 30 30 1 QD
104812 09.25.2022 60505-2671-08 Atorvastatin 80mg 30 30 1 QD
117466 02.18.2023 23490-6299-02 Spironolactone 25mg 30 30 1 QD
117466 01.09.2023 23490-6299-02 Spironolactone 25mg 30 30 1 QD
117466 12.04.2022 23490-6299-02 Spironolactone 25mg 30 30 1 QD
117466 10.26.2022 23490-6299-02 Spironolactone 25mg 30 30 1 QD
117466 09.16.2022 23490-6299-02 Spironolactone 25mg 30 30 1 QD
117466 08.09.2022 23490-6299-02 Spironolactone 25mg 30 30 1 QD
Possible Claims:
1. Pharmacist Identified DTP Rationale/Reason: According
to current ACC/AHA guidelines, this patient should be
taking an ACE-inhibitor orARB.
• Documentation:
o Reason: Needs drug therapy
o Action: Prescriber consultation
o Severity Level: 6

2. Pharmacist Identified DTP Rationale/Reason:

Guidelines recommend metoprolol succinate instead
of metoprolol tartrate
• Documentation:
o Reason: Suboptimal drug
o Action: Prescriber consultation
o Severity Level: 6
3. Pharmacist Identified DTP Rationale/Reason: The
patient should receive Prevnar 13 vaccine due to age
>65 years, educate patient to get Pneumovax 23 a year
later
• Documentation:
o Reason: Needs immunization
o Action: Prescriber consultation
o Result: Immunization administered

4. Pharmacist Identified DTP Rationale/Reason: The

patient is an anticoagulation candidate (chronic, rate
controlled AFib) recommend aspirin 81mg daily.
• Documentation:
o Reason: Needs drug therapy
o Action: Prescriber Consultation
o Severity Level: 6
MTM Case
NM is an 82-year-old white woman. She comes into the clinic for her CMR/MTM
appointment and during the appointment, she reports that she’s confused about her
thyroid medication because the doctor keeps changing it. Additionally, she’s been
feeling more out of breath lately and hasn’t been as active as she used to be
because of that. She’s been using her rescue inhaler around the clock which helps,
but then she starts feeling out of breath again. She does not report any other sudden
and unexplained symptoms. She does not report any problems with filling her
medications on time or remembering to take them, but she isn’t always sure what
she is taking or why.

Vitals: weight 152 lbs (69 kg); height 5’6” (167.6 cm); BP 119/72; HR 68
PMH: afib (chronic, rate controlled), hyperlipidemia, hypothyroidism, CKD,
asthma/COPD
Allergies: pet dander, seasonal allergies
Social History: former smoker (quit many years ago, has not relapsed), social drinker
once or twice a month (has one glass of wine on occasion)
Immunizations:
• Annual influenza: current
• COVID-19: 2 doses
• Tdap: does not recall her last booster
• Pneumococcal: received 1 dose many years ago, at least a decade
• Zoster: never received, has childhood history of chickenpox
Objective information/labs:
• BMP: electrolytes within normal limits, serum creatinine 1.5 mg/dL baseline
• Thyroid labs (normal values for TSH 0.3-3.0 mIU/L): has frequently fluctuated out of
range, as low as 0.1 or high as 4.5, over the last several years according to EHR
• Lipid panel: total cholesterol 223 mg/dL, LDL 134 mg/dL, HDL 54 mg/dL, TG 132
mg/dL
Medication Profile:
• Eliquis (apixaban) 5 mg PO BID
• Atorvastatin 10 mg PO QD
• Levothyroxine 75 mcg PO QD
• Levothyroxine 88 mcg PO QD
• Montelukast 10 mg PO QD
• Albuterol HFA (90 mcg/actuation): Inhale 1 puff PO Q4-6H PRN
• Spiriva HanidHaler: Inhale 1 capsule PO QD
• Anoro Ellipta 62.5-25 mg/actuation: Inhale 1 puff PO QD
Possible Claims
1. Pharmacist Identified DTP Rationale/Reason: Eliquis is inappropriately dosed based on patient age
and serum creatinine.
a. Documentation:
i. Reason: Inappropriate drug therapy
ii. Action: prescriber consulted
iii. Severity level: 8

2. Pharmacist Identified DTP Rationale/Reason: Patient may be taking levothyroxine inappropriately,

explaining abnormal lab fluctuations.
a. Documentation:
i. Reason: medication nonadherence
ii. Action: patient consulted and educated
iii. Severity level: 6

3. Pharmacist Identified DTP Rationale/Reason: Discontinue Spiriva Handihaler, since patient’s therapy
duplicates LAMA use and Spiriva is a single agent product.
a. Documentation:
i. Reason: duplicate therapy
ii. Action: prescriber consulted
iii. Severity level: 6

4. Pharmacist Identified DTP Rationale/Reason: Patient is not well managed for asthma/COPD and is not
using ICS therapy without documentation of intolerance. Discontinue montelukast 10 mg and switch
Anoro Ellipta to triple therapy (ex: Trellegy Ellipta) according to GOLD/GINA guidelines.
a. Documentation:
i. Reason: suboptimal therapy
ii. Action: prescriber consulted; patient educated about inhaler use technique
iii. Severity level: 8
5. Pharmacist Identified DTP Rationale/Reason: Patient is eligible to receive
Tdap booster and restart pneumococcal vaccine series based on age and last
known vaccination.
a. Documentation:
i. Reason: needs immunization
ii. Action: immunization provided
iii. Severity level: 4
6. Pharmacist Identified DTP Rationale/Reason: Patient is overusing albuterol
rescue inhaler due to poor control of asthma/COPD.
a. Documentation:
i. Reason: suboptimal therapy
ii. Action: prescriber consulted for therapy change; patient
educated about proper use of inhaler.
iii. Severity level: 4
7. Pharmacist Identified DTP Rationale/Reason: Patient is eligible for statin
therapy escalation based on ASCVD 10-year risk (21.1%) and no documented
intolerance. Increase atorvastatin 10 mg to 20 mg (or moderate intensity statin)
a. Documentation:
i. Reason: suboptimal therapy
ii. Action: prescriber consulted
iii. Severity level: 8