Medicare Quality Improvement Organizations' Ambulatory Drug Therapy Improvement Activities and Partnerships With Medicare Part D Prescription Drug Plans and Medicare Advantage Plans

BACKGROUND: The Medicare Modernization Act (MMA) has provided an opportunity for quality improvement organizations (QIOs) to partner with Medicare Part D plan sponsors. These new relationships have developed into a set of diverse projects, each approved by the Centers for Medicare Medicaid Services. OBJECTIVES: To provide information about the scope of the projects being conducted by the QIOs and their partners. SUMMARY: The document describes a variety of quality improvement projects addressing medication use by beneficiaries enrolled in Medicare Part D.Private Medicare QIO contractors are implementing these projects in each state. Descriptions of each project were developed by individual QIOs with the assistance of lead staff for the Physician Practice/Pharmacy QIO SupportCenter for all QIOs nationwide. These projects vary in their complexity, in the quality measures used, and in the clinical processes and economic impact they seek to improve. The summaries in this supplement were prepared 6 months into the current 3-year contract period, which began August 2006. Accordingly, the summaries reflect varying stages of development, funding reductions could occur that necessitate project redesign, and projects have not yet been evaluated. With few exceptions, these projects are not designed as research but as quality improvement projects following the “Plan, Do, Study, Act” model for speeding acceptance of evidence-based practice. CONCLUSIONS: This survey describes the promise of partnerships whose value will be fully realized in future years. The results of these early QIO initiatives will not be available until projects are evaluated, but QIOs and many Medicare Part D plans have established promising partnerships and have begun to share data for the purpose of assessing and improving plan and practitioner performance as well as patient engagement.Most projects are focused on ambulatory care, but some QIOs are addressing nursing home care and continuity of care between settings.Most ambulatory care projects are limited to prescription drug claims data,but a few plans are providing medical and lab data to QIOs in addition to drug claims. QIOs have historically worked almost exclusively with physicians and nurses but in many states are now engaged with colleges of pharmacy as well as with managed care and community pharmacists. QIO partnerships will provide managed care organizations and pharmacists with the opportunity for innovative quality improvement initiatives that might not otherwise be possible because of limitations of available data or resources.Pharmacists can use this document to review a wide array of options for working with QIOs and other partners in their market to design or strengthen their organization's medication therapy management and quality improvement programs. Managed care pharmacists may be particularly interested in the ability of QIOs to assist them in comparing their plans' performance with other national and regional plans.


Authors ss Scope of This Survey
The Medicare Modernization Act (MMA) has provided an opportunity for Medicare quality improvement organizations (QIOs) to partner with Medicare Part D plan sponsors. These new relationships have developed into a set of diverse projects, each approved by the Centers for Medicare & Medicaid Services (CMS). With few exceptions, these projects are not designed as research but as quality improvement projects following the "Plan, Do, Study, Act" model for speeding acceptance of evidence-and consensus-based practice.
The Academy of Managed Care Pharmacy (AMCP) and the American Health Quality Association (AHQA) identified the need for health care professionals and managed care organizations to become knowledgeable about the scope of the projects being conducted by the QIOs and their partners.
The document describes the variety of projects being implemented in each state. Descriptions of each project are based on summaries developed by individual QIOs with the assistance of Elaine Krantzberg and Jim Grant of Florida Medical Quality Assurance, Inc., the Florida QIO, where they serve as lead staff for the Physician Practice/Pharmacy QIO Support Center for all QIOs nationwide. These projects vary in their complexity and in the clinical processes they seek to improve. The summaries in this supplement were prepared 6 months into the current 3-year contract period, which began August 2006. Accordingly, the summaries reflect varying stages of development, funding reductions could occur that necessitate project redesign, and projects have not yet been evaluated. As experience with these projects becomes available, AMCP and AHQA look to research that will examine their effectiveness and practicality for professionals working in the field.

David G. Schulke; Elaine Krantzberg, RN; and Jim Grant, MA
This survey describesthe promiseofapartnership whosevalue will be fully realized in futurey ears. Medicareo fficials provided standardized quality measures and baseline data to each QIO in the spring of 2007, after partners had been recruited and projects had been designed and launched. Many QIOs and their drug benefit plan partners used other previously defined quality measures. Progress in the projects may be affected by the proposed rescission of millions of dollars in funding for the program to pay for other priorities at CMS. Also, CMS has not yet obtained the funding necessaryt op rovide QIOs with "integrated" Part A, B, and Dclaims data.
QIOs have worked around these challenges by designing their own quality measures; requesting data directly from health plans and from ad hoc requests to CMS; engaging in local partnerships with pharmacies, physician group practices, colleges of pharmacy and nursing homes; and, when necessary, scaling back their efforts.

■■ Medicare Modernization Act Quality Provisions
In addition to creating an outpatient drug benefit for Medicare beneficiaries, the MMA signed into law in December 2003 authorized an umber of lesser-known demonstrations and initiatives aimed at measuring and improving the quality of carepurchased by Medicare. These MMA provisions included the following: •S ec. 101: Providing comparative plan information to beneficiaries •S ec. 101: Medication therapy management services •S ec. 101: Electronic drug prescribing •S ec. 109: Quality improvement organizations' assistance to drug plans and professionals •S ec. 501: Submission of hospital quality data for public reporting •S ec. 649: Medicarecaremanagement performance demonstration •S ec. 721: Chronic careimprovement pilot •S ec. 722: MedicareAdvantage plan quality improvement program •S ec. 944-945: Improvements in implementation of the Examination and Treatment for Emergency Medical Conditions and Women in Labor Act Tw oo ft hese provisions arep articularly promising for their likely long-term effect on the quality of drug therapy: (1) the requirement for everyM edicarep rescription drug plan (PDP) to establish amedication therapy management (MTM) program, and (2) the extending of quality improvement assistance through the existing QIO program. Officials at CMS have taken important steps to coordinate these 2n ew efforts to maximize their benefits.
The MTM program was championed in Congress by the pharmacy profession and by pharmacies. The program' sobjective is to give patients the benefit of interventions by health careproviders, including pharmacists, to improve the safety and effectiveness of drug therapy purchased by Medicare. Under the law,t he MTM program is aservice, paid for by Medicarethrough administrative fees to its private plan contractors, which everyM edicarep lan must offer to beneficiaries most dependent on safe, high-quality pharmacotherapy: those who have multiple chronic ailments and areusing multiple medications and who arethereforeexpected to have veryhigh annual drug costs.
MEDICATION THERAPY MANAGEMENT PROGRAM-(A) DESCRIPTION-(i) IN GENERAL-A medication therapy management program described in this paragraph is aprogram of drug therapy management that may be furnished by ap harmacist and that is designed to assure, with respect to targeted beneficiaries described in clause (ii), that covered part Dd rugs under the prescription drug plan areappropriately used to optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events, including adverse drug interactions. Such ap rogram may distinguish between services in ambulatoryand institutional settings.
In section 109(b) of the MMA, Congress added anew assignment to the QIO program, instructing QIOs to work with the new MedicareA dvantage plans and PDPs to improve the quality of therapy: PRESCRIPTION DRUG THERAPY QUALITY IMPROVE-MENT-The [Quality Improvement Organization] shall… [offer] to providers, practitioners, MedicareA dvantage organizations offering MedicareA dvantage plans under partC ,a nd prescription drug sponsors offering prescription drug plans under part D [,] quality improvement assistance pertaining to prescription drug therapy.
By law and under the implementing regulations, every Medicaredrug plan hasagreat deal of discretion in implementing its MTM program. CMS officials also gave QIOs alot of latitude, but encouraged them to work with plans to strengthen their MTM programs.

