Share Our Selves Uses Medication Therapy Management (MTM) to Help Control Diabetes

Share Our Selves (SOC) community health center image.Share Our Selves (SOS) HRSA BPHC Exit Disclaimer is a community health center located in Costa Mesa, CA.

At SOS, visits for patients with diabetes are scheduled a using specific appointment type in their Electronic Health Record (EHR). This triggers a list of care elements for that visit, such as a foot exam, depression screening, dental care assessment, referral for eye exam, evaluation for medication therapy management (MTM), immunization status and the current HbA1c. If further dental care is required, the dental clinic prioritizes these patients. A multidisciplinary team (nurse, pharmacist, primary care provider, etc.) engages the patient in establishing a personalized care plan. This helps the team better understand the patient’s history, build a relationship, and tailor their care plan to support the patient’s goals. The team coordinates all areas of the patient’s care, using morning huddles and care plans in the EHR to communicate.

One innovative program SOS uses to support patients with diabetes is Medication Therapy Management (MTM) appointments. The goal of MTM is to improve diabetes control, optimize medication lists, engage patients in medication management and lifestyle modifications, and decrease their risk of an adverse medication event.

Candidates for MTM are patients who are at high risk for medication mismanagement if they:

  • Have three or more diagnoses,
  • Take five or more medications, or
  • Take a controlled substance or medication with a high side effect profile.

High-risk patients meet with a clinical pharmacist where they review the patient’s medications to create an accurate and comprehensive medication list. Patients also receive insulin training, nutrition counseling, guidance on other lifestyle modifications, as well as adherence tools, such as medication boxes. Patients are encouraged to bring family members to these ongoing appointments to educate everyone in the household about the patient’s condition and how to achieve a healthier lifestyle.

SOS measures impact and sustainability by considering the reduction in primary care provider time spent with patients on health education, medication optimization and diabetes self-management. MTM also adds value by decreasing adverse medication events, which can result in cost savings.

How to Implement

SOS took the following actions to implement the MTM model:

Date Last Reviewed:  November 2018


More Information

SOS Uniform Data System (UDS) Data

For more information about this promising practice, contact:

Dr. Mary Ann Huntsman
Director of Clinical Pharmacy Services
mahuntsman@shareourselves.org