- Email: [email protected]
Use of community pharmacy–provided diabetes services to aid physicians in the National Committee for Quality Assurance recognition program
SPECIAL FEATURE
Use of community pharmacy– provided diabetes services to aid physicians in the National Committee for Quality Assurance recognition program Kristy L. Brittain and Catherine H. Kuhn
Received October 31, 2008, and in revised form January 27, 2009. Accepted for publication January 30, 2009.
Abstract Background: Pay-for-performance (P4P) models are being adopted by many health care payers, including Medicare, for payment of physician services. To receive financial incentives in P4P programs, physicians are encouraged to attain recognition or credentialing from an agency, such as the National Committee for Quality Assurance (NCQA). Objective: To explore the potential roles of a community pharmacy–provided diabetes services in collaboration with physicians and to assist them in becoming acknowledged by the NCQA Diabetes Physician Recognition Program. Summary: KDI Health Solutions pharmacists have demonstrated success in the management of diabetes through the Asheville Project and the Diabetes Ten City Challenge. Continued pharmacists’ efforts may focus on expanding current disease state management programs, community pharmacy diabetes education programs, and collaborative practices with physicians. Studies are currently being conducted to assess physician willingness to use pharmacists as part of the NCQA recognition process. Conclusion: Collaboration of physicians and pharmacists may improve diabetes standards of care and aid physicians in becoming NCQA-recognized providers. NCQArecognized physicians can align themselves with current and future P4P programs. Keywords: National Committee for Quality Assurance, pay for performance, diabetes, pharmacy services. J Am Pharm Assoc. 2009;49:209–211. doi: 10.1331/JAPhA.2009.08161
Journal of the American Pharmacists Association
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Kristy L. Brittain, PharmD, is Assistant Professor, Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Medical University of South Carolina Campus, and Clinical Coordinator, KDI Health Solutions, Charleston, SC. Catherine H. Kuhn, PharmD, is Assistant Professor, Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Medical University of South Carolina Campus, and Clinical Coordinator, KDI Health Solutions, North Charleston, SC. Correspondence: Kristy L. Brittain, PharmD, South Carolina College of Pharmacy, MUSC Campus, Department of Clinical Pharmacy and Outcome Sciences, 43 Sabin St., QE213C, MSC 132, Charleston, SC 29425. Fax: 843-792-3759. E-mail: brittain@musc. edu Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings or honoraria. See related article on page 143.
M a r /A p r 2 0 0 9 • 4 9 : 2 •
JAPhA • 209
SPECIAL FEATURE
Pharmacists and physicians in NCQA recognition
I
n a 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine recommends a redesign of the American health care system to close the gap or “chasm” between the health care that America has now and the health care that America could have.1 The recommended redesign requires changes in structures and processes in the health care environment. One of the proposed changes is to align health care payment policies with quality improvement.1 Existing fee-for-service plans are criticized for rewarding health care providers regardless of providing high-quality or poor-quality care.2 In contrast, pay-for-performance (P4P) programs incentivize physicians and other health care professionals who provide quality-driven improvements in the health of their patients and who adopt a more efficient model of practice. P4P programs may also focus on prevention of diseases through proactive preventive care.2,3 In 2006, an estimated 80 or more health plans offered P4P programs covering approximately 60 million members in the United States.3 Currently, a number of payers and clinicians support P4P programs or are exploring P4P programs. For example, the Centers for Medicare & Medicaid Services is conducting demonstration projects in various health care settings to assess whether implementation of P4P programs will improve the quality of care provided to Medicare beneficiaries.2 To receive financial incentives in P4P programs, physicians are encouraged to attain recognition or credentialing from an agency such as the National Committee for Quality Assurance (NCQA). NCQA is a private, not-for-profit organization that accredits and
At a Glance
Synopsis: The increased use of financial incentives to improve quality of care by health plans, such as payfor-performance programs, provides an opportunity for pharmacists to collaborate with physicians. Physicians are encouraged to become credentialed to benefit under these plans, and one recognition program—the National Committee for Quality Assurance’s (NCQA’s) Diabetes Physician Recognition Program—is described. Pharmacists can serve as valuable resources for physicians seeking to improve care of patients with diabetes, and the services provided in the community pharmacy can be a component of attaining recognition by NCQA. Analysis: The Asheville Project and the Diabetes Ten City Challenge have demonstrated success on the basis of the evidence-based outcomes measures required in the NCQA Diabetes Physician Recognition Program. KDI Health Solutions, a subsidiary of Kerr Drug, Inc., is a group of residency-trained clinical pharmacists providing diabetes education and management for the Asheville Project and the HealthMapRx Program (formerly the Diabetes Ten City Challenge), among other diabetes care programs. Studies are being conducted to assess physician willingness to use pharmacists as part of the NCQA recognition process.