■■ Quality Improvement Organizations
QIOs areprivate organizations with avariety of public and private customers, including the Medicareprogram. Medicareenters into contracts with QIOs to evaluate and assist providers and professionals to reliably provide the highest-quality care.
As private contractors with quality expertise, most QIOs also performq uality and access monitoring for Medicaid programs, many supports tate patient safety initiatives by contributing staff time and funding, and many adjudicate appeals under ascoreof state managed care"patients rights" laws.
Al ist of QIOs with their corporate names and the states for which they serve as the MedicareQ IO contractor may be found at the Webs ite of AHQA, the national association of the QIOs: http://www.ahqa.org/pub/connections/162_694_2450.cfm. In addition, each summaryinthis supplement identifies the QIO by name and provides contact information for the staffp erson leading the MedicarePartDwork.
The Medicarew ork of the QIOs is authorized under the title "Utilization Review and Quality Control Peer Review Organization Program" (today known as the Quality Improvement Organization or QIO Program). The program was created by Congress in 1982 in title XI of the Social Security Act. Congress gave the secretaryofthe Department of Health and Human Services (HHS) abroad statutory scope for the MedicareQ IO program, authorizing the secretaryt o use the QIOs to review and improve the quality and effectiveness of any item or service for which Medicarepays any part. The secretaryisauthorized to fund the QIOs through adirect draw on the MedicareH ospital Insurance and Supplemental Medical Insurance Tr ust Funds.
The 3main purposes of the QIO program areto(1) improve the quality of caref or beneficiaries; (2) protect the integrity of the Medicaret rust funds by ensuring thatM edicare pays only for services and goods that arereasonable, aremedically necessary, and areprovided in the most appropriate setting; and (3) protect beneficiaries by expeditiously addressing individual complaints and appeals.
This supplement focuses on the main work of QIOs, which is to provide technical assistance to providers, practitioners, and plans. QIOs area lso responsible for addressing caret hat falls short of professionally recognized standards. If aQ IO confirms aq uality complaint or finds substandardcarethrough other means, theQIO contacts the provider and requests additional information. After assessing that information, aQIO may ask aprovider,practitioner,or plan to undertake aq uality improvement plan to address ac onfirmed problem, and the QIO will usually assist in this process. If a provider,practitioner,orplan does not take appropriate action, the QIO may refer that individual or entity to state regulatoryauthorities or to the HHS Office of Inspector General for action. That office may impose civil monetaryp enalties or exclude the individual or entity from Medicarea nd Medicaid for ap eriod of time or permanently. The sanction process is rarely needed or invoked, because most individuals or entities will work with the QIO to take appropriate action when the QIO requests it.
While the statutoryscope of activities is remarkably broad for which the secretarym ay use QIOs to perform for the Medicare program, the secretarymay limit the scope of work that QIOs are hired to perform by the specific content of contracts with the organizations.
The secretaryr evises the QIO contract extensively every 3years. The 8th Statement of Work (or SoW8, so named because it is eighth in aseries of multiyear contracts that began with implementation of the program in 1984) began in August 2005 and will run through the end of July 2008. Funding for this latest 3-year contract period was initially budgeted at $1.265 billion, of which the QIO contractors themselves may be paid approximately $860 million over 3y ears (equivalent to about $287 million a year nationally,orabout 56 cents per beneficiaryper month). The amount actually available to QIOs has been significantly diminished by the reprogramming of some of these funds to other HHS initiatives.
The contract assigns QIOs to tasks in the following cares ettings and topics: •H ospitals (including rural and critical access hospitals)improving caref or heart attack, heart failure, community acquired pneumonia, and surgical complications •P hysician offices-helping physician practices to choose and use health information technology to improve the caret hey provide to chronically ill people and to promote greater awareness of the needs of racial and ethnic minorities •N ursing homes-reducing the rate of pressureu lcers among high-risk individuals, decreasing the use of physical restraints, and improving the management of pain in chronic (

Interventions:
The project supplies participating health carep roviders with information and guidelines on lipid-modifying agents, and treatment information for patients with diabetes and dyslipidemia. On-site visits will be made if resources allow.P atients receive diabetes and dyslipidemia educational materials, patient record keeping tools, as well as information emphasizing the importance of prescription adherence.

Project Description:
At baseline, the 5organizations involved in these 8plans represent 1,877 beneficiaries and 460 physicians. Through analysis and examination of claims data, AQAF will evaluate the prescribing of lipidmodifying agents and the incidence of hospitalizations for cardiovascular events in eligible beneficiaries. Blinded data results will be reviewed and discussed on aregular basis at meetings with PDPs and MA-PD plans. Lessons learned will be discussed and evaluated during regularly scheduled meetings of essential partners and will be shared with other QIOs on monthly QIO support center calls.
6. Primary Outcomes: Evaluate whether the rate of prescribing lipid-modifying agents to eligible beneficiaries increased and hospitalizations for cardiovascular events decreased. Evaluate whether providers' lipid panel measurements improved.
7. Evaluation Design and Methods: Through analysis and examination of Part Dd ata, the project will evaluate whether the rate of prescribing of lipid-modifying agents to eligible beneficiaries increased. Through analysis and examination of Part Bclaims data, AQAF will determine whether providers' lipid panel performance measurement improved. Through examination and analysis of Part Aclaims data, AQAF will determine whether the incidence of hospitalizations for cardiovascular events decreased in the cohort of eligible beneficiaries. Objective: Devise acollaborative project in the long-term care(LTC) setting that will focus on opportunities to simplify medication regimens. Specifically,promote guideline-based appropriate use of anemia treatment in elderly,at-risk LTCresidents.

Background:
The setting is 2L TC facilities in Alaska that have agreed to collaborate in amedication regimen simplification and anemia treatment project. The project targets beneficiaries, LTCp roviders, nurses, and pharmacists providing medication services to residents in each of those facilities.

Interventions:
The intervention builds on consensus-driven quality indicators that have been developed in conjunction with medical, pharmacy,a nd nursing staff. Examples of materials areq uick-list formularyc ards, process-driven guidelines for medication use in the facility,and/or educational sessions summarizing information about the most recent evidence-based practice guidelines specific to 1o rm orec linical indicators. After clinical indicators have been agreed upon and materials developed to support the indicators, Mountain-Pacific Quality Health Foundation will work with LTCstafftoimplement aquality improvement cycle.

Project Description:
The QIO assists and supports partnering LTCf acilities in the development of 2medication-related quality indicators. The first quality indicator focuses on an evidence-based review of clinical practice guidelines and clinical practice recommendations for use of epoetin (EPO)/darbepoetin in the treatment of anemia. The second quality indicator directly supports the minimum data set quality measure/quality indicator for clinical management of 9o rm orem edications (medication regimen simplification) for residents in each facility.
6. Primary Outcomes: Anemia Project: Increase the number of residents evaluated through use of the established collaborative protocols and subsequent potential discontinuation/modification of EPO therapy.N ine or MoreM edications Project: Increase the number of residents whose drug therapy regimens have been simplified by using the efforts of the QIO and facility as compared with the baseline number.

Evaluation Design and Methods:
Determine whether the LTCfacility implemented asystem to assureonly appropriate initiation, and continuous reexamination of acontinued need for EPO and other medications. Do a summaryanalysis identifying the number and type of medication regimen simplifications. Objective: Demonstrate as imple, low-cost framework that will increase the number of prescriptions submitted with diagnoses. It is expected that an increase in prescriptions submitted with adiagnosis will result in increased accuracy of prescriptions dispensed, ultimately resulting in greater patient safety.
3. Background: Approximately 5pharmacies have been recruited for this project. Each pharmacy recommends 10 to 12 physicians, from whom Health Services AdvisoryGroup (HSAG) recruits aselect number who agree to include adiagnosis code for each written or electronic prescription.

