May 20, 2025
By: Hadley Fitzgerald, Center for Health Care Strategies
Pharmacists play an essential role in the health care ecosystem. They facilitate medication management, educate patients, provide vaccinations, and engage in public health promotion initiatives. They are also among the most familiar and accessible health care professionals — visited nearly twice as often as physicians and located within five miles of 90 percent of Americans. The frequent interactions and familiarity people have with pharmacists build trust, positioning them as valuable assets in health care. People with complex health needs, including Medicaid beneficiaries who are disproportionately affected by chronic disease, can particularly benefit from pharmacist interventions. Despite this, the role of pharmacists remains underutilized in the health care system, especially in terms of improving health outcomes and reducing costs for people with complex health needs.
Evidence Roundup
This blog post is part of a Playbook series connecting evidence and implementation resources with emerging state and federal policies to help enhance services for people with complex needs.
How can pharmacists help individuals with complex health needs?
Traditionally, pharmacists’ primary role was safely dispensing medications. However, in response to nationwide issues — such as provider shortages, health care deserts, and high rates of chronic diseases — the role of the pharmacist has evolved significantly. Today, it is common for pharmacists to provide care in diverse settings and work more directly with patients. This expanded role can be crucial for people with complex needs, whose care is often delivered by multiple providers, increasing the risk for fragmented and uncoordinated care. Additionally, people with complex health needs may have complex medication regimens. If not coordinated and monitored, these medication regimens can put them at risk for adverse effects and complications, as well as high costs and poor outcomes. Pharmacists can be a powerful resource to mitigate these risks and expand the health care workforce.
Below are some approaches used by pharmacists to support people with complex health needs:
- Interdisciplinary teams: Pharmacists collaborate with primary care providers, nurses, and social workers, sometimes even paramedics, in various settings such as hospitals, outpatient, home-based care, and telephone-based interventions. They often support transitions of care by ensuring careful medication therapy management during post-hospitalization transitions for people with chronic diseases, such as diabetes and hypertension, and behavioral health conditions.
- Collaborative Practice Agreements (CPA): Pharmacists are increasingly participating in CPAs with physicians to promote a more integrated approach. These agreements allow pharmacists to perform certain care functions that are traditionally in a physician’s scope of practice, such as initiating, modifying, or discontinuing medications.
Public health and preventive service: Pharmacists are increasingly playing a greater role in public health efforts, particularly in addressing the substance use disorder (SUD) crisis. They support harm reduction initiatives by facilitating access to naloxone and providing greater access to medications for addiction treatment (MAT). They also increasingly perform health screenings and offer wellness advice.
What is the evidence behind innovative care models involving pharmacists?
The evidence on complex care interventions involving pharmacists in prominent roles is varied, reflecting a range of positive and promising outcomes. This variation is partly due to the diverse approaches and the limited research available on these models.
- Medication Management for Complex Patients in Primary Care: Application of a Remote, Asynchronous Clinical Pharmacist Model: This study examined a telephonic Comprehensive Medication Management intervention for Medicare Advantage patients at risk for drug therapy problems. The intervention included a collaborative practice agreement that allowed pharmacists to prescribe and modify medications, and order and interpret lab tests. The study found that a considerable number of patients were engaged, and a majority of drug therapy problems (79 percent) were resolved.
- A Motivational Interviewing Intervention to Improve Adherence to ACEIs/ARBs Among Nonadherent Older Adults with Comorbid Hypertension and Diabetes: This study demonstrated how a brief telephone-based motivational interviewing intervention delivered by trained student pharmacists within a Medicare Advantage plan, in coordination with other providers, significantly improved medication adherence among older adults with comorbid hypertension and diabetes, and a history of non-adherence.
- Outcomes of an Integrated Practice Unit for Vulnerable Emergency Department Patients: This study assessed the impact of an Integrated Practice Unit (IPU) on both insured and uninsured patients. The IPU, an interdisciplinary model typically comprising a primary care provider, registered nurse, social worker, and pharmacist, demonstrated significant reductions in emergency department (ED) visits, hospitalizations, and hospital days, particularly among uninsured patients.
- Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program: This study assessed a pilot home-based primary care program that included physician-pharmacist co-visits. The results showed a reduction in ED visits and inpatient hospitalizations, along with a significant reduction in health care costs.
- Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-Being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial: This randomized controlled trial evaluated the impact of a telephone- and web-based dementia care navigation program involving a pharmacist, advanced-practice nurse, and social worker. The program resulted in reduced ED visits for patients, decreased caregiver burden, and increased caregiver confidence.
- Impact of a Pharmacist-Led Substance Use Disorder Transitions of Care Clinic on Postdischarge Medication Treatment Retention: This study examined a pharmacist-led transitional care telephonic clinic within a Veteran’s Health Administration hospital for patients with opioid use disorder or alcohol use disorder. The findings revealed significantly higher retention rates for specific medications for opioid use disorder (MOUD) and medications for alcohol use disorder, along with increased enrollment in addiction specialty clinics post-hospital discharge.
- Naloxone Co-Dispensing with Opioids: A Cluster Randomized Pragmatic Trial: This study demonstrated that pharmacies co-dispensing naloxone with prescribed opioids significantly enhanced naloxone accessibility and improved opioid overdose prevention knowledge, without increasing risk behaviors.
What do these interventions look like in practice?
The following Playbook resources provide insights into the design and implementation of innovative complex care approaches that integrate pharmacists:
