Pharmacist Evidence Base

(last edit 9/14/2015)

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Clinical Pharmacist References


Clinical Pharmacy Practice Guidelines and Positions

2015 Pharmacy ACCP White Paper – Collaborative Drug Therapy Management (CDTM) and Comprehensive Medication Management (CMM)

2014 ACCP Standards of Practice for Clinical Pharmacists

2014 Pharmacists Patient Care Process – Joint Commision of Pharmacy Practitioners (JCPP)

2012 PCPCC Practice Guidelines for Comprehensive Medication Management (CMM) in PCMH

2012 PCPCC (Patient Centered Primary Care Collaborative) Medication Management Quick Resource Guide

2008 APhA Core Elements of Medication Therapy Managment (MTM)

2003 ACCP Postion Paper on Collaborative Drug Therapy Management



Outside Support for Clinical Pharmacy Practice

2015 ACC Statement on Cardiovascular Team Based Care and the Role of Advanced Practice Providers (PAs, NPs, PharmDs)  (Web link here)

2015 National Governors Association (NGA) paper The Expanding Role Of PHARMACISTS in a Transformed Health Care System    (Web link here)

2014 Centers for Disease Control (CDC) Grand Rounds – PHARMACISTS Can Improve Public Health      (Web link here)

2012 Institute of Medicine (IOM) – Priniciples & Values of Effectice Team Based Health Care (features roles of clinical pharmacists)

2012 CDC Partnering with PHARMACISTS in Prevention and Control of Chronic Diseases

2011 US Surgeon General – Advanced PHARMACY Practice Report

2011 US Surgeon General – Support Letter for Advanced PHARMACY Practice



Studies, Presentations and Reviews on the benefits of Clinical Pharmacy Practice

2015 Practice Report PharmD led Medication Management program in PCMH

2015 Article – Pharmacists on Primary Care Teams Save Money and Lives

2015 Practice Spotlight – NC Mountain AHEC

2014 APhA Medication Therapy Management (MTM) Digest

2014 Presentation USC Integrating Clinical Pharmacy into Health Care Delivery

2014 ASHP PPMI (Pharmacy Practice Model Initiative) Recommendations

2014 PharmD case management for blood pressure and lipid level control after minor stroke

2013 Prescription Medicine Adherence Action Agenda – Be Medicine Smart

2008 Integration of a PharmD into a Stroke Prevention Clinic Team

2008 Literature Review Economic Effects of Clinical Pharmacy Interventions

2005 Lipid management in patients with coronary artery disease by a clinical pharmacy service.



Medication Related Problems (MRPs) and Interventions:

Summary of Medication Related Problems MRPs — Pharmaceutical Care Practice

2011 iMAP individualized medication assessment and planning tool (link)

2010 PCNE Classification for Drug Related Problems V6.2

2006 PCNE Classification for Drug Related Problems V5.01



Medicare Wellness Visits:

2015 Assessing Pharmacist-led Annual Wellness Visits MAHEC Experience

2014 Medicare Wellness Visits Can Pay for a Pharmacist

2013 ASHP Practice Report on Medicare Wellness Visits

2012 ASHP Spotlight Medicare Wellness Visits at UNC



01/19/2015 ASHP: Pharmacists Praise New Medicare Billing Opportunities

06/15/2014 ASHP: CMS Chief Affirms Incident-to Billing for Pharmacists is Allowed

Article: CMS Clarifies Incident-to Billing Relating to Pharmacist’s Services

CMS Letter response regarding Incident-to billing 03 2014

01/17/2014 White Petition Response: Pharmacists and the Social Security Act

ASHP Fact Sheet CCM and TCM billing

2014 ASHP Billing in Physician Based Clinic FAQ

ASHP FAQ Billing Medicare in a Facility Based/Provider Based Clinic

Article: Billing Incident-to Services



University of Wisconsin Anticoagulation Services Link

2013 University of Wisconsin Peri Procedure Guideline

2012 Chest Supplement PREVENTION OF HIT 9th edition ACCP




Summary of: Community and Clinical Pharmacy Services a Step by Step Approach by Ellis, Sherman

Medication Therapy Management (Chapter 4)

Pharmaceutical care is defined as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life (7)”.


  1. Assure that all of a patient’s drug therapy is appropriate, effective, safe, and convenient to take as indicated and to identify, resolve and prevent any medication (drug therapy) related problems (8).