Interventions:
Pharmacists aretrained to track and recordinthe database whether the diagnosis is included in the written prescription or the e-prescription. Pharmacists aretrained to urge physicians to include the diagnosis on the prescription. HSAG distributes stamped prescription pads to the recruited physicians to remind them to write the ICD-9 (International Classification of Diseases, Ninth Revision) code or diagnosis and trains the physicians in their use.

Project Description:
This project focuses on training physicians to include ap atient' sd iagnosis on the written or electronic prescription, which should result in an increase in prescriptions correctly filled and, ultimately,ingreater patient safety.
6. Primary Outcomes: Improve patient medication safety by increasing the accuracy of prescriptions filled.

Evaluation Design and Methods:
The evaluation design is both quantitative and qualitative. The quantitative component involves the evaluation of the data that the pharmacy submits to HSAG. The QIO will evaluate the increase in the number of prescriptions submitted with adiagnosis, as well as the number of potentially inappropriate medications prescribed for the Medicarep opulation. The qualitative component is as urvey in which pharmacists will be asked to evaluate how the project has impacted their workflow and the accuracy of prescription dispensing.

Background:
This project focuses on medication management of the state' sg eriatric Medicarep opulation for appropriateness, cost, and potential toxicity.Geriatric physiology can alter drug metabolism and increase side effects. Use of certain agents could unnecessarily expose patients to toxicities that could be avoided by safer or moreeffective medications. Inappropriate medication in the elderly has been defined as medication for which the potential risk outweighs the potential benefit and for which agood alternative drug is available. Gerontologist Mark H. Beers, MD, 1 has been advocating the use of explicit criteria developed by expert consensus panels for identifying inappropriate use of medications in the elderly.In1991, he developed explicit criteria for nursing facilities to use to determine the appropriateness of medication for the frail elderly.Hehas updated these criteria to include medication therapy in all persons over the age of 65 years. Beers' sCriteria have been used as national guidelines and references for physicians and pharmacists to improve medication use in the elderly.T hese criteria aret he coreo fA rkansas Foundation for Medical Care' s(AFMC' s) educational foundation for intervention development and implementation.

Intervention:
Quality improvement programs aredeveloped to ensureappropriate drug utilization for this population. The program includes appropriate drug selection, dosing, duration of use, and monitoring. Interventions include interactive reduction strategies and educational offerings at annual statewide pharmacist meetings. AFMC assists pharmacists with defining better internal processes for identification of adverse prescribing patterns. The QIO identifies and promotes systems and technologies that encourage optimal prescribing. Educational outreach with practitioners and pharmacists is conducted to facilitate review of the medications in this population, as well as statewide letters detailing the rationale for avoiding commonly used drugs that arepotentially inappropriate. Long-term care(LTC) facility medication watch lists aredeveloped to provide medication administration staffquick references for adverse drugs.

Project Description:
The target Medicarep opulation includes older adults with chronic and acute disorders, including those that reside in community dwellings as well as those in LTCfacilities. This project is being deployed in collaboration with essential partners such as the Arkansas Pharmacists Association, University of Arkansas for Medical Sciences College of Pharmacy,and the top prescription drug plans (PDPs) covering Arkansas beneficiaries. The project focuses on the clinical settings of family,general, geriatric, and internal medicine practices and nursing homes and independent and chain pharmacies. AFMC is seeking to partner with the top 4PDPs, which represent 70% of the beneficiarypopulation in the state.
6. Primary Outcomes: Reduce inappropriate prescribing, decrease polypharmacy,a void adverse events, and maintain functional status.
7. Evaluation Design and Methods: AFMC uses 2r elated measures to assess the project goal to improve therapy by reducing use of potentially inappropriate medicines in elderly individuals who arereceiving 1ormoresuch drugs. The first measureiswhether therapy was improved in beneficiaries who received at least 1drug to be avoided in the elderly.T he second measurei st oi mprove therapy in beneficiaries who received at least 2d ifferent drugs to be avoided by the elderly.

Background:
This project focuses on the outpatient setting. The partners are6h ealth plans, all of which sponsor MedicareA dvantage prescription drug plans within California. The clinical rationale for selecting this project is that clinical quality relevance for PIMs and DDIs has been demonstrated in the literature, current and past. On the practical side, Part Ddata arereadily available at the point of adjudication, and this study is aprelude to the futureintegration of Parts A, B, and Ddata, which requires additional infrastructuredevelopment beforethe process can be feasible.

Interventions:
The interventions aretargeted to prescribers with high rates of PIMs identified in the study' s baseline data analysis and include distribution of printed information for both beneficiaries and providers about PIMs, DDIs, and medication safety.F ocused interventions include academic detailing using the 2003 Beers Criteria, 1 provider feedback based on prescription utilization data, and explicit suggestions for therapeutic alternatives and changes in practice.

Project Description:
Lumetra uses 2q uality indicators commonly used in medication safety studies: the prevalence of PIMs used in the elderly and DDIs. Lumetra gathers pharmacy claims data from the participating health plans, performs retrospective claims data analysis, and assists Part Dsponsors to implement interventions aimed at reducing potentially harmful prescriptions.
6. Primary Outcomes: Evaluate improvement from baseline of the PIM quality indicator.E valuate the DDI indicator describing frequency of the identified DDI pairs. The descriptive analyses provided to the participating plans will contribute to futuredevelopment of this measure. 3. Background: Prescribing of PIMs in the elderly has been the subject of av ariety of peer-reviewed articles. Colorado Foundation for Medical Care(CFMC) is working with 5to10selected LTCfacilities to identify asubject pool of approximately 500 or moreelderly persons who may have been prescribed 1ormorePIMs.

Interventions:
The intervention builds on educational sessions and educational materials designed to change the deliveryofthe identified drugs and to heighten the awareness of other PIMs. Thereisatleast 1face-to-face meeting with each facility to provide feedback on the data and educational information about the PIMs. CMFC staffw ill present and lead teleconferences on aq uarterly basis to intervene on the use of PIMs; local opinion leaders will participate. Other intervention items to be considered include reminder stickers, prompts, and posters designed to address the use of the medications.

Project Description: This project addresses PIMs in Medicareb eneficiaries residing in LTCf acilities.
The quality indicator will be the proportion of residents 65 years old or older with at least 1PIM as part of their regularly scheduled medications. The numerator will be the number of residents 65 years old or older receiving at least 1PIM, and the denominator will be the total number of residents 65 years old or older for whom data werecollected in the LTCfacilities. Medications available on an as-needed basis will be reviewed and addressed separately,asitmay be difficult to determine if these medications areactually being administered to the residents.
6. Primary Outcomes: Decrease the number of PIMs prescribed to LTCresidents.

Evaluation Design and Methods:
Alower proportion of residents with 1ormorePIMs, between baseline and remeasurement, will be considered improvement. Additional measures, such as the nursing home depression quality measure, the nursing home falls quality indicator,orthe National Committee for Quality Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS) Drugs Avoided in the Elderly (DAE), will be used, as appropriate, to gain amorecomplete pictureoftherapy being provided to this population.

Interventions:
Qualidigm is spearheading the provision of amedication use reportbased on the Health Plan Employer Data and Information Set (HEDIS) data set from the health plan. Alist of the physician' spatients with diabetes is available from the health plan to assist the physicians in reaching out to patients whom ay need services or medication changes. After the provision of the medication use report, an interactive and structured educational session is scheduled and conducted with physicians individually or,i ft hey prefer,i ng roups. The educational session includes the discussion of potential intervention strategies to mitigate the barriers physicians may encounter when prescribing lipid-modifying therapy for their patients with diabetes. The IPAmedical director uses as tandards cript that reviews the 2006 American Diabetes Association and National Cholesterol Education Program recommendations and clinical guidelines for diabetes care. The medical director also reviews common barriers to patient medication adherence and the benefits of using generic forms of statin medication. Educational handouts for patients areleft with physicians to support their subsequent interactions with patients. 3. Background: Gelbach et al. 2 have shown that feedback to physicians on prescription volume and potential savings from greater generic drug use influences physician behavior.This project seeks to increase use of generic ACEIs in persons over the age of 65 by increasing physician awareness.