210 • JAPhA • 4 9 : 2 • M a r /A p r 2 0 0 9
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certifies a wide range of health care organizations, including physicians and physician groups. NCQA offers physician recognition programs that assess physician performance on evidence-based clinical standards of care for their patients. In addition to the financial incentives, NCQA recognition allows the physician to be included in an online directory of “high-quality” doctors, which patients can search. This allows the patient to feel confident that the doctor “consistently treats patients according to the best available scientific evidence.”4 The NCQA physician recognition programs include the Diabetes Physician Recognition Program, Heart/Stroke Recognition Program, Back Pain Physician Recognition Program, Physician Practice Connections, and Patient-Centered Medical Home.4 Specifically, community pharmacists can assist physicians with the Diabetes Physician Recognition Program because of pharmacists’ experiences and success with diabetes disease management as shown in nationwide initiatives such as the Asheville Project and the Diabetes Ten City Challenge. The Diabetes Physician Recognition Program has been developed in collaboration between NCQA and the American Diabetes Association (ADA). Physician performance is evaluated by using the following measures: glycosylated hemoglobin, blood pressure, low-density lipoprotein cholesterol, eye examinations, foot examinations, nephrology assessment, and smoking status or cessation advice and treatment.4 Information on how physicians apply for program recognition is provided on the NCQA website (www.ncqa.org), and includes instructions for ordering application materials. The application materials include an overview of the program, eligibility criteria, and pricing information. Physicians are required to pay an application fee and complete a data collection tool, which requires the submission of data from the charts of 25 patients with diabetes for review. The diabetes measures evaluated are the same measures used by community pharmacists to assess outcomes in the Asheville Project, the Diabetes Ten City Challenge, and other diabetes education programs.5–8 Community pharmacy–provided diabetes services can assist physicians in attaining NCQA recognition.
Summary Community pharmacists have demonstrated great success with the management of diabetes in the community as demonstrated in the Asheville Project and Diabetes Ten City Challenge.3,5,6,8 In both programs, pharmacists are active providers in the collaborative care of diabetes patients and follow the standards of care as set by ADA. Pharmacists communicate with physicians on a regular basis to update the physician on the status of the patient’s progress and make recommendations for care. They also use their expertise in medication therapy management and motivate patients to follow a healthy lifestyle. As evidenced by impressive results as part of these national efforts, community pharmacists are a valuable resource for those physicians striving to improve their diabetes patients’ care and become recognized under the NCQA program. Kerr Drug, Inc., a regional community pharmacy chain located in North and South Carolina, exemplifies the impact pharmacists can have in diabetes care. Clinical pharmacists, who practice in Kerr Drug pharmacies, are part of a subsidiary of Kerr Drug, Inc., known as KDI Health Solutions (KHS). KHS is a group of residency-trained clinical pharmacists and has been recognized for the delivery of
Journal of the American Pharmacists Association
Pharmacists and physicians in NCQA recognition SPECIAL
innovative, community-based clinical pharmacy services. Awards include the prestigious 2006 American Pharmacists Association Foundation Pinnacle Award for Demonstrating Quality in the Medication Use Process and 2008 North Carolina American Diabetes Association Provider of the Year. Currently, KHS pharmacists provide diabetes education and management for the Asheville Project and HealthMapRx Program (formerly the Diabetes Ten City Challenge) and offer the ADA-recognized Diabetes Self-Management Education program in the community pharmacy setting. KHS began the diabetes program in 2005 and has continued to grow its diabetes education efforts over the past few years. Through this program, KHS pharmacists see patients regularly over a 3-month period for diabetes education classes. During the patient-centered education program, pharmacists track patients’ outcomes and management of diabetes. This gives the patient increased opportunity for better diabetes control through commitment to lifestyle changes and overall health. The program also promotes a continuous circle of care among the patient, pharmacist, and physician. KHS pharmacists are collaborating with physicians to improve the quality of care of their patients and to promote pharmacists as