Chronic Conditions - Key Activity 12


Manage Medication Therapies


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; care coordination; address social needs.


Managing diabetes and hypertension with medication therapies requires a comprehensive approach to care, which should be tailored to the needs of each patient. Practices should work to:

  • Implement a fixed-dose combination of medications for hypertension.
  • Continually assess the need for medications to manage type 2 diabetes and hypertension as some patients can come off antihypertensives with lifestyle change and weight loss (less common).
  • Assess and explore patients’ experience regarding unwanted side effects of medication.
  • Use preferred medication protocols as per guidelines. Practices should make sure that the guidelines clearly specify which provider types are authorized to make those changes.

Managing medication therapy is important because it helps patients to have better clinical outcomes. It also allows for the use of medications to be streamlined and have a level of regular clinical monitoring, which allows for adjustments to be made on a regular basis in order to best serve patients. Revisiting medication therapy avoids clinical inertia (i.e., when clinicians do not up-titrate medications despite persistence of high blood pressure. The Bellows study (2023) found that treatment intensification is likely the most important driver of blood pressure control.[1]

Clinicians should work to prescribe medications in a manner that is within their best judgment and that promotes equitable access to medications. The chosen plan of treatment should also take into account the patient’s available resources. Clinicians should also work with their care teams to reduce barriers to medication access.

An aspect of effective medication management is to involve patients and families in their care. When deciding upon a medication for treatment, clinicians should involve the patient in deciding upon the type of treatment that best fits their lifestyle. This can include addressing patients’ social needs, as unmet social needs can contribute to difficulties in medication and diet adherence, or more broadly, difficulties in adhering to medication and recommended lifestyle changes.

If a family member or caregiver is involved, they should be included in the conversation so that they understand how to best assist the patient. Care management may also be used to further assist in effective usage of medications.

Relevant health information technology (HIT) capabilities to support this activity include care guidelines, EHR medication lists and alerts, clinical decision support, and medication adherence assessments. Additional tools include condition-specific resources for optimizing medical therapy. When available, clinical pharmacists are an excellent resource for compliance and prescribing recommendations. guidance.

(See Appendix E: Guidance on Technological Interventions.)

Action steps and roles

1. Consult clinical practice guidelines for how to best manage the condition.

Suggested team member(s) responsible: clinician.

Practices should work to update/implement clinical practice guidelines to ensure they are up-to-date and effective for managing diabetes and hypertension. See Key Activity 2: Update or Implement Clinical Practice Guidelines for more information.

Please also review the following resources:


2. Decide upon a set course of treatment with the patient. If available, a clinical pharmacist may also be consulted.

Suggested team member(s) responsible: clinician or patient or clinical pharmacist (if available).

Clinicians should work to develop a treatment in conjunction with the patient’s wishes. Chronic disease management is significantly related to lifestyle choices. Therefore, it is crucial that a plan is developed to work with the patient’s lifestyle, rather than not taking the patient’s current status into account.


3. Screen patients for assistance programs.

Suggested team member(s) responsible: medication assistance enrollment personnel.

Screen patient for Medi-Cal and Covered California eligibility through the enrollment personnel and then to Medication Assistance Programs if there is a gap or need in their care. Assist the patient (if needed) to enroll them in assistance programs to make medications more affordable, such as Medication Assistance Programs, vouchers or 340B.


4. Decide upon a shared frequency of management with the patient (i.e., every three months, six months, etc.)

Suggested team member(s) responsible: clinician and patient.

Part of the patient’s follow-up should include discussing whether their current medications are still meeting their needs. The patient’s adherence to the medication regime should also be evaluated.

Specific consideration for patients with hypertension

Patients who have uncontrolled hypertension should be followed up at least on a monthly basis until considered controlled. Patients who have controlled hypertension should be seen every three to six months or potentially more frequently based on their comorbidities. This can be done in person or virtually.

For the purposes of regular monitoring, practices should establish a biweekly follow-up for elevated blood pressures. This can occur with an MA/LVN. This follow-up should include looking at home blood pressure readings. See Activity 14: Foster Patients’ Ability to Self-Monitor Their Blood Pressure and/or A1c at Home and Activity 24: Develop System to Provide Remote Monitoring for further information.

Specific consideration for patients with diabetes

The patient should be contacted one to four days prior to their appointment to ask them to bring in their glucometer and/or readings so that the clinician can review them. To determine if the medication is still adequate, the clinician should also take into account the patient’s latest A1c and home glucose readings.


5. Monitor patient for medication adherence.

Suggested team member(s) responsible: clinician, pharmacist and nurse or MA.

Medication adherence should be assessed at every visit or clinical encounter using a question that normalizes missing medications (i.e., “On an average week, how many doses do you miss?”). Ideally, responses should align with pharmacy refill data. Clinicians may be able to obtain pharmacy data to assist with medication adherence monitoring. Suboptimal adherence (typically defined as <80%) should be addressed using standard tools and open-ended questions (i.e., motivational interviewing). Consider leveraging the use of your EHR or patient management platform to obtain this data.