Interventions:
Quality Insights provides physicians reports of the total (or estimated) number of patients linked to their practice who arer eceiving ACEIs and the number and proportion receiving generic ACEIs after baseline analysis. Using Red Book 3 data or price data, if available in the prescription claim data, the QIO will estimate the total cost for medications prescribed and dispensed and estimated savings if the physician prescribed generic formulations or if generic formulations weredispensed.

Project Description:
Quality Insights of Delawarew ill work with 18 Delawarep rimaryc arep hysicians participating in the physician office health information technology (HIT) and carem anagement improvement project (Group 1) with 2comparison groups randomly selected from physicians not participating in the HIT/care management project. Group 2will receive profile reports but no other intervention. Group 3will not be contacted as part of the project, but patient drug utilization will be reported.
6. Primary Outcomes: Increase the use of generic ACEIs, thereby decreasing the cost of ACEIs.

Evaluation Design and Methods:
The QIO will assess rate of use of generic ACEIs in each of the 3groups and document changes from baseline to remeasurement. The QIO anticipates little change in Group 3, al arger change in Group 2, and the largest change in Group 1. The QIO will assess changes by measuring the confidence limits around the preintervention and postintervention relative risk of generic ACEI prescription in each of the 3groups. 3. Background: Poor compliance to medication regimen, increased costs associated with care, increased HbA1c and dyslipidemia can all be influenced by poor patient self-management of medication therapy.Studies have shown that pharmacists' face-to-face MTM services can improve patient self-management of their medication regimen.

Interventions: FMQAI is conducting monthly teleconferences with project partners AvMed and Humana
Inc. and their contracted community pharmacies to discuss FMQAI' sp roject and its continuous progress. FMQAI is assisting those contracted MTM pharmacies with their implementation of MTM services. Face-toface appointments with the targeted beneficiaries arescheduled by the MedicareAdvantage prescription drug (MA-PD) plans and contracted community pharmacy personnel. FMQAI' scommunication plan promotes the improvement of the quality indicators for this project. FMQAI reviews and analyzes data and provides feedback using these quality indicators to the MA-PD plans.

Project
Description: FMQAI has created partnerships with AvMed and Humana to improve patient selfmanagement through pharmacist face-to-face MTM services. These services will be provided at various retail pharmacies contracted by the MA-PD plans. FMQAI collects and analyzes data provided by the MA-PD plans for Medicarebeneficiaries with diabetes who are taking medications in at least 2drugcategories, areenrolled in MA-PD plans, and have received pharmacist face-to-face MTM services. FMQAI will also develop and distribute intervention tools to contracted retail pharmacies for the purpose of increasing awareness of MTM services, and will provide technical assistance to the MA-PD plans.
6. Primary Outcomes: Decrease in overall health carec osts (all clinical and drug costs) at remeasurement factoring in an expected increase in health carecosts (taking into consideration aprojected 5.1% average health cost growth); reduced number of medications at remeasurement (consolidation of anumber of distinct medications); decreased hemoglobin A1C and total cholesterol; and increased medication compliance. Objective: Improve patient self-management and therapeutic outcomes in patients with diabetes mellitus using pharmacist-directed medication therapy management (MTM) services.

Background:
The project design is based on the Asheville Project, which sought to provide education and personal oversight for patients with chronic health conditions. The Georgia Pharmacy Association (GPhA) conducted asimilar project in Dublin, Georgia, with an employer group. Georgia Medical CareFoundation (GMCF) has taken the concept of this project and targeted diabetic Medicarebeneficiaries.

4.
Interventions: GMCF will analyze the effect of face-to-face MTM services provided by community pharmacists.

Project Description:
The collaboration between the GMCF,G PhA, Community CareR x, and the Institute for Wellness and Education shares the common goal of empowering patients to appropriately manage their diabetes. The project gives participating pharmacists the opportunity to directly affect Medicareb eneficiaries' therapeutic outcomes. It also demonstrates the vital role of the pharmacist as amember of the health careteam and the most qualified professional to provide MTM services.
6. Primary Outcomes: Obtain ap ositive impact of MTM services using patient outcomes that include a reduction in hemoglobin AlC compared with baseline values. Other measures include improvement in patient self-awareness and self-management of their diabetes, satisfaction with MTM services provided by pharmacists, and reduction in overall health carecosts.

Evaluation Design and Methods:
The QIO is coordinating the study of this project. The project involves 100 patients, 50 control patients, and 50 experimental/intervention patients within 10 independent community pharmacist service areas. Patients areselected from 10 counties, with an equal representation of rural and urban settings. Therew ill be 5c ommunity pharmacies (with 10 patients each) in the control group and 5c ommunity pharmacies (with 10 patients each) in the intervention group. This design will enable GMCF to comparep atients receiving MTM services with patients not receiving MTM services, and to comparepatients in rural versus urban areas. An independent variable that will be measured is the education level of the patients participating, by obtaining data describing literacy and health literacy.I mprovement in patient self-awareness and self-management of their diabetes and satisfaction with MTM services will be measured through the use of as urvey assessment tool that participating patients will complete at the end of the study period. Health carec ost reduction will be measured by acquiring financial and other billing costs from MedicareP arts Aa nd Bd ata, as well as costs of medications and pharmaceutical/diabetic supplies on file with the participating pharmacy,t hen comparing the 12-month period immediately preceding the study period with the 12-month intervention period. 3. Background: MTM services ared esigned to improve member understanding, appropriate medication use, and reduce the risk of adverse events.

Intervention:
This educational intervention is designed to increase the knowledge and positive perception of MTM services to increase beneficiaryparticipation in the Plans' MTM services. The QIO supports the Plans' MTM services program enrollment through activities such as providing educational materials describing the potential benefits of MTM services to providers/physicians, providing information on MTM services to advocacy groups, and helping the partnering plan develop am ember survey that will enable the plan to evaluate their MTM program and determine beneficiaries' knowledge and satisfaction with the Plans' MTM services.

Project Description:
The QIO is working within the Plans' provider networks to promote aconsistentmessage about the value of MTM services for Medicarebeneficiaries in order to garner local provider support for these services. Mountain-Pacific Quality Health Foundation evaluates patient satisfaction with MTM services and improvement in medication understanding through MTM services. The QIO maintains ongoing contact with the Plans and evaluates overall satisfaction with the project.
6. Primary Outcomes: Determine patient satisfaction with MTM services and improvement in medication therapy understanding through MTM services.

Evaluation Design and Methods:
This collaboration utilizes the knowledge and assets of the QIO and Plans with significant resources and presence in the region. By tracking performance and improvement in beneficiaries' medication therapies, the project will be able to evaluate the outcome of the member survey and educational components of MTM services. Objective: Three QIOs in 5s tates and ap harmacy consulting group, Improve RX, arec ollaborating to evaluate the effectiveness of an audit and feedback style intervention. In such aprogram plans receive data comparing the performance of their MTM services population and their population as awhole with blinded data from the other plans participating in the project.

Background:
The project includes 7participating plans, both national and regional. The participating plans have amix of standalone prescription drug plans and MedicareAdvantage prescription drug plan products.

Interventions:
The project team meets with each plan quarterly to review and discuss the plan' sp erformance on the quality measures, and the comparison plan performance. The participating plans determine how best to intervene with their MTM services population and/or population as aw hole, based on these performance results. The plans have access to as ecureW eb-based portal that can be used to queryw hich specific patients werei ncluded in each stage of the analytic algorithm to calculate quality measurer ates. The project team is available to provide assistance as needed with quality improvement planning and implementation.

