Comprehensive medication review and MTMSee the whole medication picture.
A comprehensive medication review is a pharmacist's check of everything a person takes, including over-the-counter products and supplements, against their diagnoses, labs and daily condition. We find interactions, duplication, dosing concerns, side effects, monitoring gaps and discrepancies, and send clear recommendations to each prescriber.
When several prescribers are involved, someone needs to review everything together.
People with complex needs often see several prescribers who can't see each other's orders. Medications pile up, doses drift, and side effects get mistaken for new symptoms or behaviors. In a small 2020 study of 15 adults in Michigan group homes, a pharmacist found 2.4 medication problems per person.
When to refer
- Five or more medications, or several prescribers
- A recent hospital stay or ED visit
- New behaviors, falls, sleepiness or confusion
- Psychotropic medications, especially more than one
- A new admission to a home or program
- Quarterly drug regimen reviews in ICF/DD homes
Every medication, in context
- A current reason for every medication
- Doses that fit age, weight, kidney and liver function
- Interactions and duplicate therapy
- Side effects and adverse drug events
- Monitoring: labs, vitals and follow-up
- Discrepancies between orders, MAR and pharmacy records
- Psychotropic use and gradual dose reduction
- Opportunities to simplify or deprescribe
- Lower-cost alternatives and Medi-Cal Rx coverage
Psychotropic review
Behavioral medications should have a documented reason, never serve as a restraint, stay at the lowest dose that works, and come after non-drug approaches. They can also stay on long after the reason for starting them has passed, and their side effects can look like new behaviors.
Reconciliation after hospital stays
Catch medication discrepancies before they become care problems. After a hospital stay or ED visit, we reconcile discharge orders with the home's records and the pharmacy, and confirm anything unclear with the prescriber.
Three kinds of review
- Medication reconciliation
- Comparing every list (orders, the MAR, pharmacy records, discharge papers and what the person actually takes) and resolving the differences.
- Comprehensive medication review
- Assessing the whole regimen against the person's conditions, labs, goals and daily life, with recommendations to each prescriber. It's the core of MTM.
- Routine regimen review
- The scheduled record review some facilities require (monthly in nursing facilities, quarterly in ICF/DD homes), reporting problems to the facility and prescriber.
A review done from records alone lists what it couldn't see, such as how medications are actually given or orders missing from the records sent.
MTM: review, plan and follow up
MTM keeps the review going. The pharmacist works with the person, their caregivers and prescribers over time and follows each problem until it's resolved. It works for one person at home or a whole caseload.
- Medication therapy reviewEvery medication checked for need, effectiveness, safety and how it's really taken.
- Personal medication listOne up-to-date list for the person, family, home and every prescriber.
- Medication action planClear next steps for the person and caregivers, in plain language.
- Intervention and referralRecommendations to prescribers, and referral when something needs another clinician.
- Follow-upTargeted check-ins after each change, and a full review on an agreed schedule.
Built on the five core elements of an MTM service described by the American Pharmacists Association and NACDS: J Am Pharm Assoc, 2008.
Findings your team can act on
Written review
A prioritized summary of findings for each person, in plain language.
Prescriber recommendations
Brief, evidence-based recommendations, tracked to a response.
Caregiver instructions
What changed, when, and what to watch for, for every change.
Follow-up and reporting
Re-review after changes, and problems resolved in your monthly report.
Questions about medication review and MTM
How often should medications be reviewed?
At referral, after any hospital stay or ED visit, and whenever health or behavior changes. ICF/DD homes must have a pharmacist review each person's drug regimen at least quarterly, and other settings can follow a similar schedule.
Is this the same as medication therapy management (MTM)?
Closely related, and both are included. A comprehensive medication review is a one-time, in-depth check. Medication therapy management builds on it with a personal medication list, an action plan and follow-up over time.
Can I use ChatGPT or another AI tool to review my medications?
AI tools can explain general information, but they shouldn't be used to review your own medications: they can't see your full record or lab results, can't contact your prescriber, and get drug questions wrong often enough to matter (ASHP, 2023). Ask a licensed pharmacist. More on using AI for medication questions.
Can individuals and families request a review?
Yes, in California. We review medications for individuals and families as well as organizations. How it works for individuals.
Does Medicare pay for a medication review?
If you have Medicare drug coverage, your plan may offer a free MTM review if you qualify (Medicare). Call your plan to ask. Who qualifies.
Do you change prescriptions?
No. Recommendations go to the treating prescriber, who decides. We then help the home and pharmacy carry out any change.
Need a clinical medication resource for your organization?
Schedule a conversation about your population, workflow and medication-management needs. You'll speak directly with Stefania Ana, PharmD, MA.