disease state managers and medication experts. Lisa Adams Padgett, a community pharmacy resident with KHS and the University of North Carolina, has approached current NCQA-recognized physicians in the state of North Carolina. Padgett is evaluating physician perceptions of the NCQA process and asking physicians to identify how community-based clinical pharmacists can assist them in maintaining NCQA recognition. Padgett and other Kerr Drug pharmacists hope to use this information to tailor future programs and collaborative efforts. Future collaborative efforts with physicians and patients may also improve the outlook for the pharmacy profession. Increased use of community pharmacist–provided services, such as diabetes education, will encourage expansion of current diabetes education programs and establishment of new programs in community pharmacies. Establishing new sites for diabetes education programs run by community pharmacists will increase patient access to quality programs. Continued growth of diabetes self-management programs, such as the Asheville Project and the Diabetes Ten City Challenge, will allow more patients and employer groups to save health care dollars and improve overall patient health. Physicians may also benefit by establishing collaborative practice agreements with pharmacists for diabetes management within a medical practice. Collaborative agreements could include pharmacist-provided clinical services through the use of medication therapy management or by providing in-house diabetes education programs. These models will reinforce the expansion of the role of the community pharmacist to patient care provider as well as medication dispenser. Once pharmacists are recognized as patient care providers, many doors will open for the reimbursement of services. One successful model involves pharmacists and immunizations. Pharmacists have provided immunizations for many years with limited reimbursement from third-party payers. As recently as late 2008, pharmacists in North Carolina have been recognized as patient care providers by Blue Cross Blue Shield of North Carolina (BCBSNC), giving them the ability to bill BCBSNC for the administration of immunizations in a community pharmacy. This is the result of
Journal of the American Pharmacists Association
FEATURE
many years of hard work on the part of immunizing pharmacists, who were previously limited to reimbursement from Medicare. Through pharmacist-provided immunization programs, pharmacists have increased access to patients in the community. By increasing access, pharmacists have also assisted physicians and the health care community by increasing immunization rates of their patients. This example illustrates how a collaborative effort among health care providers can benefit all in the circle of care, including the patient, physician, and pharmacist. It is hoped that through recognition of the pharmacist as a patient care provider, reimbursement opportunities for nontraditional, nondispensing activities will continue to improve.9 Improvement in the reimbursement process will encourage more pharmacists to expand their role in the health care setting.
Conclusion By addressing current community pharmacy efforts on diabetes care, we have identified potential areas where physicians and community pharmacists can collaborate to improve achievement of standards of care in diabetes. This can aid physicians in achieving NCQA recognition and thereby better align physicians for current and future P4P programs from various health care payers. The time is now for pharmacists to become key players in the P4P arena and assist physicians in the NCQA recognition process. References 1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001. 2. Fenter TC, Lewis SJ. Pay-for-performance initiatives. J Manag Care Pharm. 2008;14(6 suppl C):S12–S15. 3. Endsley S, Kirkegaard M, Baker G, Murcko A. Getting rewards for your results: pay-for-performance programs. Fam Pract Manag. 2004;11(3):45–50. 4. National Committee for Quality Assurance Web site. Accessed at www.ncqa.org, January 23, 2009. 5. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46:133–47. 6. Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economical outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48:23–31. 7. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: longterm clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173–84. 8. Fera T, Bluml BM, Ellis WM, Schaller CW, Garrett DG. The Diabetes Ten City Challenge: interim clinical and humanistic outcomes of a multistate community pharmacy diabetes care program. J Am Pharm Assoc. 2008;48:181–90. 9. National Association of Chain Drug Stores, American Pharmaceutical Association, National Community Pharmacists Association. Implementing effective change in meeting the demands of community pharmacy practice in the United States. Washington, DC: American Pharmaceutical Association; 1999.
