Skip to main content

As a follow-up to the UNC catalyst events, we would like to keep the conversation going by highlighting participant examples of collaborative pharmacy practice models. We encourage you to reach out to the case study authors to learn more. Our final case study is Optimizing Medication Use (OMU) by Benjamin Smith (


Program Overview:

Duke Population Health Pharmacy Services is part of the Duke Department of Pharmacy and is based out of Duke’s Population Health Management Office (PHMO). The services assist patients and providers that are part of Duke Health’s value-based arrangements or Duke Connected Care (DCC), an accountable care organization.  The team consists of two primary groups:

  • A team of pharmacy technicians and pharmacists who serve patients remotely as part of PHMO’s DukeWELL care management team. The technicians primarily assist with medication access, medication histories, and medication adherence. The pharmacists assist with medication reviews/advice for providers and care managers, patient education, virtual population health interdisciplinary data-driven rounds with various specialties, virtual interdisciplinary telehealth conferences with specific skilled nursing facilities, and quality measure/cost savings proactive outreach. A pharmacist also has a presence in a post-discharge Hospital Follow-Up clinic.
  • Primary Care Population Health Clinical Pharmacists: These pharmacists practice as clinical pharmacist practitioners (CPPs) in Duke Primary Care (DPC), the health-system’s primary care network. Full-time pharmacists in this position cover two clinics each. Focus is on patients with uncontrolled HTN, DM, or CAD. Providers can submit e-consults for other disease states. Patients are seen in a payer agnostic manner, based on provider referrals. Schedule includes dedicated time for clinic-specific population health outreach, driven by gaps in Epic clinic dashboards. Team also engages in payer-specific value-based arrangement gaps for their clinic(s). Significant improvements in clinical metrics, positive patient and provider satisfaction, and success with CCM and incident-to billing have been demonstrated.

Drivers of Success:

  • Positive relationships: 1) Physician and administrative leadership champions outside of pharmacy; 2) Pharmacy involvement in PHMO and DCC quality and leadership meetings
  • Pharmacy access to data (internal and payer) AND data analysts through PHMO
  • Ability to track productivity and clinical impact via tableau dashboards
  • Documentation activities and workflow built in manner to ensure data capture


  • Challenging, but possible, to directly cover costs of hiring primary care population health pharmacists
  • Difficult to balance proactive quality measure outreach needs with volume of internal care management and provider referrals
  • Support and tracking for overcoming medication access barriers

What’s Next:

  • Improved reporting of medication access interventions
  • Expansion of Primary Care Population Health Clinical Pharmacist program to include additional embedded clinic support and non-embedded virtual visits
Comments are closed.