Project Description:
The project quality measures address careo fp atients with diabetes, dyslipidemia, and asthma, and address inappropriate prescribing in general. In Phase Ispecific metrics include prevalence of lipid-modifying drug prescribing in patients receiving drug therapy for diabetes, measurement of statin adherence, utilization ratio of generically available statins, excessive/overuse of beta-agonist inhaler(s), regular users of beta-agonist inhalers not receiving inhaled corticosteroids, prevalence of drug-drug interactions, use of certain drugs that experts have judged to be generally inappropriate for use in the elderly,and adherence to prescribed antidepressants. These Phase Im easures can be calculated from prescription drug utilization data. Phase II measures requireintegration with MedicareParts Aand Bclaims.
6. Primary Outcomes: Achieve improvement in measurescores for the plans' MTM services to the Medicare population, using the quality metrics listed under Project Description above. The QIOs will assist and support the provision of medication therapy management (MTM) services by the partnering prescription drug plans/MedicareA dvantage prescription drug plans. The QIOs' supportw ill include leveraging established partner relationships, providing data analysis, and acting as an educator and trainer of quality improvement, culturechange, and change management.

Background:
The Region 25 states shares imilar rural and geographic challenges in implementing this project. Partners for this project are2p rescription drug plans. Participants arep lan members who aree ligible for MTM services. The plans' MTM programs will target members with multiple diseases tates, multiple medications treating those diseases, and whose annual prescription drug expenses areestimated to exceed $4,000.

Interventions:
The QIOs will provide educational materials outlining the potential benefits of MTM to many providers, such as pharmacists, physicians, and home health agencies. Each QIO will also work with their state' sbeneficiaryo utreach organizations and consumer groups to increase their understanding of MTM services. The QIOs will survey plan members regarding their understanding and use of MTM services. QIOs will calculate specific clinical quality indicators using prescription claims data and report the results to each plan.

Project Description:
MTM services ared esigned to improve member understanding and use of appropriate medications to reduce the risk of adverse events and yield optimal outcomes of therapy.This project is intended to increase awareness of MTM services, provide information on how plan members view different MTM programs, and explorehow MTM affects specific clinical quality indicators.
6. Primary Outcomes: Increase visibility and understanding of MTM services and maximize utilization by eligible beneficiaries, assess members' view of MTM services via survey,r eview automated MTM services messaging to determine intervention effectiveness, and analyze Part Dp rescription drug event (PDE) data and calculate clinical indicators.

Evaluation Design and Methods:
By tracking performance across states, the project may demonstrate differences in the deliveryofMTM services both from 2different plans and between states even when provided by the same plan. Performance indicators include the following: •M ember Survey Data-Information will be collected from asurvey instrument developed in collaboration with the partnering plans and the QIOs. The survey will evaluate satisfaction with MTM services whether the beneficiaryenrolled or disenrolled. •C linical automated MTM services messaging to pharmacists regarding PDEs that trigger messages in relation to specific and significant drug-drug interactions. •C linical indicator using PDE data-Percentage of Part Dbeneficiaries with heart failureenrolled in the plans' MTM program that have prescription claims for angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers. •C linical indicator using PDE data-Medication possession ratio for branded selective serotonin reuptake inhibitors (SSRIs) versus generic SSRIs.

Project Description:
This project is amultistate collaboration to maximize MTM program enrollment and help plans identify access and deliverycomponents of successful MTM services.

Primary Outcomes: Measureutilization in each plan type by eligible plan members' participation in MTM.
Analyze medication possession ratio data and prescription costs based on MTM access and deliveryprogram characteristics.

Evaluation Design and Methods:
Preintervention and postintervention design will be used to evaluate the effectiveness of the QIOs' interventions in improving eligible members' participation in MTM programs. The MTM service effectiveness will be determined by comparing preintervention and postintervention outcome measures. The evaluation will seek to identify program access and deliveryd ifferences through qualitative and quantitative comparisons. 3. Background: Phase Iw ill focus on work with MedicareA dvantage prescription drug (MA-PD) plans, prescription drug plans (PDPs), LTCfacilities, and LTCconsultant pharmacists on improvement opportunities in the careofL TC facility residents with diabetes. The QIOs will identify and prioritize improvement opportunities, and develop facility specific continuous quality improvement (CQI) plans.

Intervention:
The project incorporates the MTM services model along with adiabetes data collection tool developed by aQ IO, in addition to the drug regimen review (DRR) mandated by the Centers for Medicare& Medicaid Services, to assess the value of the pharmacist' sr ole in educating LTCprescribers and staff. LTCconsultant pharmacists play an integral role in the medication management of LTCb eneficiaries with diabetes, including those on anticoagulation therapy.The QIO and LTCconsultant pharmacists will provide educational sessions for medical directors and amultidisciplinaryteam from each LTCfacility.QIOs also will assist each facility to develop and implement aC QI plan. QIOs will develop facility-specific reports indicating performance improvement on their respective projects.

Project Description:
This 3-state project involves 2p hases in which the identified QIOs will work with MA-PD plans, PDPs, LTCconsultant pharmacists, and nursing facilities stafftoimprove pharmaceutical careto residents with diabetes. Phase Iwill include LTCfacilities regionally located in southeast Indiana; western, central, and southeast Kentucky; and southwest Ohio. Phase II will include LTCf acilities dispersed throughout each state. During Phase II, the lessons learned from Phase Iwill be spread to other LTCfacilities in each participating state through regional educational meetings and other communication venues. Phase II also will include evaluation of the effectiveness of strategies and reporting. Aconsultant from Purdue University School of Pharmacy will provide valuable support and insight in the development and adaptation of the project.
6. Primary Outcomes: Improved pharmaceutical management and therapeutic monitoring of residents with diabetes, as assessed by as et of quality indicators derived from the American Medical Directors Association (AMDA) guidelines for diabetes carei nt he LTCs etting. Each LTCf acility is provided data and then selects 2indicators for focused interventions. Following is alist of the quality indicators included in the data collection: •P ercentage of residents with diabetes prescribed multiple oral hypoglycemic medications •P ercentage of residents with diabetes prescribed multiple hypertensive medications •P ercentage of residents with diabetes receiving insulin prescribed sliding scale insulin dosage •P ercentage of residents with diabetes with documentation of pneumococcal immunization •P ercentage of residents with diabetes angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker •P ercentage of residents with diabetes receiving antithrombotic therapy •P ercentage of residents with diabetes prescribed astatin (lipid-modifying drug) •P ercentage of residents with diabetes experiencing ahypoglycemic event requiring intervention •P ercentage of residents with diabetes who also have adiagnosis of heartfailurewho are prescribed thiazolidinedione or metformin •P ercentage of residents with diabetes who have received renal function testing •P ercentage of residents with diabetes receiving warfarin •P ercentage of residents with diabetes prescribed warfarin who have received the International Normalized Ratio test •P ercentage of residents with diabetes having ahypoglycemic event who have been transferred to the hospital for that hypoglycemic event •P ercentage of residents with diabetes who have received ahemoglobin A1C test in the previous 12 months •P ercentage of residents with diabetes having the most recent A1C value within the previous 12-month period reported as equal to or less than 7% •P ercentage of residents with diabetes having the most recent A1C value within the previous 12-month period reported as greater than 7% •P ercentage of residents with serum creatinine results within normal range 7. EvaluationD esign and Methods: The QIOs will provide information that will include the number of Medicareb eneficiaries with diabetes in the participating LTCf acilities and selected medications prescribed to these residents. The LTCconsultant pharmacists will document resident diagnoses, medications ordered, laboratorym onitoring parameters, recommendations for medication changes, additional labs to be ordered or reordered. These data will be used for ar egional comparison of LTCf acilities and may enable comparisons between LTCconsultant pharmacist on-site review and MA-PD or PDP off-site review.