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JAPhA • 211
Use of community pharmacy– provided diabetes services to aid physicians in the National Committee for Quality Assurance recognition program Kristy L. Brittain and Catherine H. Kuhn
Received October 31, 2008, and in revised form January 27, 2009. Accepted for publication January 30, 2009.
Abstract Background: Pay-for-performance (P4P) models are being adopted by many health care payers, including Medicare, for payment of physician services. To receive financial incentives in P4P programs, physicians are encouraged to attain recognition or credentialing from an agency, such as the National Committee for Quality Assurance (NCQA). Objective: To explore the potential roles of a community pharmacy–provided diabetes services in collaboration with physicians and to assist them in becoming acknowledged by the NCQA Diabetes Physician Recognition Program. Summary: KDI Health Solutions pharmacists have demonstrated success in the management of diabetes through the Asheville Project and the Diabetes Ten City Challenge. Continued pharmacists’ efforts may focus on expanding current disease state management programs, community pharmacy diabetes education programs, and collaborative practices with physicians. Studies are currently being conducted to assess physician willingness to use pharmacists as part of the NCQA recognition process. Conclusion: Collaboration of physicians and pharmacists may improve diabetes standards of care and aid physicians in becoming NCQA-recognized providers. NCQArecognized physicians can align themselves with current and future P4P programs. Keywords: National Committee for Quality Assurance, pay for performance, diabetes, pharmacy services. J Am Pharm Assoc. 2009;49:209–211. doi: 10.1331/JAPhA.2009.08161
Journal of the American Pharmacists Association
w w w.j a p h a . o r g
Kristy L. Brittain, PharmD, is Assistant Professor, Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Medical University of South Carolina Campus, and Clinical Coordinator, KDI Health Solutions, Charleston, SC. Catherine H. Kuhn, PharmD, is Assistant Professor, Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Medical University of South Carolina Campus, and Clinical Coordinator, KDI Health Solutions, North Charleston, SC. Correspondence: Kristy L. Brittain, PharmD, South Carolina College of Pharmacy, MUSC Campus, Department of Clinical Pharmacy and Outcome Sciences, 43 Sabin St., QE213C, MSC 132, Charleston, SC 29425. Fax: 843-792-3759. E-mail: brittain@musc. edu Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings or honoraria. See related article on page 143.
M a r /A p r 2 0 0 9 • 4 9 : 2 •
JAPhA • 209
SPECIAL FEATURE
Pharmacists and physicians in NCQA recognition
I
n a 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine recommends a redesign of the American health care system to close the gap or “chasm” between the health care that America has now and the health care that America could have.1 The recommended redesign requires changes in structures and processes in the health care environment. One of the proposed changes is to align health care payment policies with quality improvement.1 Existing fee-for-service plans are criticized for rewarding health care providers regardless of providing high-quality or poor-quality care.2 In contrast, pay-for-performance (P4P) programs incentivize physicians and other health care professionals who provide quality-driven improvements in the health of their patients and who adopt a more efficient model of practice. P4P programs may also focus on prevention of diseases through proactive preventive care.2,3 In 2006, an estimated 80 or more health plans offered P4P programs covering approximately 60 million members in the United States.3 Currently, a number of payers and clinicians support P4P programs or are exploring P4P programs. For example, the Centers for Medicare & Medicaid Services is conducting demonstration projects in various health care settings to assess whether implementation of P4P programs will improve the quality of care provided to Medicare beneficiaries.2 To receive financial incentives in P4P programs, physicians are encouraged to attain recognition or credentialing from an agency such as the National Committee for Quality Assurance (NCQA). NCQA is a private, not-for-profit organization that accredits and
At a Glance
Synopsis: The increased use of financial incentives to improve quality of care by health plans, such as payfor-performance programs, provides an opportunity for pharmacists to collaborate with physicians. Physicians are encouraged to become credentialed to benefit under these plans, and one recognition program—the National Committee for Quality Assurance’s (NCQA’s) Diabetes Physician Recognition Program—is described. Pharmacists can serve as valuable resources for physicians seeking to improve care of patients with diabetes, and the services provided in the community pharmacy can be a component of attaining recognition by NCQA. Analysis: The Asheville Project and the Diabetes Ten City Challenge have demonstrated success on the basis of the evidence-based outcomes measures required in the NCQA Diabetes Physician Recognition Program. KDI Health Solutions, a subsidiary of Kerr Drug, Inc., is a group of residency-trained clinical pharmacists providing diabetes education and management for the Asheville Project and the HealthMapRx Program (formerly the Diabetes Ten City Challenge), among other diabetes care programs. Studies are being conducted to assess physician willingness to use pharmacists as part of the NCQA recognition process.
