A Prescription for Success: Pharmacy Collaboration in Primary Care

Patient CareOperationalPrimary Care
Written By Hannah Russell

by Kelsey Murray, MD MHA

Medications, both prescribed and over-the-counter (OTC) play an enormous role in American healthcare. According to the Centers for Disease Control, 71.9% of ambulatory office visits involve the prescription of a medication, and about 8% of all healthcare spending involves a prescription medication.

However, if a patient is prescribed medication at their primary care appointment, it is not always an easy process to pick up medications. You’ve been there - leaving a visit wondering when your prescription will be ready, driving to the pharmacy before it closes, having to sit in a drive-thru line, and then finally still having to pay your medication copay - and that’s if everything goes off without a hitch.

Of the few minutes allotted to a primary care visit, a provider may spend about 49 seconds explaining a medication’s purpose and reviewing administration instructions. This is not very much time - it may take them longer to enter the order into the health record! 

Add that to the process to pick up the prescription above, and it is no surprise then that 20-30% of medications are never even filled at the pharmacy, and 1/4 of people do not get refills on time. Additionally, up to 50% of people take medications incorrectly. Medication non-adherence has serious effects including worsening chronic health conditions and is a major cause of Emergency Department visits and hospitalizations.

Pharmacy Team Members

The primary members of the pharmacy team include pharmacists and technicians. First, we have Pharmacy technicians. They can dispense medications, assist with questions, and deal with insurers. There are no specific educational requirements for technicians. However, they can complete 1- or 2-year training programs. Depending on the state, technicians may need a certification or licensure as well.

Next, we have pharmacists who can have a variety of different roles across healthcare settings. In the ambulatory setting, they can oversee medications, assist with medication access instructions, give vaccines, and even prescribe medication. Pharmacists have obtained their Doctor of Pharmacy (PharmD) degree through either an accelerated 6-year pharmacy program or a bachelor’s degree followed by an additional 4 years of pharmacy school. They need to pass licensing exams and may have additional requirements set by the state they practice in. There are also 1- and 2-year pharmacy residency programs across many specialty areas. After work experience or residency programs, pharmacists can also take advanced specialty certification exams, such as in ambulatory care pharmacy. Lastly, depending on the state, they may be able to obtain additional training or certifications to do examinations and prescribe medications (more on that below).

Let's dive into the role that pharmacy can play in primary care!

Ways pharmacy and primary care can collaborate

Many people go to the pharmacy more frequently than their doctor’s office, and 90% of people in the US live within 5 miles of a pharmacy. With technology, pharmacists can be available by phone and virtual consults in addition to in person. This degree of exposure begs for pharmacy integration into primary care.

There are 4 main models for primary care-pharmacy integration:

  • Pharmacy-based Primary Care: Retail pharmacies have been entering this space for a number of years. However, recent news that Walmart and Walgreens are closing their pharmacy-based clinics and telemedicine shows that their primary care models were not sustainable. With CVS partnering with Aetna managed Medicare models, they take on some of the risk sharing and revenue sharing benefits that come from primary care, thus their interest in primary care delivery within their retail walls.

  • Collaborative Agreements: Individual primary care offices or healthcare systems may have collaborative agreements in place with local pharmacies. They may provide specific consultation or prescription services to the practice.

  • Direct Provider Dispensing: This is an option where the physician’s office directly dispenses medication, with or without a pharmacist. They often can get medications at wholesale prices and pass the savings on to patients. This is similar to how many hospitals dispense medications prior to discharge, or how some health centers or free clinics have pharmacies on-site. Some direct primary care offices do this as well. Each state has specific regulations regarding dispensing medications.

  • Embedding Pharmacy into Primary Care: This is a model of advanced primary care, increasing the value provided at the primary care location. Pharmacists and/or technicians may work full time or part time with the office in various roles, typically optimizing medications of patients with chronic conditions. They may provide additional services as described below. This is an ideal future model of team-based primary care and works best in value-based care settings.

Embedding Pharmacy Team Members into the Primary Care Setting

Pharmacists and technicians can serve many functions as integral members of the primary care team. Their expertise is not limited to just dispensing medication refills. Pharmacy team members can be incorporated into the team in the many ways described below.

  • Medication Reconciliation: Pharmacists can review and reconcile a patient’s medication list. Often, patients have medications at more than one pharmacy. A specialist who recently prescribed a new medication may not be on an interoperable electronic health record, potentially keeping the PCP blind to a new medication or a change. People may take OTC meds and supplements. Sometimes they are unable to get a medication or have stopped a drug due to a side effect. Therefore, reconciliation is a crucial part of primary care, especially after transitions of care. Pharmacists can monitor for medication interactions, duplications, and appropriateness, and can recommend alterations or deprescribing. This is especially useful for chronic care management in a value-based reimbursement system. This can be done through chart reviews, patient outreach, or provider appointments.

  • Refills: Pharmacists and technicians can queue up medications for refills. They can also work on increasing prescription quantities, automating refills, and syncing timing of refills resulting in fewer trips needed to the pharmacy. Additionally, they can fill pill boxes or pre-package medication for ease of home administration. They can even set up home delivery of medications. These measures can drastically improve medication adherence, improving health outcomes and the value of care provided. This may additionally improve the facility’s or health plan’s Star Rating from the Centers for Medicare and Medicaid Service. 

  • Monitoring: Many medications require periodic laboratory monitoring. These include but are definitely not limited to drugs for anticoagulation, autoimmune conditions, antidiabetics, antihypertensives, and certain antibiotics and antivirals. Pharmacists can remind both patients and providers about monitoring needs.

  • Access: If a new medication is prescribed, a pharmacist can assist with making sure the price is accessible. This may involve services such as GoodRx or prescription assistance program signups. They can also help with prior authorizations or recommend appropriate alternatives.

  • Initiation: With the prescribing of a medication, pharmacists can review administration instructions. This is especially important for non-pill medications such as injectables, which may require significant training on the part of the patient or a family member. They can also discuss anticipatory guidance about common temporary side effects and prevent patients from stopping the drug if they experience these side effects.

  • Prescription: In all states, pharmacists are able to prescribe Paxlovid if a patient has COVID with additional risk factors. In many states, they can also prescribe birth control, smoking cessation medications, naloxone, and HIV prevention medications. Certain states allow for additional prescribing privileges, although pharmacists may need additional training or licensure for this. Often, there are specific protocols, formularies, or practice agreements they follow for these prescriptions. This is ever-evolving and varies state to state. (Of note, Tennessee just expanded the scope of practice for Pharmacists in May 2024, so check your state’s rules and regulations.)

  • Vaccine administration: Vaccines have recently become something that can be administered by pharmacists. This can allow more patients to get their needed vaccines and increase the value provided at the office.

  • Staff Education: Pharmacists can provide crucial education for providers and other staff members. This may include regular medication updates and best practices.

There are a multitude of ways to collaborate with pharmacy team members and have them more fully incorporated into primary care settings. There is also the potential for more innovation around decreasing care fragmentation and improving medication delivery services.

Does your primary care practice incorporate a pharmacy team member yet?

Practice Tips: AAFP, AMA

State Laws: GoodRx Breakdown by State, National Alliance of State Pharmacy Associations

Hannah Russell
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