Contacts:
Health

Background:
The clinical literaturei sr eplete with studies documenting suboptimal prescribing practices, particularly in the elderly population. The project will increase the knowledge and understanding of prescription drug plans and physicians regarding inappropriate prescribing practices in the elderly that have been described in the literature, identify barriers to improvement, and determine if targeted awareness efforts and collaborative relationships can decrease the rate of inappropriate prescribing in the elderly.

Interventions:
The Louisiana Health CareR eview Pharmacy Practice team will conduct an awareness campaign through press releases and will facilitate dissemination to prescribers of age-related precautionarydrug information via the Epocrates electronic drug information system, through real-time, online electronic reminders. The public awareness campaign consists of the following steps: •d istribution of apress release to local media and to appropriate association newsletters •h ealth plan project partners wereasked to distribute the press release information in their pharmacy/physician newsletters •l etters sent to 2,135 primarycarephysicians in Louisiana •l etters sent to Epocrates (a nationwide electronic drug information system) advising prescribers that age-related warnings did not appear in their softwarefor 4ofthe 10 drugs targeted by this project •l etters sent to pharmacists •a second mailing sent to primarycarephysicians The team will also use Katrinahealth.orgt oi mprove access to medical and pharmacy information for beneficiaries formerly residing in the state who weredisplaced outside of Louisiana by hurricanes.

Project Description:
Because of the need for measurement data the initial project team members will consist of Louisiana Health CareR eview,M edicareA dvantage prescription drug (MA-PD) plans in the state of Louisiana, and the 2colleges of pharmacy in Louisiana (Xavier University School of Pharmacy and University of Louisiana School of Pharmacy). Amain tactic will be to reach pharmacies and physicians through their MA-PD plans.
6. Primary Outcomes: Interventions will be evaluated by adherence to timeline, follow-through, and the professional expertise of representatives of the participating health plans. The ultimate success of all interventions will be confirmed when therei sa ni mprovement in quality indicators. Louisiana Health CareR eview will also ask each of the project team members to assess the returno ni nvestment they have observed as ar esult of the interventions.

Evaluation Design and Methods:
The project will be evaluated by comparing remeasurement rates with baseline rates for each indicator using plan data. Indicators to be measured include (1) total number of prescriptions filled for target drugs/therapeutic classes, (2) prescriptions filled for the targeted drugs/therapeutic classes as ap ercentage of the total number of prescriptions, (3) the number of unique Medicareb eneficiaries receiving 1ormoreprescriptions for targeted drugs/therapeutic classes, and (4) Medicarebeneficiaries receiving 1o rm orep rescriptions for the targeted drugs/therapeutic classes as ap ercentage of Medicareb eneficiaries receiving prescriptions.

Contact:
Louisiana 3. Background: Electronic Health Records (EHRs) have shown some promise as atool for preventing drug therapy problems. Practices benefit from assistance in using these systems to manage care, including drug therapy.

Intervention:
Direct implementation via ongoing design work, using clinical microsystems. Working through existing relationships in the physician offices, communications with the practices concerning drug therapy problems will be included in the QIO' sstrategies for EHR implementation and caremanagement.

Project Description:
The QIO will recruit as ubset of the group of physician offices that ares uccessfully working with the QIO to implement EHRs to decrease the prescribing rate for avoidable and duplicative medications. The QIO will use Part Ddata to inform practice teams and guide their efforts to reduce use of avoidable and duplicative medications.
6. Primary Outcomes: Reductions in the rate of avoidable and duplicative medication use.

Evaluation Design and Methods
: When appropriate quality indicators become available, the QIO will calculate measures related to avoidable and duplicative medications. 3. Background: MassPRO will perform the analysis on the data from only those prescription drug plans (PDPs) and MedicareAdvantage prescription drug (MA-PD) plans that agree to work with the QIO and submit Part D enrollee data and details of the MTM services provided.

Intervention:
MassPRO will conduct quarterly conference calls with the participating PDPs and MA-PD plans. MassPRO will develop as aconvener,afacilitator,abridge communicator,and as aconfidential source of comparative analyses.

Project Description:
This project seeks to collaborate with interested PDPs and MA-PDP plans to assess the impact of MTM services on patients with diabetes mellitus (DM) and/or hypertension (HTN).
6. Primary Outcomes: One focus will be in the area of hospitalizations and emergency department (ED) visits. Anticipated reductions in these costs from improved management of DM and HTN with delays and/or reductions in end-stage renal disease, cardiovascular disease (CVD), and amputations will be tracked as data are available.

Evaluation Design and Methods
: Analytic reports will be generated on aquarterly basis, first for the baseline period and subsequently for the intervention periods. MassPRO will assess each plan for their satisfaction and recommendations for services provided by MassPRO as evidenced by improvement in the following indicators: •B earingPoint Measures 4 •P ercentage of Part Denrollees (by plan or intervention) participating in MTM services with DM with claims for lipid-modifying drugs •P ercentage of Part Denrollees (by plan or intervention) participating in MTM services with DM with claims for angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers •P ercentage of Part Denrollees (by plan or intervention) with DM who areenrolled in an MTM program who arehospitalized during the enrollment period •P ercentage of Part Denrollees (by plan or intervention) with DM who have an ED visit during the enrollment period •P ercentage of Part Denrollees (by plan or intervention) with DM who arehospitalized during the enrollment period with CVD, stroke, and or DM. 3. Background: Diabetes is am ajor source of morbidity and mortality in the United States. While risk and severity of acute and chronic complications from diabetes areh igher in older adults compared with younger persons with diabetes, the negative health consequences from the disease may be even greater for the elderly LTCresident.

Intervention:
The CPs will perform monthly chart reviews of the eligible patients using the 7q uality measures chosen for this project to assess the careb eing given to those with diabetes and its 2m ost common comorbidities: hypertension and dyslipidemia. The CPs will enter an intervention note in the chart, when appropriate, as defined for each measure, and recordphysician responses to the recommendations. HealthcareQuality Strategies, Inc. (HQSI) will analyze the monthly data to generate facility-specific profiles for residents with diabetes, which can be used to monitor the facility' spopulation with diabetes. An education toolkit will be disseminated to project participants to provide atool for supporting inservices focusing on diabetes care.

Project Description:
This project incorporates aspects of medication therapy management (MTM) services to improve drug therapy of people with diabetes. MTM has not been well studied in the LTCsetting. The mandatoryr equirement of drug regimen reviews (DRRs) already performed in LTCf acilities could either confound or provide ap latform for the application of MTM services in this setting. MTM services offer an opportunity to improve the safe and appropriate use of medication and disease monitoring for residents to agreater degree than traditional DRR.

Primary Outcomes:
It is hoped that this project will demonstrate improvement in the quality measures to support the value of medication management in the LTCenvironment. Although not specifically measured in this project, the design also encourages communication among health careprofessionals to improve carethat may lead to improved patient outcomes and/or quality of life.

Evaluation Design and Methods:
The CPs will capturedata using an HQSI data collection tool. HQSI will analyze the collected data to evaluate the changes in the quality measures and impact of the interventions.

Intervention:
One coalition focus is to establish, review and promote understanding in New Mexico of existing common clinical guidelines for medication monitoring. NMPIC provides evidence-based educational materials chosen for their clinical and/or economic value. NMPIC strives to inform physicians of the evidence regarding clinical appropriateness, therapeutic equivalence within drug classes, and potential cost savings for patients. The coalition developed an e-prescribing model and defined cost savings and outcomes for each setting (see http://www.nmmra.org/resources/Physician/91_797.pdf).

