Tailored Pharmacy-Based Interventions to Improve Medication Adherence
In The Community Guideexternal icon, the Community Preventive Services Task Force (CPSTF) recommends tailored pharmacy-based interventionsexternal icon to support adherence to medications prescribed to prevent cardiovascular disease (CVD).1 The CPSTF found these interventions to be cost-effective for preventing CVD.1
The Surgeon General’s 2020 Call to Action to Control Hypertension also encourages the use of supportive strategies for medication adherence, including pharmacists as integral members of hypertension care teams.2
Public health practitioners and state and local health departments can support use of the CPSTF recommendation by promoting and helping pharmacies implement tailored pharmacy-based interventions.
Tailored pharmacy-based interventions aim to help patients who are at risk for CVD take their medications as prescribed. Interventions include the following:
- Assessment—Interviews or assessment tools are used to identify adherence barriers.
- Tailored guidance and services—A pharmacist use the results obtained from the patient’s assessment to develop and deliver tailored guidance and services that aim to remove or reduce identified barriers.
Medication nonadherence is when a patient does not take a prescribed medicine or follow the provider’s instructions for taking the medicine. Barriers that prevent patients from taking their medications can appear at the patient, provider, or health system level. Nonadherence is associated with uncontrolled blood pressure and higher rates of hospital admissions.4
The Pharmacists’ Patient Care Process was established by the Joint Commission of Pharmacy Practitioners to help pharmacists deliver patient care and services in a consistent way.5
- Tailored guidance includes focused medication counseling or motivational interviewing sessions.
- Tailored services include one or more of the following: patient tools, such as pillboxes, medication cards, and calendars; medication refill synchronization; and enhanced follow-up.
Interventions may be set in community or health system pharmacies. They may include additional components, such as patient education materials or communication between the pharmacist and the patient’s primary care provider. Interventions may be used alone, or as part of a broader intervention to reduce patients’ cardiovascular disease risk.
Tailored pharmacy-based interventions address barriers to medication adherence by examining the factors that affect a person’s ability to take their medications. These barriers may be complex and include factors related to socioeconomics, health care system structures and processes, severity of co-occurring medical conditions, complexity of medication and nonmedication therapies, and patient concerns.3
Factors that affect a patient’s medication adherence may include:
- Medication cost.
- Busy schedules that make it hard to remember to take medications consistently.
- Ease of scheduling appointments.
- Time needed to schedule and attend appointments.
- Ease and comfort level of communicating with the pharmacist or other providers.
- Understanding when and how often to take medications.
- Ability to sync medications and receive automated 30-day or 90-day refills.
- Health condition severity and beliefs about their condition.
- Expectations around possible effects of the medication.
These factors may be intensified by a lack of health care and pharmacy access in the community; lack of trust and effective communication with providers; and limited patient involvement in shared decision-making.
Studies have shown that patients who were adherent to their antihypertensive medications were 30% to 45% more likely to achieve blood pressure control compared to those who were not.6,7
Nonadherence to medications to prevent CVD has been associated with a significant increase in the risk of premature death from any cause, CVD death, hospitalization for heart attack or heart failure, and coronary revascularization procedures.8
Strategies that Support the Pharmacists’ Patient Care Process and Tailored Pharmacy-Based Interventions
The Joint Commission of Pharmacy Practitioners developed the Pharmacists’ Patient Care Processexternal icon to address medication nonadherence for chronic diseases. Steps in the process (collect, assess, plan, implement, follow-up, and monitor) closely align with how a pharmacist selects tailored actions to remove or reduce patient adherence barriers.
Tailored, pharmacy-based interventions may be implemented as one component of the broader Pharmacists’ Patient Care Process pdf icon[PDF – 2 MB]external icon. Strategies that support the Pharmacists’ Patient Care Process include medication therapy management, the appointment-based model, collaborative practice agreements, and text messaging.
- Medication therapy management (MTM)9 includes a broad range of health care services provided by pharmacists—the medication experts on a patient’s health care team. It allows pharmacists to actively manage patients’ medications and identify, prevent, and resolve medication-related problems. This support helps patients get the most benefit from their medications. MTM services include medication therapy reviews, pharmacotherapy consults, anticoagulation management, immunizations, health and wellness programs, and many other clinical services.
