Medication Therapy Management Services

The pharmacy practice offers medication therapy management (MTM) services delivered by a pharmacist focused on improving patients’ therapeutic outcomes. The MTM services are patient-centered, based on individual patient need, and use a standard patient care process. Delivery of MTM services includes a comprehensive approach to identifying and resolving medication therapy problems in collaboration with other health care providers during the time period the patient is under the pharmacist’s care. The service design empowers patients to take an active role in managing their medications.

MTM services may be targeted to specific patients. The practice conducts evaluations of patient populations utilizing information such as number of prescriptions/patient, patient-focused surveys, or health plan initiatives, to identify those patients in need of MTM services. Patients may also be referred by prescribers or may self-refer for services.

Medication Therapy Management Process of Care

The fundamental process steps for medication management services are the same as described in the previous section. In addition, the following details for the MTM process are expected in order to deliver consistent, predictable, measurable medication therapy management:


The pharmacist will collect the necessary subjective and objective information about the patient in order to understand the relevant medical/medication history and clinical status of the patient. The pharmacist will:

  • Identify patients with a potential need for patient care services
  • Obtain relevant health, medical, socioeconomic, and medication history, including patient’s medication experiences/history and preferences/beliefs
  • Obtain pertinent health data (laboratory values, blood pressure readings, etc.)
  • Verify/clarify data with patient and provider(s)


The pharmacist will assess the data collected and the clinical effects of the patient’s therapy and will identify and resolve problems. The pharmacist will:

  • Assess health/functional status, including health literacy
  • Perform a comprehensive medication review of therapy to identify, resolve, and prevent medication-related problems
  • Identify use patterns of all medications, including samples, OTCs, and supplements
  • Assess each medication for appropriateness, effectiveness, safety, and adherence
  • Identify medication-related problems

Develop Goals and Care Plans

The pharmacist will develop patient-centered goals and a care plan in collaboration with the patient and other health care providers. The pharmacist will:

  • Establish goals of therapy and develop a medication-related care plan in collaboration with the prescriber and the patient that address recommended steps to achieve optimal outcomes
  • Select, initiate, modify, or administer medication therapy as permitted under scope of practice and enabled by collaborative practice agreements
  • Create a patient medication-related action plan and personal medication list


The pharmacist will implement the care plan in order to achieve the patient’s goals. The pharmacist will:

  • Provide education, training, and support services to the patient to ensure that the patient agrees with and understands their medications and the medication-related care plan
  • Communicate the medication-related care plan to the prescriber and other relevant members of the health care team
  • Document care, including goals of therapy and information for reporting outcomes
  • Coordinate medication management services within the broader services provided to the patient


The pharmacist will evaluate the outcomes of the patient’s therapy, the effectiveness of the care plan, and modify the plan as needed. The pharmacist will:

  • Assess outcomes of care, including achievement of goals of therapy, and recommend further therapeutic changes to achieve desired goals/outcomes
  • Determine quality and value of care delivered

Monitor or Transition

The pharmacist will monitor the patient to ensure goals in the care plan are met or transition the patient to the appropriate health care provider as necessary. The pharmacist will:

  • Provide ongoing monitoring and follow-up care as required to achieve goals of therapy
  • Coordinate the transition of the patient to another provider as necessary
  • Provide other patient care services permitted under the pharmacists’ scope of practice as needed by the patient

The MTM Core Elements Service Model packages this process into MTM service deliverables. The heart of the model is a comprehensive medication review and follow-up monitoring (much like an annual physical with a physician followed by any follow-up needed that is identified in the physical exam). The follow-up monitoring encounters OR unique encounters to address specific new problems are termed targeted medication reviews. As a result of comprehensive medication reviews, the patient receives a reconciled medication list containing all of their medications, including prescription, OTC, and herbal and dietary supplements AND a medication action plan (MAP) with items for the patient to work on to improve therapeutic outcomes. The MAP is in addition to the health care provider specific care plan that the pharmacist develops and documents in the patient record. At targeted reviews, ideally the pharmacist should update the medication list and review the MAP. The service model is intended to be collaborative in that every effort should be made to communicate and collaborate with the patient’s physician so that the patient’s therapy goals from the MTM visit are integrated and coordinated with the patient’s overall health care plan.

Medication Therapy Management Deliverables

Comprehensive Medication Review (CMR) includes:

The pharmacist collects necessary subjective and objective information about the patient including a complete medication history (prescription and nonprescription medications, herbals and other dietary supplements) to understand the relevant medical/medication history and clinical status of the patient. (Note that information can be collected by trained support personnel for the pharmacist to then assess). This is the 'Collect' part of the patient care process.

Patient information including:

  • Recipient’s full, legal name
  • Address and telephone number
  • Gender
  • Date of birth or age
  • Current medical conditions
  • Past and resolved medical conditions
  • Allergies and sensitivities
  • Primary physician and contact information

Complete history to include:

  • List of all prescription and nonprescription drugs with their indications, including those that are administered in the physician office or hospital and those filled elsewhere
  • List of drug doses, directions and intended use for this patient
  • List of all relevant medical devices
  • List of all dietary supplements, herbal products, and vitamins
  • Alcohol and tobacco use history and illicit drug use (if pertinent)
  • Relevant clinical information such as height, weight, labs, test results
  • List of relevant environmental factors that impact the patient including socioeconomic status, exercise or activity level, if applicable
  • Identifying communication issues including disability, language, cultural influences, literacy, health literacy, etc.