Project Description:
The New Mexico Medical Review Association (NMMRA) is providing technical assistance and quality improvement tools to coalition members pertaining to e-prescribing and MTM. NMPIC provides user-friendly,u p-to-date, and objective information on best practices and lessons learned to both providers and Medicarebeneficiaries.
6. Primary Outcomes: Outcome evaluation will be conducted via annual monitoring using the following indicators: drugs to be avoided in the elderly,annual monitoring of patients on persistent medications, lipid-modifying agents in diabetes, beta-blockers in postmyocardial infarction and heart failure, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers in diabetes and heart failure, and diuretics in hypertension.

Evaluation Design and Methods:
The e-prescribing project will evaluate returno ni nvestment for e-prescribing implementation. The project hypothesis is that most of the value identified will not come from reductions in prescription costs but in avoiding hospitalizations as aresult of better adherence and fewer medication errors. The MTM pilot clinical outcome measures include: baseline, 6-month and 1-year measurements of hemoglobin A1C, fasting blood glucose, blood pressure, low-density lipoprotein cholesterol, and weight. Additionally,Health Outcome Survey data will be used at baseline, 6months and 1year to assess quality of life using av alidated survey,t he SF-36, as well as questions regarding satisfaction with MTM services. Diseasespecific resource utilization, such as emergency department visits, hospitalizations, clinic visits, and medication adherence, will be assessed for enrolled patients. Resource utilization calculations will be performed by the NMPIC Data Workgroup, led by NMMRA with clinical support from the MTM pilot faculty of the College of Pharmacy. 3. Background: Anticholinergic drugs have been shown to contribute to cognitive impairment, falls, low blood pressure, and urinaryretention, and many arelisted as "potentially inappropriate" for use in the elderly.Despite mounting evidence documenting their harmful effects, and despite the availability of moresuitable alternatives, anticholinergic drug use continues to be remarkably common among the community-dwelling elderly.

Contact
The increasing age of the American population and its growing reliance upon pharmaceuticals suggest that anticholinergic drug use will continue to be aproblem unless effective interventions aredeveloped and implemented.

Intervention:
With input from an expert panel of physicians, pharmacists, nurses, and researchers, IPRO has developed continuing medical education, accredited educational materials, and clinical tools that highlight the problems associated with anticholinergic drug use and that seek to generate dialogue between patients and prescribers to facilitate change (http://providers.ipro.org/index/presc-drug-plan). IPRO has partnered with 11 organizations offering Part Dplans to morethan 250,000 beneficiaries in New York and is working with them to distribute program materials to pharmacists and prescribers across the state. In addition, IPRO will promote distribution of the materials through professional organizations, interest groups, colleges, and other interested parties. Educational programs specifically for beneficiaries are under development.

Project Description:
The DADE project is am ultifaceted educational campaign seeking to increase the awareness of the problems associated with anticholinergic drug use in the elderly.The project provides tools to prescribers and pharmacists to foster effective communication with beneficiaries, leading to improved patient careand prescribing.
6. Primary Outcomes: IPRO has developed specifications for several quality measures for the project, including the proportion of beneficiaries prescribed PIADs, the proportion of claims that aref or PIADs, and the proportion of patients treated for dementia that receive PIADs.

Evaluation and Design
Methods: Improvement in the quality measures will be assessed through serial analysis of prescription claims data. Objective: Improve adherence to evidence-based drug therapy for heart failure(HF) and improve therapeutic monitoring. The Carolinas Center for Medical Excellence (CCME) will also investigate the relationship of drug therapy adherence and therapeutic monitoring with health outcomes including readmissions, emerency department visits, mortality,and costs.
3. Background: HF is the cause of substantial morbidity,m ortality,a nd costs in the Medicarep opulation. Evidence from randomized clinical trials suggests that appropriate pharmacotherapy with angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and beta-adrenergic blockers reduces HF adverse outcomes and costs.

Intervention:
The project utilizes academic detailing in the form of on-site visits and teleconferences. CCME distributes practice-level tools and educational materials to participating practices. Practice assessment and guidance regarding carem anagement using electronic systems is provided. Am ajor component of the intervention involves the development, implementation, and pilot testing of anovel patient-level intervention, the Heart Failure CareK it (HFCK). Pharmacist interventions include education about the importance of ACEIs/ARBs and betaadrenergic blockers in the ongoing treatment of HF.

Project Description:
This project focuses on the fee-for-service outpatient primaryc ares etting in North Carolina and South Carolina. This project is conducted by CCME, the MedicareQIO for North Carolina and South Carolina.
6. Primary Outcomes: Improvement in prescribing, adherence, and therapeutic monitoring for drug treatment of persons with HF.
7. Evaluation Design and Methods: CCME plans to use practice-level chartdata to assess drug therapy adherence and therapeutic monitoring at least quarterly during 2007. These evaluation measures ared rug adherence with ACEIs and beta blockers, and therapeutic monitoring (for potassium levels, blood urea nitrogen, and creatinine). Quarterly adherence rates will also be obtained from prescription drug plan (PDP) claims for patients within participating practices enrolled in participating PDPs. Data to be collected for other process measures include the number of HF patients encountered and the number of HFCKs distributed at participating practices. 3. Background: Medication errors and preventable medication-related injuries arec ritical patient safety issues. An adverse drug event (ADE) is defined by the Institute for Safe Medication Practices as "a deviation in the medication use process (prescribing, dispensing, administrating, monitoring) OR undesirable clinical manifestation that is consequent to and caused by the administration or omission of medications." In the July 2006 Institute of Medicine report, "Preventing Medication Errors," it is noted that an average of 1.5 million preventable ADEs occur annually in the United States, representing at least aquarter of all medication-related injuries. In aCanadian study of discrepancies between patient medication regimens and patient histories taken at the hospital, Cornish et al. found the most common medication error was the omission of aregularly used medication from the patient admission history. The authors reported that "38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration." 5 4. Interventions: Primaryproject interventions are: (1) providing the participating hospital pharmacists access to patient-level MedicareP art Dd ata, thereby increasing the accuracy of the medication historya nd enhancing the medication reconciliation process at admission; and (2) medication reconciliation and patient counseling provided by the community-based pharmacists (for patients filling discharge medications at participating pharmacies) using hospital discharge medication information.

Project Description:
The QIO enhances the accuracy of the prescription medication historyu pon hospital admission by obtaining the patient' sPart Dmedication historydirectly from PartDplans in the state, and improves carea fter discharge by using community pharmacists to identify duplications, omissions, potential DDIs, and provide education regarding appropriate medication administration and regimen.
6. Primary Outcomes: North Dakota Health CareReview hypothesizes that Medicarebeneficiaries who receive the benefit of both the augmented admission historyand the postdischarge pharmacy follow-up will have fewer ADEs and that Medicarebeneficiaries who receive even 1intervention component will receive some benefit.
7. Evaluation Design and Methods: All Medicareb eneficiaries who ared ischarged from the participating hospital to the community after an inpatient stay between October 2006 and July 2007 will receive as urvey approximately 30 days postdischarge. The survey will obtain information about the patient' sp osthospital course relative to ADEs during the 30-day post discharge time frame. The project' si mpact will be evaluated by comparing the frequency of ADEs reported by Medicarebeneficiaries in an intervention group with those not in an intervention group. 4. Intervention: Quality Insights of Pennsylvania (QIP) and Highmark arep reparing aj oint letter that will be sent to the 50 physician practices that will receive face-to-face detailing regarding DAE, as defined by the Highmark Clinical Performance Indicator list. As econd letter from Highmark and QIP will be sent to the 100 practices that will receive reports detailing their prescribing activity for DAE and polypharmacy.H ighmark will provide QIP analysts with the Part Ddata to develop the reports that QIP will provide to practices. Areport generated for each physician within apractice will list prescriptions written for DAE and note which patients received these prescriptions. Al ist of patients currently filling prescriptions for 10 or morem edications within ad efined time period will also be provided to each physician. QIP project staffw ill make at otal of 3v isits to each of the 50 practices: 1atbaseline to provide the reports and interventions to assist the physicians and staffwith improvement, 1inFebruary2007, at the halfway point for the project, and 1inSeptember 2007 at the completion of the project.