- The appointment-based model (ABM)10 is a patient-focused care model that can help patients take their medications, make a pharmacy’s workflow more efficient, and prevent problems before patients arrive at the pharmacy. Patients enrolled in the ABM have a designated appointment day to pick up all medications. Pharmacy staff call patients before their appointment to identify any changes to their medications and confirm that each prescription should be refilled. The ABM shifts the pharmacy staff’s focus from passively filling prescriptions at the request of the patient on an unaligned schedule to proactively synchronizing a pick-up date for chronic medicines. Staff also review the patient’s medications each month to ensure that they are getting the correct medications and to identify any potential problems.
- A pharmacist collaborative practice agreement (CPA)11 is a formal agreement between prescriber(s) and pharmacist(s). A CPA allows licensed health care providers to make diagnoses, supervise patient care, and refer patients to pharmacists. Pharmacists are then allowed to perform specific patient care functions, such as renewing prescriptions, modifying medication therapy according to the protocol, and ordering lab tests.
- Text messaging12 is available on mobile devices and is used widely by people in all age and socioeconomic groups. It can be used to communicate health information to patients to improve medication adherence.
The benefits and considerations of each of these strategies are outlined in the table below.
Table 1. Strategies that Support The Pharmacists’ Patient Care Process and Tailored Pharmacy-Based Interventions
|Medication therapy management (MTM)9||
|Collaborative practice agreement (CPA)11||
The CPSTF found these tailored pharmacy-based interventions to be cost-effective in preventing CVD among patients with CVD risk factors. They also found evidence that among patients with existing CVD, the cost savings from averted health care exceeded the costs of implementation.
CVD is a major driver of health care costs in the United States—with over $363.4 billion going toward health care services, medications, and lost productivity due to premature death each year.13
The implications of medication nonadherence are widespread and have financial impacts on health systems, providers, payers, and most importantly, patients. In the United States, the costs of nonadherence to prescribed medications are high and place significant financial strains on the health care system as a whole.14
Medication nonadherence is associated with worse health outcomes and higher health care costs among people with CVD or CVD risk factors.14-17 In one study, higher adherence to prescribed medications for congestive heart failure, high blood pressure, and high LDL cholesterol levels reduced annual health care spending per person by an estimated $7,800, $3,900, and $1,250, respectively, compared to patients with poorer adherence.17
Tailored pharmacy-based interventions to improve medication adherence among patients with CVD risk factors help address growing health care costs. These interventions lead to cost savings from reductions in outpatient primary care and specialist visits, hospitalizations, and emergency department use.18 The full economic impact of implementing these interventions for key partners and participants involved in the delivery, payment, and receipt of these interventions have been largely unexplored by researchers.
As state and local health departments consider introducing or expanding these interventions in their communities, an important first step is to recognize and convene partners involved in implementing the interventions to ensure greater efficiencies, better health, and cost savings. By considering each key player’s role in terms of potential costs and benefits, state and local health departments and their partners may better understand how each may facilitate their implementation and be affected by them.
The role and implementation considerations for key players involved in the delivery, payment, and receipt of tailored pharmacy-based interventions are outlined in the table below.
Table 2. Implementation Considerations for Key Partners and Participants
|Partner Perspective||Role in Interventions||Implementation Considerations|
|Other members of the care team||
The tools and resources listed in this section offer steps that public health practitioners and state and local health departments may take.
Identify patient populations that need help. For example, practitioners and health departments can
- Map populations with high medication nonadherence rates.
- Measure medication adherence in a population with high blood pressure. The proportion of days covered (PDC) is the leading method used to calculate medication adherence at the population level. A population is considered adherent if 80% of people have access to their medications for at least 80% of days in a defined study period (e.g., 80% of 365 days).
- Interactive Atlas of Heart Disease and Stroke
This CDC interactive mapping resource provides data and filter options, including social and economic data, county-level blood pressure medication nonadherence, number of pharmacies and drug stores, and Medicare beneficiaries with heart disease.
- GIS Example: South Dakota Blood Pressure Medication Nonadherence
This state-level example uses GIS to identify target areas for heart disease prevention efforts related to medication nonadherence in South Dakota. It is part of a CDC GIS Capacity Building Project.