210 • JAPhA • 4 9 : 2 • M a r /A p r 2 0 0 9
w w w.j a p h a . o r g
certifies a wide range of health care organizations, including physicians and physician groups. NCQA offers physician recognition programs that assess physician performance on evidence-based clinical standards of care for their patients. In addition to the financial incentives, NCQA recognition allows the physician to be included in an online directory of “high-quality” doctors, which patients can search. This allows the patient to feel confident that the doctor “consistently treats patients according to the best available scientific evidence.”4 The NCQA physician recognition programs include the Diabetes Physician Recognition Program, Heart/Stroke Recognition Program, Back Pain Physician Recognition Program, Physician Practice Connections, and Patient-Centered Medical Home.4 Specifically, community pharmacists can assist physicians with the Diabetes Physician Recognition Program because of pharmacists’ experiences and success with diabetes disease management as shown in nationwide initiatives such as the Asheville Project and the Diabetes Ten City Challenge. The Diabetes Physician Recognition Program has been developed in collaboration between NCQA and the American Diabetes Association (ADA). Physician performance is evaluated by using the following measures: glycosylated hemoglobin, blood pressure, low-density lipoprotein cholesterol, eye examinations, foot examinations, nephrology assessment, and smoking status or cessation advice and treatment.4 Information on how physicians apply for program recognition is provided on the NCQA website (www.ncqa.org), and includes instructions for ordering application materials. The application materials include an overview of the program, eligibility criteria, and pricing information. Physicians are required to pay an application fee and complete a data collection tool, which requires the submission of data from the charts of 25 patients with diabetes for review. The diabetes measures evaluated are the same measures used by community pharmacists to assess outcomes in the Asheville Project, the Diabetes Ten City Challenge, and other diabetes education programs.5–8 Community pharmacy–provided diabetes services can assist physicians in attaining NCQA recognition.
Summary Community pharmacists have demonstrated great success with the management of diabetes in the community as demonstrated in the Asheville Project and Diabetes Ten City Challenge.3,5,6,8 In both programs, pharmacists are active providers in the collaborative care of diabetes patients and follow the standards of care as set by ADA. Pharmacists communicate with physicians on a regular basis to update the physician on the status of the patient’s progress and make recommendations for care. They also use their expertise in medication therapy management and motivate patients to follow a healthy lifestyle. As evidenced by impressive results as part of these national efforts, community pharmacists are a valuable resource for those physicians striving to improve their diabetes patients’ care and become recognized under the NCQA program. Kerr Drug, Inc., a regional community pharmacy chain located in North and South Carolina, exemplifies the impact pharmacists can have in diabetes care. Clinical pharmacists, who practice in Kerr Drug pharmacies, are part of a subsidiary of Kerr Drug, Inc., known as KDI Health Solutions (KHS). KHS is a group of residency-trained clinical pharmacists and has been recognized for the delivery of
Journal of the American Pharmacists Association
Pharmacists and physicians in NCQA recognition SPECIAL
innovative, community-based clinical pharmacy services. Awards include the prestigious 2006 American Pharmacists Association Foundation Pinnacle Award for Demonstrating Quality in the Medication Use Process and 2008 North Carolina American Diabetes Association Provider of the Year. Currently, KHS pharmacists provide diabetes education and management for the Asheville Project and HealthMapRx Program (formerly the Diabetes Ten City Challenge) and offer the ADA-recognized Diabetes Self-Management Education program in the community pharmacy setting. KHS began the diabetes program in 2005 and has continued to grow its diabetes education efforts over the past few years. Through this program, KHS pharmacists see patients regularly over a 3-month period for diabetes education classes. During the patient-centered education program, pharmacists track patients’ outcomes and management of diabetes. This gives the patient increased opportunity for better diabetes control through commitment to lifestyle changes and overall health. The program also promotes a continuous circle of care among the patient, pharmacist, and physician. KHS pharmacists are collaborating with physicians to improve the quality of care of their patients and to promote pharmacists as disease state managers and medication experts. Lisa Adams Padgett, a