Clinicians should utilize the Medication Refill Adherence Rate (MRAR) and Days of Supply Remaining (DSR):


Like Portion of Days Covered (PDC) but with a few key differences:

  • MRAR is more specific to drug class.
  • PDC is used for chronic conditions.


  • MRAR: rolling 12 months
  • PDC: calendar year.

Both systems require that there is a patient count for the denominator.

  • MRAR removes inactive prescriptions (the goal is greater than 80%).
  • PDC outcomes may be lower than MRAR because the PDC system may still include medications that become inactive in the denominator.


Calculates how many days remain of the patient’s current supply. The last prescribed medication for the class should be utilized.

  • One challenge of this system is that there may be fewer days remaining if a patient is finishing a prescription when switching to a different medication in the same class.
  • For example: When switching from simvastatin to atorvastatin, the DSR system assumes a switch to atorvastatin immediately.

A negative number represents that the patient is overdue for a refill if the medication is taken as prescribed.

  • For example, if a patient’s DSR number is −10, they have been out of medication for 10 days.
  • A negative DSR may serve as an earlier indicator before the MRAR system that a patient is nonadherent.


6. Manage multiple medications.

Suggested team member(s) responsible: clinician, patient, and clinical pharmacist (if available).

If the patient is taking multiple medications or has difficulties taking or managing their medication, personnel who have enhanced expertise in complex medication management, such as a clinical pharmacist, should be consulted. This is to assist with streamlining the patient’s medication regimen or with making alterations to medication administration (such as bubble packaging) to center adherence towards the patient. Practices should check with the patient’s pharmacy to determine if they can do bubble packaging if appropriate for patient care.


7. Clinicians should be trained to manage common side effects or lab abnormalities of commonly prescribed medications.

Suggested team member(s) responsible: medical director (or equivalent) and Quality improvement lead (or equivalent).

For specific medications, a standard system for follow-up should be established in order to facilitate best patient care. This helps to ensure that side effects are monitored properly. Clinicians should be aware of which medications should be titrated when being stopped, which medication side effects are dose dependent, and how to best manage a side effect that occurs as a result of a medication.


8. If appropriate, utilize care managers to assist the patient with managing their medications.

Suggested team member(s) responsible: patient and care manager.

Patients may be identified for care management based on qualifying criteria as part of risk stratification. Some EHRs may already have this feature available. The American Academy of Family Physicians also provides guidance on risk stratification. See Key Activity 18: Coordinate Care and Key Activity 21: Provide Care Management for more information.


9. Patients who have not been in for their regularly scheduled appointments should be contacted directly if they have not been seen in one year.

Suggested team member(s) responsible: EHR specialist (or equivalent), patient services representative and MAs.

See Key Activity: 8: Proactively Reach out to Patients Due for Care for more information.


10. Reevaluate current medication regime.

Suggested team member(s) responsible: clinician, pharmacist and patient.

If a medication regime is not currently working for a patient, it should be adjusted to achieve their goals per established clinical guidelines. An example of this is from the Sonoma County Indian Health Project, which utilized a pharmacist-led clinic to facilitate switching to glucagon-like peptide-1 (GLP-1) agonists and incorporating lifestyle changes to assist diabetic patients.

Consider updating diabetes treatment regimens to include medications that lower cardiovascular morbidity. This should be based upon the patient’s other health risks, other chronic diseases, etc. Practices should consult the ADA’s latest Standards of Care in Diabetes for further information. For certain populations (such as those at high risk for atherosclerotic cardiovascular disease, etc.), SGLT2 and GLP-1 agents are recommended within the following guidelines:

  • For inpatients with established, or high risk for, atherosclerotic disease, heart failure and chronic kidney disease, the treatment regimen should include agents that reduce cardiorenal risk. The ADA recommends using a cardiovascular disease risk calculator to assess risk, such as the calculator on the ACC website.
  • A person-centered approach should guide the choice of pharmacologic agents, including (but not limited to) cost and access.
  • In adults with type 2 diabetes, a GLP-1 receptor agonist is preferred to insulin when possible.

Before making substantial changes to a patient’s medication regime, practices should determine with the patient if the medications are affordable, therefore making it possible for them to continue adherence. Programs such as 340B or medication assistance should also be leveraged to assist patients in their ability to continue to afford medications.


Example workflow

Chapa-De Indian Health developed a registered nurse case manager workflow and a respective protocol, which encourage medication adherence by allowing diabetes nurse case managers to order refills for diabetes-related medications. This ensures timely refills and promotes patient adherence.

Implementation tips

  • If available, integrating pharmacists into the primary care team to provide comprehensive medication management can be greatly beneficial. The University of Southern California School of Pharmacy collaborated with AltaMed Health Services to provide comprehensive medication management for patients with poor chronic disease control, which has been shown to improve care as a whole.
  • An effective strategy to effectively monitor adherence is to ask patients to bring in their medications and home blood pressure/glucose meter readings. This is a valuable tool for clinicians when making clinical decisions. Consider utilizing nursing staff to assist with reconciliation.


  1. Bellows BK, Kazi DS. Ultralow-dose quadruple combination therapy: A cost-effective solution for hypertension control. Heart. 2023;109(22):1659–60. doi:10.1136/heartjnl-2023-323007