Assess facilitators and the barriers to implementing tailored pharmacy-based interventions. For example, practitioners and health departments can
- Identify pharmacies that offer tailored pharmacy-based interventions or supporting strategies or pharmacies that are interested in implementing these services.
- Determine what factors help patients access and enroll in pharmacies that provide MTM, ABM, or medication synchronization—and what factors prevent access.
- Methods & Resources for Engaging Pharmacy Partners pdf icon[PDF – 765 KB]
This CDC guide describes how health departments can establish or expand pharmacy services. The information is summarized in a Coffee Break webinar pdf icon[PDF – 1 MB].
- Using the Pharmacists’ Patient Care Process to Manage High Blood Pressure: A Resource Guide for Pharmacists pdf icon[PDF – 633 KB]
This CDC guide provides information about current resources and emerging practices, as well as tools and examples that pharmacists can use to help them improve health outcomes associated with cardiovascular disease.8
- A Program Guide for Public Health: Partnering with Pharmacists in the Prevention and Control of Chronic Diseases pdf icon[PDF – 389 KB]
This CDC guide is for state health departments and communities that want to build or maintain existing relationships with pharmacists and other stakeholders. It includes basic definitions, information about the role of a pharmacist in team-based care, information about scope of practice laws, state health department examples, and strategies to consider.
Act to implement tailored pharmacy-based interventions with strategies that complement the CPSTF recommendation. For example, practitioners and health departments can
- Share information with pharmacy partners and support ABM and medication synchronization.
- Promote team-based care through MTM and other tailored pharmacy-based interventions.
- Pharmacy’s Appointment-Based Model pdf icon[PDF – 1 MB]external icon
This American Pharmacists Association (APhA) Foundation implementation guide has five modules: Introduction, Gaining Organizational Support, Developing the Operational Plan (includes sample documents), Sharing Benefits, and Integrating Technology and Data Monitoring. It also includes stories from the field.
- MTM Libraryexternal icon
This APhA portal contains tools for starting or improving MTM services.
- Advancing Team-Based Care Through Collaborative Practice Agreements pdf icon[PDF – 4 MB]
This CDC resource and implementation guide defines collaborative practice agreements, provides information about state laws and other factors to consider, and provides a template for drafting a sample agreement.
- Field Notes: HealthPartners Pharmacy Program pdf icon[PDF – 714 KB]
- Case Study: Team-Based Care in Arizona, Georgia, Iowa, Utah, Virginia, West Virginia, and Wyoming pdf icon[PDF – 475 KB]
- Field Notes: University of California, San Diego (UCSD) Pharmacy Program pdf icon[PDF – 782 KB]
- Field Notes: Michigan Medicine and Meijer Pharmacy Program pdf icon[PDF – 604 KB]
- MTM Profilesexternal icon
Website addresses of nonfederal organizations are provided solely as a service to our readers. Provision of an address does not constitute an endorsement by the Centers for Disease Control and Prevention (CDC) or the federal government, and none should be inferred. CDC is not responsible for the content of other organizations’ web pages.
- The Community Guide. (2019). Cardiovascular disease: tailored pharmacy-based interventions to improve medication adherenceexternal icon.
- U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Control Hypertension. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2020.
- Ferdinand KC, Senatore FF, Clayton-Jeter H, Cryer DR, Lewin JC, Nasser SA, Fiuzat M, Califf RM. Improving Medication Adherence in Cardiometabolic Disease: Practical and Regulatory Implications. J Am Coll Cardiol. 2017 Jan 31;69(4):437-451. doi: 10.1016/j.jacc.2016.11.034. PMID: 28126162; PMCID: PMC5604316.
- Centers for Disease Control and Prevention. CDC Grand Rounds: improving medication adherence for chronic disease management — innovations and opportunities. MMWR 2017;66(45).
- Joint Commission of Pharmacy Practitioners. (2019). The Pharmacists’ Patient Care Processexternal icon.
- Bramley TJ, Gerbino PP, Nightengale BS, Frech-Tamas F. Relationship of blood pressure control to adherence with antihypertensive monotherapy in 13 managed care organizations. J Manag Care Pharm. 2006 Apr;12(3):239-45. doi: 10.18553/jmcp.2006.12.3.239. PMID: 16623608.