Performing or obtaining necessary assessments of the patient’s health status

  • BP check, Cholesterol Check, etc.

Assessment of the patient’s therapies, laboratory results, and other factors whereby the pharmacist identifies and resolves the patient’s medication therapy problems. The pharmacist comprehensively assesses the patient’s medical history, medications, laboratory results, socio-economic factors, health literacy, cultural issues, and other relevant data and the clinical effects of the patient’s therapy, including medication adherence, to identify and resolve problems. This is the 'Assess' part of the patient care process.

Assessment of drug problems identified, including but not limited to:

  • Determining if the medications are appropriately indicated
  • Determining if there is therapeutic duplication in therapy
  • Determining if the recipient needs additional medications (gaps in therapy)
  • Determining if the medications are the most effective products available for the conditions
  • Determining if the medications are dosed appropriately to meet goals of therapy
  • Identifying adverse effects caused by medications
  • Determining if the medications are dosed excessively and causing toxicities
  • Determining if the recipient is taking the medications appropriately to meet goals of therapy, including barriers to compliance such as multiple times per day dosing, cost of medications, etc.
  • Evaluating effectiveness and safety of current drug therapy

Develop a Care Plan with the involvement of the patient and prescriber so that appropriate patient goals are identified and coordinated with the patient’s overall care. The plan is updated during follow-up monitoring. This is the 'Develop a Plan' part of the patient care process.

The care plan includes:

  • Patient-centered goals and a care plan developed in collaboration with the patient and other health care providers.
  • Intervention and/or Referral. This is the 'Implement the Care Plan' part of the patient care process and includes the personal medication list and medication action plan deliverables from the core elements service model.
  • Intervention/Referral whereby the pharmacist intervenes with the patient, prescriber, or appropriate provider to address potential problems/issues identified during medication reviews. As appropriate, the pharmacist refers the patient to other providers/services based on information discussed in the medication therapy review.
  • The pharmacist provides patient education and training to improve the patient’s self-management of his or her medications.
  • Furnishing the patient with additional education, materials, devices, aids, or services in conjunction with the care plan (adherence aids, pill minders, BP cuff, etc.)
  • Personal Medication List (or sometimes referred to as a Personal Medication Record): Personal Medication List is developed after assessing and reconciling medications and given to the patient. Personal Medication List includes an accurate list of all of the patient’s prescription and nonprescription medications, herbals and other dietary supplements. The patient shares this list with other health care providers to improve continuity of care and prevent adverse events due to medications. The list is updated during follow-up monitoring. This deliverable is part of the 'Implement the Care Plan' in the patient care process.
  • Medication Action Plan (MAP): The medication action plan (MAP) is a patient-specific document that is developed in addition to the patient’s care plan. The MAP contains several items for the patient to work on in order to optimize medication therapy outcomes, and is developed with the patient’s input and engagement. The MAP is designed to empower the patient to take an active role in appropriate medication management. This deliverable is part of the 'Implement the Care Plan' in the patient care process.
  • Documentation/Follow-up whereby pharmacist documents the MTM visit in the patient’s chart, including the patient’s goals of therapy, care plan, interventions and referrals made, communication with the prescriber, etc. The pharmacist will document this encounter in a retrievable format that is accessible to all pharmacy staff, at the point of care, ideally electronically in an interoperable EHR format. The pharmacist monitors the outcomes of the patient’s therapy and/or transitions the patient to the appropriate health care provider as necessary. A follow-up visit is scheduled for the patient for ongoing monitoring as appropriate. This section includes the ‘Evaluate' and 'Monitor or Transition’ parts of the patient care process.

Documentation can include:

  • Date of encounter
  • Date of documentation
  • Time spent with patient
  • Written care plan
  • Complete reconciled medication list including OTC
  • Information, instructions and resources delivered to the patient
  • Content of pharmacist’s communications to patient’s other health care providers
  • Follow-up plan
  • Evaluation of success in meeting goals of medication treatment plan
  • Processes to improve continuity of care, outcomes, and outcome measures

MTM Targeted Medication Review

Targeted medication reviews are conducted by the pharmacist when:

  • Follow-up monitoring is needed to address problems identified during a comprehensive medication review or for patient-specific needs identified through a variety of mechanism. For example, targeted medication reviews to address medication adherence issues, high risk medications, or ongoing monitoring of cholesterol medications. Another example would be when the patient experiences a new medication-related problem that needs to be addressed.
  • The pharmacist assesses the new therapy problem or reassesses the problem needing monitoring, intervenes where necessary, and provides education and information to the patient, the prescriber, or both, as appropriate. Ideally, targeted medication reviews are performed for patients who have received a comprehensive medication review within the past year.

Targeted medication reviews:

Are conducted for ongoing monitoring of medications and interventions

  • Identify issues that need to be addressed on a longitudinal basis post-comprehensive medication review. Many chronic, complex patients will require ongoing monitoring target population to monitor
  • Determine parameters (such as current MTM patient with a specific medication issue, or Beers Criteria for medication use in the elderly to identify patients at risk that may not meet criteria for a CMR) 

Are to address new specific potential or actual medication-related problems

  • Collect/update necessary data in patient health record
  • Assess and intervene to resolve any identified problem(s)
  • Documentation of intervention or issue
  • Communication with patient and health care provider
  • Written plan including goals and actions needed to resolve the issue
  • Follow up plan
  • Evaluation of success in meeting goals of medication treatment plan
  • Provide updated personal medication list and MAP if appropriate
  • Refer patient if necessary
  • Schedule follow-up visit if necessary