Pharmacy Services for Older Adults: Medication Reviews and Adherence Programs

Pharmacy services for older adults extend well beyond prescription dispensing to encompass structured medication reviews, adherence monitoring programs, and collaborative care frameworks designed to reduce the risks associated with complex drug regimens. Adults aged 65 and older fill an average of 27 prescriptions per year (Medicare Payment Advisory Commission, MedPAC), making systematic pharmacy oversight a critical component of geriatric health management. This page covers the definition and regulatory scope of elder pharmacy services, the operational mechanics of medication review and adherence programs, common clinical scenarios in which these services are deployed, and the boundaries that determine when different program types apply.

Definition and Scope

Elder pharmacy services comprise a category of clinical and administrative functions delivered by licensed pharmacists — and in some programs, pharmacy technicians under pharmacist supervision — specifically structured to address the medication-related needs of adults 65 and older. The scope is defined in part by the Centers for Medicare & Medicaid Services (CMS), which classifies Medication Therapy Management (MTM) as a covered benefit under Medicare Part D (42 C.F.R. § 423.153(d)).

MTM is the primary regulatory framework under which most elder-focused pharmacy services operate in the United States. Under CMS criteria, Part D plan sponsors must offer MTM to enrollees who meet at least 3 of the following eligibility thresholds: having multiple chronic conditions (a minimum of 2–3, depending on plan), taking multiple Part D drugs (typically 8 or more), and being likely to incur annual drug costs that exceed a CMS-set threshold (set at $4,696 in 2024 per the CMS MTM Fact Sheet).

Beyond MTM, elder pharmacy services include:

• Comprehensive Medication Review (CMR): An annual, interactive, person-specific consultation with a pharmacist resulting in a written medication action plan.
• Targeted Medication Review (TMR): Shorter, ongoing assessments between annual CMRs, focused on high-risk medications or new clinical changes.
• Adherence packaging and blister packing: Dispensing systems that reorganize medications by day and time to reduce missed doses.
• Pharmacist-conducted medication reconciliation: Reconciling home medication lists at care transitions, a function aligned with The Joint Commission's National Patient Safety Goals (NPSG.03.06.01).

The American Society of Consultant Pharmacists (ASCP) sets professional practice standards specific to consultant pharmacists working in long-term care and senior care settings.

How It Works

Medication Therapy Management: Structured Process

MTM delivery follows a defined sequence, as outlined in the CMS MTM Program Standardization Strategy:

1. Eligibility identification — The Part D plan's algorithm screens enrolled members against MTM eligibility criteria quarterly.
2. Enrollment and outreach — Eligible enrollees are contacted by the plan or its MTM vendor pharmacist within a defined window.
3. Comprehensive Medication Review (CMR) — A real-time, interactive consultation (telephone or face-to-face) reviews all medications, including prescriptions, over-the-counter drugs, herbals, and supplements.
4. Medication Action Plan (MAP) generation — The pharmacist produces a written MAP itemizing medication-related problems, recommended changes, and self-management goals, delivered to the patient.
5. Prescriber communication — A summary is sent to the primary care physician or specialist, though action on recommendations remains the prescribing clinician's authority.
6. Targeted Medication Review (TMR) follow-up — Ongoing quarterly reviews identify new medication concerns between CMR cycles.

For older adults managing chronic disease management or conditions such as diabetes and endocrine disorders, the CMR process incorporates disease-specific medication risk criteria. The Beers Criteria®, published by the American Geriatrics Society (AGS), provides a validated list of potentially inappropriate medications (PIMs) for adults 65 and older. Pharmacists conducting CMRs use the Beers Criteria® as a primary reference for flagging drug-disease interactions and high-risk prescribing patterns.

Adherence Programs

Medication adherence programs use behavioral, packaging, and monitoring tools to reduce non-adherence rates. Non-adherence in older populations is linked to adverse outcomes across polypharmacy management contexts, where 5 or more concurrent medications are common. Pharmacy-led adherence interventions documented in Agency for Healthcare Research and Quality (AHRQ) evidence reviews include synchronized refill programs, automatic refill enrollment, and pharmacist-led telephone follow-up at 7 and 30 days post-discharge.

Common Scenarios

Hospital-to-home care transitions: At discharge, patients are at high risk for medication discrepancies. Pharmacists reconcile the discharge medication list against pre-admission home medications, a process relevant to elder transitional care services and required under Joint Commission accreditation standards for hospitals.

Long-term care facilities: Consultant pharmacists conduct drug regimen reviews (DRRs) for nursing facility residents under federal requirements at 42 C.F.R. § 483.45, mandating monthly pharmacist review of each resident's medication regimen.

Community pharmacy adherence support: Community pharmacists offer medication synchronization — aligning all refill due dates to a single monthly pickup — combined with a brief pre-synchronization call that functions as a mini-medication review.

Mental health and cognitive impairment contexts: For individuals receiving care through elder mental health services or dementia and Alzheimer's care, pharmacists assess psychotropic medication appropriateness, particularly antipsychotic use, which is subject to CMS quality measures under the Nursing Home Quality Initiative.

Decision Boundaries

CMR vs. TMR: A CMR requires a real-time interactive patient encounter. A TMR does not require direct patient interaction and may be completed through claims data review and prescriber outreach. Plans cannot substitute TMR for the annual CMR requirement.

MTM vs. medication reconciliation: MTM is a proactive, scheduled review program governed by Part D plan design. Medication reconciliation is an event-triggered safety process occurring at care transitions — hospital admission, discharge, or transfer — governed by accreditation standards and The Joint Commission, not by Medicare Part D.

Pharmacist prescribing authority: Collaborative Practice Agreements (CPAs) in 48 states allow pharmacists to initiate, modify, or discontinue medications under defined protocols (per National Alliance of State Pharmacy Associations, NASPA). The scope of these agreements varies by state statute and does not constitute independent prescribing authority equivalent to a physician license.

Medicare Part D MTM vs. Medication Management in Medicaid: MTM is a Part D benefit with defined federal eligibility criteria. Medicaid health services for older adults may fund pharmacy case management under state plan amendments or managed care contracts, but eligibility criteria and program structures differ by state and are not standardized federally.

Adherence packaging vs. clinical intervention: Blister packing and pill organizers address logistical adherence barriers. They do not substitute for pharmacist clinical review of appropriateness, interactions, or dosing accuracy — functions that require professional licensure and fall under MTM or DRR frameworks.

Access to pharmacy services in rural communities is an active area of policy attention; rural elder health access resources document disparities in both community pharmacy density and MTM program reach.

References

• Centers for Medicare & Medicaid Services — Medication Therapy Management
• Electronic Code of Federal Regulations — 42 C.F.R. § 423.153(d): Medication Therapy Management Programs
• Electronic Code of Federal Regulations — 42 C.F.R. § 483.45: Pharmacy Services (Nursing Facilities)
• American Geriatrics Society — Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults
• The Joint Commission — National Patient Safety Goals (NPSG.03.06.01)
• [Agency for Healthcare Research and Quality (AHRQ) — Medication Adherence Interventions](https://www.ahrq.gov/patient-