How Pharmacy Graduates Can Prepare for Roles on Primary Care Teams

It is estimated that there will be a shortage of 17,800 to 48,000 primary care physicians in the United States by 2034, according to the Association of American Medical Colleges (AAMC). AAMC states that addressing the shortage will require a multipronged approach, including innovative care delivery, use of technology, and improved use of all health professionals on the care team.^1,2 In addition to midlevel practitioners, such as physician assistants and advanced registered nurse practitioners, pharmacists are health professionals that can be utilized to close the gaps in care within primary care settings.

Pharmacists can bring value to primary care teams through a variety of patient care services. In fact, published literature has demonstrated that pharmacists can improve the management of chronic conditions as well as the quality of prescribing and medication appropriateness.³

Each state has their own laws outlining the scope of practice for pharmacists, and many states now allow pharmacists to provide expanded clinical services through collaborative practice agreements (CPAs). CPAs are formal agreements between a pharmacist and prescriber—typically a physician—that outline specific functions that can be delegated to the pharmacist under the supervision of the prescriber. This can include initiating, modifying, or discontinuing medication therapy and ordering and interpreting laboratory tests.⁴ Disease states that may be commonly managed by pharmacists under CPAs include diabetes, hypertension, and hyperlipidemia.

This opportunity for supporting primary care physicians to a greater degree is one that pharmacy graduates can seize by rising to the challenge of closing health care gaps in primary care settings.

Early Exposure During Pharmacy School

Students with interests in ambulatory care and the provision of pharmacy services in primary care settings can start preparing for these roles early in their pharmacy school career. Introductory pharmacy practice experiences expose students to community and hospital pharmacy practices early in the curriculum. Beyond this, students should be proactive and seek opportunities to shadow pharmacists practicing in primary care settings, specifically those practicing with a CPA in place. Most schools and colleges of pharmacy are likely to have faculty who specialize in ambulatory care who could mentor students in this aspect.

As students prepare for their advanced pharmacy practice experiences (APPEs) in the final year of the curriculum, they should aim to select rotations that will allow them to work alongside preceptors that are actively engaged in the care of patients in primary care settings. The Accreditation Council for Pharmacy Education (ACPE) requires that students complete at least 1 APPE in an ambulatory care practice setting.⁵

However, students may also select additional elective APPEs that are also in ambulatory or primary care settings for further exposure to pharmacists’ delivery of services in these settings. Although common pharmacist-managed disease states may include diabetes, hypertension, and hyperlipidemia as noted above, pharmacists may also manage other disease states in ambulatory and primary care settings, such as infectious diseases, cancer, and other cardiovascular diseases (ie, heart failure).

Postgraduate Training

Although postgraduate residency training is not necessarily required to work in primary care settings or enter CPAs, completion of residency training does allow recent graduates to gain additional exposure to various practice settings and hone their clinical skills.

Traditionally, postgraduate year 1 (PGY1) pharmacy residencies have provided advanced general training in a health system setting. However, as the roles of pharmacists have evolved, PGY1 residencies have also expanded to include programs that have a focus in ambulatory care. Additionally, PGY1 community-based pharmacy residency programs may also include experiences that allow residents to rotate through various clinics to provide patient care services.

Following completion of a PGY1 residency, graduates may pursue postgraduate year 2 (PGY2) training concentrating in ambulatory care practice, which provides specialized training to create clinical pharmacy practitioners that can manage patients with a variety of chronic disease states while exposing trainees to practice management principles. Compared with other available PGY2 pharmacy residency programs, ambulatory care pharmacy residency positions have grown exponentially in recent years,⁶ which demonstrates an increased need for—and supply of—pharmacists trained to practice within primary care settings.

Students with an interest in ambulatory or primary care practice should review residency offerings on the American Society of Health-System Pharmacists residency directory to determine if a residency program’s experiences align with their interests and career goals.⁷

Certification

Beyond post graduate training, pharmacists may seek certification to expand their skillset and prepare to care for patients with chronic disease states. The Board of Pharmacy Specialties (BPS) establishes criteria for pharmacists to earn certification in various practice areas including ambulatory care practice (BCACP), pharmacotherapy (BCPS), geriatric pharmacy (BCGP), and cardiology pharmacy (BCCP), among others.⁸

Other certifications that may be pursued by pharmacists wishing to work in primary care settings include Medication Therapy Management (BCMTMS) and disease-specific certifications in human immunodeficiency virus (HIV) (AAHIVP), hypertension (CHC), lipids (CLS), heart failure (HF-Cert), and diabetes (Certified Diabetes Care and Education Specialist [CDCES] and Board Certified-Advanced Diabetes Management [BC-ADM]), among others. Holding these types of credentials can help prescribers identify pharmacists as experts in specific therapeutic areas.

