This study successfully demonstrated how an early implementation contextual analysis within a hybrid type 2 study design can be leveraged to identify and address initial barriers to the implementation.30,31 The critical value of such an assessment when implementing an evidence-based practice model in settings new to the evidence-based practice was highlighted by the dramatic increase in adoption after programmatic changes were made based that data. Moreover, the study emphasized the importance of rapidly assessing and disseminating contextual factors to program stakeholder so that implementation strategies may be adapted during the early phases of implementation.
Based on the real-time reporting of rapid analysis findings for early implementation barriers and facilitators, TennCare implemented several key changes to their implementation strategy in the last quarter of 2019 and first half of 2020. These included:
Promoting network weaving: Conference call between North Carolina pharmacists experienced in Medicaid MTM implementation and Tennessee MTM pharmacists (Quarter 4, 2019)
Provide ongoing consultation: Expert MTM implementation consultation (by University expert faculty) (Quarter 4, 2019)
Use Train the Trainer Strategies (Quarter 4, 2019)
Pharmacist fee schedule increases (Quarter 1, 2020)
A restructure strategy to decrease time to “go live” via a re-sequencing of MTM software training concurrent with credentialing process (rather than afterward) (Quarter 1, 2020)
Waiver of need for initial face-to-face visit (Quarter 1, 2020)
Duplicate documentation workaround in (Quarter 2, 2020),
Eligibility expansion in (Quarter 3, 2020),
Program adoption increased during and after these implementation strategy changes (Fig. 2).
The primary goal of the study was to describe implementation outcomes and contextual determinants of a Medicaid MTM pilot program during the initial phase of implementation. To our knowledge this is the first study to assess the feasibility, acceptability, and appropriateness of an implementation strategy to support MTM delivery. Overall, the study found that key stakeholders are supportive of the MTM program, but significant challenges with implementation persisted despite a well-evidenced and multi-faceted implementation strategy to reduce barriers. For instance, in a similar MTM pilot project in North Carolina was successfully launched despite no pharmacist remuneration during the first year. In contrast, a significant barrier for Tennessee pharmacists was pharmacist remuneration – a barrier identified during contextual inquiry. We believe this particular finding is related to recent declining third party reimbursement for prescription drugs over the past few years resulting in increased financial strain for community pharmacies.32,33
While participants reported a moderately high-level of feasibility in the surveys, the qualitative data suggested that there were notable barriers that may have affected feasibility. For example, double documentation was cited consistently throughout interviews as a key implementation barrier. Although web-based MTM software systems allow for MTM program patient referral, documentation, and care coordination, the lack of interfacing with the software systems already implemented at the PCHM/THL or pharmacy represent a major barrier to implementation, especially as it relates to the extra time required for duplicate documentation.12 Therefore, to increase feasibility, strategies, such as simplifying documentation requirements or providing enhanced education on efficient documentation, may be needed. Additionally, intervention complexity was frequently mentioned as a barrier, which is consistent with prior studies. 34 MTM, for some pharmacies, may represent a drastic shift from a prescription dispensing model to a more patient-centered workflow34, requiring change at multiple levels (e.g., job roles, IT systems, workflow).35,36 Given that pharmacies will likely vary in their preparedness for MTM, tailored implementation strategies may be needed to reduce barriers.14
Despite noted barriers, stakeholders indicated a high level of support for the intervention. Most participants felt that the program aligned with their organization’s mission and the pharmacy profession. One reason for this may be due to the long-standing history of MTM services. Pharmacists have been providing MTM services since the 1990s37,38 and on a nationwide scale since the introduction of Medicare Part D in 2006.39 Given the familiarity of the profession with MTM, overall positive perceptions of the program are not surprising. The recent mandate of a doctoral-level pharmacy degree emphasizing clinical therapeutics and patient care have likely further influenced pharmacist perceptions of MTM, despite its adding to pharmacist workload and disrupting workflow.
Prior studies have suggested that partnerships between pharmacists, other healthcare providers, and social service agencies are a key facilitator of MTM programs.11 The TennCare MTM Pilot used CPAs as an implementation strategy to facilitate better network ties across providers and pharmacists. However, partnership building was still cited as an early barrier to entry in the program among study participants. This suggests that implementation strategies may be needed to support partnership building and care coordination as a means to scale the program. Prior studies also suggest that payment models are critical to support MTM programs. While inclusion of a payment mechanism for pharmacist services was initially a facilitator in the TennCare MTM Pilot program, legislative restrictions led to a change from a value-based to a fee for service (FFS) model. Consequently, the FFS payment became a barrier as it was at a lower fee schedule than other reimbursable MTM programs.
Of note, there was no mention of external change agents or peer pressure during the key informant interviews, despite this having been shown to be a key driver for MTM implementation in prior studies.10,40 To address this gap, in the last quarter of 2019, a University-facilitated conference call was held to foster external collaboration with North Carolina pharmacists due to prior successful implementation of a Medicaid MTM program and similarities in practice region (Southeast United States). Anecdotal feedback was overwhelmingly positive and may represent another opportunity for future implementation strategies. Perhaps one of the reasons such external facilitation can prove useful for MTM implementation is learning of its successful implementation elsewhere given the general lack of compatibility between existing pharmacist workflows, especially those primarily of medication distribution, and clinical service delivery. Facilitated adaptation has been shown beneficial in these situations.14
Across all settings, the MTM implementation plan was informal, iterative, and mainly reactive in nature. A review of the MTM implementation literature also reveals little formal implementation planning at the organizational level.36 The use of a formal planning process, including models to guide implementation, has been shown beneficial in the implementation of new clinical initiatives in other professions.41,42 Although most sites did not have a formal plan for implementation, many sites did appoint a champion to help spearhead the intervention. As was true in previously reported MTM project implementation studies, our study found that engaging MTM champions was a clearly articulated driver of implementation even in the face of significant barriers. This is likely due to the large, intrinsic motivation to show the value of the pharmacist to patients and payers as pharmacists are not recognized as providers and reimbursement for patient care services remains largely elusive.36
As a result of this early stage assessment, TennCare has made several programmatic changes. As of the first half 2020, the following changes are now in place: pharmacist reimbursement rate increases after a nationwide review of pharmacist MTM fee schedules, re-sequencing of care coordination tool training during credentialing process to increase the speed of program enrollment, duplicate documentation workaround using existing software limitations, and an eligibility expansion. TennCare is also investigating the feasibility of removing the requirement that the first visit with patients be face-to-face facilitate patient scheduling and reduce patient “no-show” appointment rates.
This study had several limitations. These included a small sample size (15 survey participants, 9 interview participants), which limits the generalizability of our findings. Recruiting study participants was difficult, likely because of challenges encountered with implementation. It is possible that participants in our study had more positive perceptions of implementation whereas non-responders, who really struggled with implementation of the TennCare MTM Pilot, were less likely to participate. This study also collected perceptions regarding implementation from the innovation users and did not capture perceptions from the purveyor—TennCare staff who helped support implementation of this pilot.22 Future research should assess perceptions about implementation from the purveyors of MTM, who play a critical role in disseminating MTM and supporting pharmacists with implementation.