Medication Therapy Management – a distinct service or group of services that optimize therapeutic outcomes for individual patients.  MTM services are independent of the provision of a medication product (6).  The framework for MTM includes a broad focus on patients in diverse care settings and patients transitioning through health-care settings, collaborating with physicians, and empowering patients.

The Core Elements of MTM Service (as defined by 2008 APhA/NACDS)  are:

  1. Medication Therapy Review (MTR)
    1. Defined as the systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them.
    2. The purpose of the MTR is to educate patients about their medications, address medication-related problems, and motivate patients to manage their medications and conditions.
    3. An MTR may be a comprehensive assessment of all medications or it may be targeted at one particular disease state.
    4. In addition to obtaining amedication history, a pharmacist conducting an MTR may assess the following of the patient: physical and overall health, preferences and values, goals of therapy, cultural or socioeconomic issues, and laboratory values.
    5. A pharmacist will also identify and prioritize medication-related problems related to clinical appropriateness, safety,efficacy, and accessibility to the patient. A plan to resolve medication-related problems will be devised that may include patient education, monitoring of therapy, and communication to other providers.
    6. Ideally, a patient would receive one comprehensive MTR annually and additional, more focused MTRs throughout the year to address specific problems.
  2. Personal Medication Record (PMR)
    1. A comprehensive medication list provided to the patient.
  3. Medication Action Plan (MAP)
    1. Patient-centered instructions that lists interventions the patient may employ to self-manage their health and their medications. It contains only actions the patient will do.
  4. Intervention and/or Referral
    1. While providing MTM, the pharmacist may need to intervene to resolve medication-related problems.
    2. Examples of interventions include collaborating with the patient’s other health-care providers or providing education to a patient. In some instances, the resolution of medication-related problems requires a referral to another provider. For example, a pharmacist may discover a medical problem, a patient is experiencing that needs further evaluation.
    3. Resolution of all medication-related problems requires collaboration among health-care providers and self-management by the patient.
    4. A pharmacist may work under protocol or collaborative drug therapy agreements to assist in resolving medication related problems, monitoring treatment or optimizing therapy.
  5. Documentation and Follow Up
    1. Documentation is essential to MTM delivery to communicate and provide reports of patient progress, support billing for services, demonstrate quality improvement and aid in continuity of care.
    2. Follow-up care is also documented and should be scheduled according to a patient’s medication-related needs.


Comprehensive Medication Management (CMM)

Per the 2012 PCPCC Medication Management Resource Guide — Guidelines for Comprehensive Medication Management (CMM) include:

  1. An assessment of the patient’s medication related needs
  2. Identification of the patient’s medication related problems
    1. Indication
    2. Effectiveness
    3. Safety
    4. Compliance/Adherence
  3. Develop a Care Plan with individualized therapy goals and personalized interventions
  4. Follow-up evaluation to determine actual patient outcomes

Per the 2015 ACCP White Paper on Comprehensive Medication Management (CMM): …ensures that individual patients are assessed to determine whether the patient’s medications are appropriate, effective, and safe. CMM involves the development of a patient-centered care plan that the patient understands and with which the patient agrees and in which he or she actively participates. A key difference between MTM and CMM is that CMM includes an assessment of the patient’s clinical status (e.g., evaluating blood pressure in patients on antihypertensive therapy) for each of the patient’s medications and health problems. Another essential element of CMM incorporates a clinically appropriate follow-up evaluation to assess the patient’s progress toward treatment goals. Finally, CMM requires collaboration among members of the health care team.

Collaboration may be achieved through Collaborative Drug Therapy Management (CDTM) agreements.

Also see text: Pharmaceutical Care Practice by Cipolle, Strand.


Summary of 2014 Pharmacist’s Patient Care Process

The goal of high quality, cost-effective and accessible health care for patients is achieved through team based patient-centered care. Pharmacists are essential members of the health care team. Pharmacists have unique training and expertise in the appropriate use of medications and provide a wide array of patient care services in many different practice settings. These services reduce adverse drug events, improve patient safety, and optimize medication use and health outcomes. To promote consistency across the profession, national pharmacy associations used a consensus-based approach to articulate the patient care process for pharmacists to use as a framework for delivering patient care in any practice setting.

Pharmacists use a patient-centered approach in collaboration with other providers on the health care team to optimize patient health and medication outcomes.

Pharmacists’ Patient Care Process using principles of evidence-based practice:

1.  Collect

2. Assess

3. Plan

4. Implement

5. Follow-up: Monitor and Evaluate






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