Project Description:
The project includes 50 practice sites that will receive detailed reports, and QIP will conduct on-site visits for academic detailing. Additionally,1 00 practice sites will receive the detailed reports. Practices weredivided into 3groups (A-C) in such away as to be representative of practices generally.The ratio of the number of family practices to the number of internal medicine practices within each group is roughly equivalent to the underlying target population (58:42). Group Ar eceives no intervention and no reports. Group B receives only reports and access to interventions. Group Creceives all interventions and face-to-face detailing.
6. Primary Outcomes: QIP will analyze the data quarterly for each of the practices to evaluate impact on the frequency of prescribing of DAE of face-to-face detailing and reports versus providing reports alone.

Evaluation and Design and Methods
: Quarterly summaries will be used to determine the effectiveness of the reports provided and the interventions offered to the practices. It is hypothesized that those practices receiving face-to-face detailing will see the greatest improvement. Objective: Achieve annual serum potassium testing of Part Denrollees with high blood pressure(HBP) who arebeing treated with diuretic therapy.

Background:
This project includes beneficiaries enrolled in 1o f2M edicareA dvantage prescription drug plans/prescription drug plans (MA-PD plans/PDPs) who have agreed to participate. Hypokalemia is adocumented side effect of diuretics. Monitoring serum potassium when patients with HBP areo nc hronic therapy with diuretics is particularly relevant due to the potential serious complications brought about by low serum potassium.

Intervention:
Educational material for physicians is produced by the QIO and distributed via the MA-PD plan and PDP.T he QIO' se ducational activities consist of quarterly newsletters on the clinical topic and related subjects. The QIO expects to coordinate with the MA-PD plans to distribute the newsletter to its providers. The QIO will provide content including adescription of the project targeted to physicians and information targeted to beneficiaries.

Project Description:
This collaboration between the Quality Improvement Professional Research Organization (QIPRO) and the PDP and MA-PD plan identifies Medicareb eneficiaries who ared iagnosed with HBP and areprescribed adiuretic. Prescription drug event data and PartBclaims data will be reviewed to determine whether serum potassium monitoring occurredonce ayear.
6. Primary Outcomes: Increase in serum potassium testing of PartDe nrollees with HBP who arer eceiving diuretic therapy.

Evaluation Design and Methods:
The QIO performs quarterly monitoring following the first educational intervention. QIPRO consults and shares monitoring results with the QIO support centers, and seeks their feedback. Returno ni nvestment for intervention components and any improvement in the testing rate will be analyzed. 1. Title: Assessing and Improving Medication Use in Diabetes Using Part DP harmacy Data 2. Objective: Improve patient health outcomes by promoting the effective and efficient use of evidence-based drug therapies among beneficiaries having diabetes.

Background:
Diabetes mellitus is ah ighly prevalent condition that increases risk for ar ange of micro-and macrovascular diseases. Numerous studies have provided evidence that the risk of untowardhealth outcomes in diabetes can be reduced by medications for hyperglycemia, dyslipidemia, and hypertension. Epidemiologic studies have revealed that such drug therapies areoften not prescribed when indicated. Moreover,patient adherence to these therapies is frequently poor.

Intervention:
Quality Partners of Rhode Island' s(QPRI) approach is multifaceted. QPRI is collaborating with ah ealth plan that provides case-management services to ap opulation of patients who ared ually enrolled in Medicareand Medicaid. QPRI is providing expertise and tools for addressing medication-use issues common in diabetes. The QIO is also collaborating with multiple other prescription drug plans (PDPs) to measurea nd improve medication use among Part Dp lan enrollees with diabetes. QPRI' se fforts include outreach to larger provider groups, targeted academic detailing, and provider profiling.

Project Description:
This project aims to measurea nd improve the quality of medication use among MedicareP art Dp lan enrollees with diabetes, focusing on the prescribing of and adherence to angiotensinconverting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and the use of lipid-modifying medications (e.g., statins). QPRI also aims to promote the use of lower-cost therapies whereavailable. The project includes Medicareb eneficiaries residing in community and LTCs ettings and receiving pharmacy benefits through MedicareP art Dp lans. Ak ey Part DP DP partner is Blue Cross &B lue Shield of Rhode Island, which manages the largest MedicareAdvantage prescription drug plan in the state. The QIO is also working with several other PartDP DP providers. In collaboration with faculty from the University of Rhode Island College of Pharmacy,QPRI is coordinating the acquisition of data from PDP partners, composing quality indicator rates, and sharing this information and associated resources with plans and providers.
6. Primary Outcomes: The primaryo utcome to be assessed is improvement in the use of ACEIs/ARBs and lipid-modifying medications among Medicarebeneficiaries with diabetes. Additional outcomes of interest include drug plan and provider satisfaction with the program and its components, and the recognition of Quality Partners as aresource for promoting quality improvement under MedicarePart D.
7. Evaluation Design and Methods: QPRI' sevaluation of the acceptance and effectiveness of this approach will be viewed from multiple sources. Quantitatively,p roject success will evaluated in terms of improvement in rates of use of and adherence to ACEIs/ARBs and lipid-modifying therapies. Sources of qualitative data will include pharmacists and physicians from collaborating drug plans and community physicians who will be surveyed with regardtotheir perception of the program' sutility and effectiveness.

Contact:
Quality Partners of Rhode Island Lynn Pezzullo, RPh, Manager,Pharmacy Services, (401) 528-3222 lpezzullo@riqio.sdps.org 5. Project Description: This project compares health outcomes among Medicareb eneficiaries taking warfarin whose therapy is managed by pharmacists or by traditional medical care. Additionally,i tc ompares the cost effectiveness of pharmacist-managed anticoagulation services rendered in community pharmacies with traditional medical care.

Primary Outcomes:
The project is expected to demonstrate that improved health outcomes can be obtained from community pharmacists managing warfarin therapy and that this medication therapy management (MTM) is cost-effective.

Evaluation Design and Methods:
The MedicareA dvantage prescription drug (MA-PD) plan identified approximately 85 patients suitable for this study based on criteria that they have been on warfarin therapy longer than 6m onths. The MA-PD plan will send patients letters explaining the program and giving them the option to choose pharmacist management of their warfarin. Participation is offered at no charge to the patient. Patients will self-select to participate in the program (intervention group) or continue with current physician management (control group). Descriptive baseline characteristics between the pharmacist-managed patients and the traditional medical care patients will be compared using the appropriate statistical methods. Intervention data (number of MTMs, dosing adjustments, and patient INR levels) will be obtained from pharmacists. Postintervention data emergency department (ED) visits and admissions will be provided by the MA-PD plan. Data provided by the MA-PD plan will be monitored during the course of the study.P ostintervention rates for bleeding episodes, use of transfusions, thrombotic events, hospitalizations, and ED visits for warfarin-related adverse events for the intervention and traditional care groups will be calculated using data provided by the MA-PD plan. For intervention patients, pharmacists will report all INR measurements and will calculate the percentage of "time in therapeutic range." Medicare reimbursement rates will be used to estimate the cost of caren eeded to treat complications associated with warfarin therapy and to comparecosts between the 2groups. The hypothesis is that the cost of program, including pharmacist MTM services and additional lab testing, will be approximately offset by the reduction in costs for physician visits to manage warfarin. The program will seek to identify savings from reductions in ED visits, hospitalizations, and treatment cost for warfarin-related adverse events. Physician office visits for the 2groups will be compared for this purpose.