community pharmacy resident with KHS and the University of North Carolina, has approached current NCQA-recognized physicians in the state of North Carolina. Padgett is evaluating physician perceptions of the NCQA process and asking physicians to identify how community-based clinical pharmacists can assist them in maintaining NCQA recognition. Padgett and other Kerr Drug pharmacists hope to use this information to tailor future programs and collaborative efforts. Future collaborative efforts with physicians and patients may also improve the outlook for the pharmacy profession. Increased use of community pharmacist–provided services, such as diabetes education, will encourage expansion of current diabetes education programs and establishment of new programs in community pharmacies. Establishing new sites for diabetes education programs run by community pharmacists will increase patient access to quality programs. Continued growth of diabetes self-management programs, such as the Asheville Project and the Diabetes Ten City Challenge, will allow more patients and employer groups to save health care dollars and improve overall patient health. Physicians may also benefit by establishing collaborative practice agreements with pharmacists for diabetes management within a medical practice. Collaborative agreements could include pharmacist-provided clinical services through the use of medication therapy management or by providing in-house diabetes education programs. These models will reinforce the expansion of the role of the community pharmacist to patient care provider as well as medication dispenser. Once pharmacists are recognized as patient care providers, many doors will open for the reimbursement of services. One successful model involves pharmacists and immunizations. Pharmacists have provided immunizations for many years with limited reimbursement from third-party payers. As recently as late 2008, pharmacists in North Carolina have been recognized as patient care providers by Blue Cross Blue Shield of North Carolina (BCBSNC), giving them the ability to bill BCBSNC for the administration of immunizations in a community pharmacy. This is the result of
Journal of the American Pharmacists Association
FEATURE
many years of hard work on the part of immunizing pharmacists, who were previously limited to reimbursement from Medicare. Through pharmacist-provided immunization programs, pharmacists have increased access to patients in the community. By increasing access, pharmacists have also assisted physicians and the health care community by increasing immunization rates of their patients. This example illustrates how a collaborative effort among health care providers can benefit all in the circle of care, including the patient, physician, and pharmacist. It is hoped that through recognition of the pharmacist as a patient care provider, reimbursement opportunities for nontraditional, nondispensing activities will continue to improve.9 Improvement in the reimbursement process will encourage more pharmacists to expand their role in the health care setting.
Conclusion By addressing current community pharmacy efforts on diabetes care, we have identified potential areas where physicians and community pharmacists can collaborate to improve achievement of standards of care in diabetes. This can aid physicians in achieving NCQA recognition and thereby better align physicians for current and future P4P programs from various health care payers. The time is now for pharmacists to become key players in the P4P arena and assist physicians in the NCQA recognition process. References 1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001. 2. Fenter TC, Lewis SJ. Pay-for-performance initiatives. J Manag Care Pharm. 2008;14(6 suppl C):S12–S15. 3. Endsley S, Kirkegaard M, Baker G, Murcko A. Getting rewards for your results: pay-for-performance programs. Fam Pract Manag. 2004;11(3):45–50. 4. National Committee for Quality Assurance Web site. Accessed at www.ncqa.org, January 23, 2009. 5. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46:133–47. 6. Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economical outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48:23–31. 7. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: longterm clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173–84. 8. Fera T, Bluml BM, Ellis WM, Schaller CW, Garrett DG. The Diabetes Ten City Challenge: interim clinical and humanistic outcomes of a multistate community pharmacy diabetes care program. J Am Pharm Assoc. 2008;48:181–90. 9. National Association of Chain Drug Stores, American Pharmaceutical Association, National Community Pharmacists Association. Implementing effective change in meeting the demands of community pharmacy practice in the United States. Washington, DC: American Pharmaceutical Association; 1999.
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M a r /A p r 2 0 0 9 • 4 9 : 2 •
JAPhA • 211