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Medication Therapy Management

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Updated on May 11, 2021

The Medication Therapy Management (MTM) case type can help eligible members understand their medications and reinforce their knowledge of how to properly take them. It can prevent potentially harmful drug side effects and drug combinations. In addition, the medications are reviewed for opportunities to reduce prescription drug costs and help members get the most from their prescription benefits. The MTM program is a free service for eligible enrollees.

For more information, see Medication therapy management in the Pega Care Management Business Use Case Guide on the Pega Care Management product page.

The following list describes items that are related to the Medication Therapy Management Microjourney:

  • Configuring Social Determinants of Health
  • Configuring Medication Therapy Management
  • Data model
  • Extending rules in Medication Therapy Management
  • What not to do

Configuring Social Determinants of Health

To track the progress of any Social Determinants of Health (SDoH) issues, and use SDoH information and activities for optimum health and wellness for members, configure the settings in Pega Care Management.

Pega Care Management supports identifying and managing social determinants of health (SDoH) - the non-clinical factors that impact a patient’s health. It is estimated that greater than 65% of people experience at least one social determinant of health. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. You can create barriers for the supported category of SDoH in business analyst (BA) portal. The barriers that are related to SDoH categories are added directly to the member level and an associated SDoH issue is flagged for the patient. The SDoH issues identified for the member are displayed in the header of patient profile.
  1. In the header of Dev Studio, click ConfigureCare Management Configuration.
  2. Click the SDoH Categories tab.
  3. Select the check box for each SDoH category for which you want to enable tracking.
    The selected categories are available for use in a patient profile.
  4. Click Save SDoH to save your selections.
  5. Click Save to update the configuration page.

Configuring Medication Therapy Management

Medication Therapy Management (MTM) consists of a range of services that are provided to individual patients to optimize therapeutic outcomes and detect and prevent costly medication problems. Configure these settings to set the criteria against which patients who are enrolled in Medicare Part D are evaluated for enrollment in MTM.

Before you begin: Ensure that you have installed the Snomed codes in Pega Foundation for Healthcare.
  1. Log in to the application by entering the user name for the Business Analyst operator and the password that you specified. 
  2. Click Launch portalCM Business Analyst.
  3. In the navigation pane, click MTM config.
  4. Enter values for the following items to set the thresholds against which the qualified members are evaluated:
    Drug cost
    Indicates that the annual drug cost must be greater than this value for the patient to be eligible for the program
    Medication count
    Indicates the number of medications that a patient must need in order to be eligible for the program
    Late to refill days
    Sets the number of days for which a medication refill is considered late
    Chronic condition count
    Indicates the number of chronic conditions that a patient must have to be eligible for the program
  5. In the Chronic conditions section, in the Code field, select the code representing the condition from the list, and then in the Name field, type the name of the condition.
  6. Repeat step 5 for each condition that you are adding.
  7. In the Social Determinant Assessment list, select the appropriate assessment.
  8. In the MTM program list, select the appropriate program.
  9. Click Save.

Data model

In App Studio, you can view the data model for Medication Therapy Management in Case Types.

Click the Data model tab on the Medication therapy management page.

Extending rules in Medication Therapy Management

To meet your organization's needs, you can extend rules in MTM such as coverage, additional questionnaires, and calculation of delay in refills.

Rules for extension in MTM

Rule namePurposeAdditional information Example
CalculateRefillDelayDaysThe calculation of this rule is based on the system date and the next refill date. Clients can extend this rule based on their requirements.Data transformA business organization might want to modify their refill calculation strategy.
CheckMemberPlanCoverageAdd a plan in a line of business, other than Medicare. Data transformA business organization might want to include the Commercial line of business as a check for enrollment in MTM.
EvaluateMemberExpensesEvaluate the total expense of pharmacy claims for a member by using the TotalPaidValue property for the calculation. Data transform A business organization might use the value of the TotalChargeValue property for a calculation of the total amount instead of the paid amount.
ValidateDuplicateInterventionInListExtUsed for additional validation when adding interventions to the flow.Validate ruleClients might want to configure additional validations, for example, to validate a duplicate intervention based on the combination of category and the name of the intervention.
ValidateDuplicateBarrierListExtUsed for additional validation when adding barriers to the flow.Validate rule Clients might want to configure additional validations, for example, to validate a duplicate barrier based on the combination of category and the name of the barrier.
SetSpawnedInterventionAgentDataSets and passes the required values to a business analyst for creating interventions.Data transformA business organization might want to skip any validation or populate values for additional fields for intervention creation.
InitializeSdohAssessmentDetailsAdd another questionnaireData transformIn addition to the Social Determinants of Health questionnaire, a provider might add another survey, for example Health Risk Health Risk Assessment (HRA)
DrugToDrugInteractionIntegration for drug-to-drug interaction information. FlowsA business organization might integrate with a third-party application that describes drug-to-drug interactions.

What not to do

Do not override any rules for customization. Instead use the extension rules.

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