Upon connecting with prescribers, pharmacists who wish to enter CPAs should also consult with their Boards of Pharmacy for state-specific requirements as some states may require additional certifications and/or years of clinical training prior to entering these agreements.

Bringing Value to the Primary Care Team

Pharmacists wishing to take on roles on primary care teams should be prepared to provide services that will bring value to the team and the practice while keeping in mind that each practice will have unique medication-related needs and patient populations. Pharmacists can work with providers and practice managers to help identify patients who could most benefit from pharmacist-led services, including those with uncontrolled chronic disease states and those with polypharmacy issues.

Furthermore, pharmacists should consider how their services can help practices attain quality measures. For example, practices—especially those within value-based healthcare models—are often accountable for demonstrating the quality of the care they provide to patients through quality benchmarks such as those delineated by the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set. Examples of these measures include hemoglobin A1C control among patients with diabetes, blood pressure control, and statin use among patients with diabetes or cardiovascular disease.⁹

Additionally, medication adherence is an important quality metric in primary care settings. CMS employs the star-rating system to determine the quality of Medicare-sponsored plans including Medicare Advantage (Part C) and prescription drug plans (Part D). Plans are rated based on their performance in several categories, including medication adherence to antidiabetic medications (excluding insulin), angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), and statins. Adherence is defined by a proportion of days covered (PDC) of at least 80%.

Each of these measures is triple weighted and can greatly affect a plan’s overall star rating.¹⁰ Due to the impact of these ratings, primary care practices may have payment models with health plans to incentivize performance on the measures. As such, pharmacists have opportunities to initiate clinical services that are aligned with these benchmarks to improve the quality of care provided. Examples may include pharmacist-led clinics for patients with uncontrolled diabetes and/or hypertension and medication adherence interventions.

Today, pharmacists can serve as essential members of the primary care team. Pharmacy graduates are now better positioned than ever to seize this opportunity to become a vital member of the primary care team and a critical element to the successful functioning of health systems.

REFERENCES

1. New report confirms growing shortage of primary care physicians. Primary Care Collaborative. July 10, 2020. Accessed August 12, 2021. https://www.pcpcc.org/2020/07/10/new-report-confirms-growing-shortage-primary-care-physicians
2. Physician supply and demand – a 15-year outlook: key findings. Association of American Medical Colleges. Accessed August 12, 2021. https://www.aamc.org/system/files/2020-07/aamc-2020-workforce-projections-15-year-outlook-key-findings-f2.pdf
3. Tan EC, Stewart K, Elliot RA, George J. Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm. 2014;10(4):608-622. doi:10.1016/j.sapharm.2013.08.006
4. Advancing team-based care through collaborative practice agreements: a resource and implementation guide for adding pharmacists to the care team. Centers for Disease Control and Prevention. Accessed August 12, 2021. https://www.cdc.gov/dhdsp/pubs/docs/cpa-team-based-care.pdf
5. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (“Standards 2016”). Accreditation Council for Pharmacy Education. February 2, 2015. Accessed August 12, 2021. https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf
6. Residency match phase I signals steady growth in positions. News release. American Society of Health-System Pharmacists. March 12, 2020. Accessed August 12, 2021. https://www.ashp.org/News/2020/03/13/ASHP-2020-Residency-Match-Phase-I-Signals-Steady-Growth-in-Positions?loginreturnUrl=SSOCheckOnly
7. American Society of Health-System Pharmacists. Residency Directory. Accessed August 12, 2021. https://www.ashp.org/Professional-Development/Residency-Information/Residency-Directory
8. Board of Pharmacy Specialties. Accessed August 12, 2021. https://www.bpsweb.org/
9. Moreau C. The pharmacist as part of the primary care team during the COVID-19 pandemic. J Am Board Fam Med. 2021;34(suppl):S21-S25. doi:10.3122/jabfm.2021.S1.200180
10. Mercado J. Medication adherence as a path to unlock savings opportunities. Care Journey. May 21, 2020. Accessed August 16, 2021. https://carejourney.com/medication-adherence-as-a-path-to-unlock-savings-opportunities/