- Piercefield EW, Howard ME, Robinson MH, Kirk CE, Ragan AP, Reese SD. Antihypertensive medication adherence and blood pressure control among central Alabama veterans. J Clin Hypertens (Greenwich). 2017 May;19(5):543-549. doi: 10.1111/jch.12953. Epub 2016 Dec 5. PMID: 27917605.
- Ho PM, Magid DJ, Shettely SM, et al. Medication nonadherence is associated with a broad range of adverse outcomes in patients.
- American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 pdf icon[PDF – 523 KB]external icon. Washington, DC: American Pharmacists Association and National Association of Chain Drug Stores Foundation; 2008.
- American Pharmacists Association Foundation. Pharmacy’s Appointment-Based Model: Implementation Guide for Pharmacy Practices pdf icon[PDF – 455 KB]external icon. Washington, DC: American Pharmacists Association; 2013.
- Centers for Disease Control and Prevention. Advancing Team-Based Care Through Collaborative Practice Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team pdf icon[PDF – 1 MB]. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2017.
- Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, Rodgers A, et al. Mobile telephone text messaging for medication adherence in chronic disease: a meta-analysisexternal icon. JAMA Intern Med. 2016;176(3):340–349.
- Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021 Jan 27:CIR0000000000000950. doi: 10.1161/CIR.0000000000000950. Epub ahead of print. PMID: 33501848.
- Benjamin RM. Medication adherence: helping patients take their medicines as directed. Public Health Rep. 2012 Jan-Feb;127(1):2-3. doi: 10.1177/003335491212700102. PMID: 22298918; PMCID: PMC3234383.
- Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open. 2018;8(1):e016982. Published 2018 Jan 21. doi:10.1136/bmjopen-2017-016982.
- Lloyd JT, Maresh S, Powers CA, Shrank WH, Alley DE. How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program? Med Care. 2019 Mar;57(3):218-224. doi: 10.1097/MLR.0000000000001067. PMID: 30676355.
- Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lower health care use and costs despite increased drug spending. Health Aff (Millwood). 2011 Jan;30(1):91-9. doi: 10.1377/hlthaff.2009.1087. PMID: 21209444.
- The Community Guide. (2020). Economic Review Analytic Framework: Tailored Pharmacy-based Interventions to Improve Medication Adherence for Cardiovascular Disease Prevention and Management pdf icon[PDF – 387 KB]external icon.
- Taylor AM, Axon DR, Campbell P, et al. What Patients Know About Services to Help Manage Chronic Diseases and Medications: Findings from Focus Groups on Medication Therapy Management. J Manag Care Spec Pharm. 2018;24(9):904-910.
- Zhang Y, Doucette WR. Consumer decision making for using comprehensive medication review services. J Am Pharm Assoc. (2003). 2019;59(2):168-177.e5. doi:10.1016/j.japh.2018.11.003.
- Funk KA, Pestka DL, Roth McClurg MT, Carroll JK, Sorensen TD. Primary Care Providers Believe That Comprehensive Medication Management Improves Their Work-Life. J Am Board Fam Med. 2019;32(4):462-473. doi:10.3122/jabfm.2019.04.180376.
- Bonner L. Program thrives on ‘relationship of trust’ between community health workers and patients. PharmacyToday. 2019;9:33.
- Linville C. The technician’s role as a community health worker. America’s Pharmacist. 2019; 3:36-39.
- Piña IL, Di Palo KE, Brown MT, Choudhry NK, Cvengros J, Whalen D, Whitsel LP, Johnson J. Medication adherence: Importance, issues and policy: A policy statement from the American Heart Association. Prog Cardiovasc Dis. 2020 Aug 12:S0033-0620(20)30155-9. doi: 10.1016/j.pcad.2020.08.003. Epub ahead of print. PMID: 32800791.
- Miller DE, Roane TE, Salo JA, Hardin HC. Evaluation of Comprehensive Medication Review Completion Rates Using 3 Patient Outreach Models. J Manag Care Spec Pharm. 2016;22(7):796-800. doi:10.18553/jmcp.2016.22.7.796.