Population Health Pharmacy: Advancing Whole-Person Care
- aPHP
- Jun 20
- 11 min read
Updated: 2 days ago
Summary: This foundational guide highlights pharmacy’s role in population health, introducing the four core pillars that define the population health framework.
What Is Population Health—and Why Does It Matter to Pharmacy
Population health focuses on improving outcomes across defined groups by addressing clinical and non-clinical drivers of health. The field blends data, system design, and community context to close care gaps and reduce disparities. For pharmacists, this means shifting from medication fulfillment to upstream interventions, proactive efforts that address the root causes of poor health before clinical needs arise.
According to Boston Medical Center, upstream healthcare “examines and addresses root causes rather than symptoms,”² asking the question, “What would it take for this problem to never happen again?”² This mindset encourages pharmacists to engage in prevention strategies that address social, environmental, and economic barriers, targeting systemic change rather than reacting to illness.
This foundational guide highlights pharmacy’s role in population health, introducing the four core pillars that define the population health framework. It also explores the evolving practice of population health pharmacy and offers tools, such as the Social Ecological Model (SEM), that support strategic, system-level care planning.
The guide also examines real-world examples of population health in action, from whole-person assessments to data-driven interventions that reduce disparities and improve outcomes, all supported by insights from our Founder & President, Dr. La Kesha Y. Farmer, whose equity-focused leadership at aPHP delivers system-ready pharmacy solutions for today's evolving care landscape.
The Four Pillars of Population Health
According to Dr. David B. Nash, population health is grounded in four interconnected pillars that support scalable health improvement:⁴
Chronic Disease Management
Targeting high-risk conditions, such as diabetes and heart disease, to improve health outcomes and reduce avoidable costs.
Behavioral and Lifestyle Health
Addressing modifiable behaviors like tobacco use and poor nutrition to prevent illness and support wellness.
Social and Environmental Determinants of Health
Incorporating strategies that address education, housing, transportation, and economic factors.
Health System Infrastructure and Policy
Building systems and reimbursement structures that support proactive, coordinated care.
Pharmacists trained in population health are equipped to lead strategic, outcomes-driven programs that address these four pillars, reducing disparities, improving care quality, and contributing to long-term healthcare cost savings in the U.S.
What is Population Health Pharmacy?
At the Academy of Population Health Pharmacy (aPHP), we believe pharmacists are essential to healthcare transformation. As value-based care (VBC) models expand, pharmacists step beyond traditional roles to help shape systems that prioritize prevention, chronic disease management, and equitable outcomes. This is the heart of population health pharmacy.
Innovation plays a significant role in integrating population health pharmacy into healthcare systems. Technological solutions, such as EHRs, telehealth platforms, and data analytics tools, enable pharmacists to deliver more personalized and efficient care.
Additionally, innovative care models, such as patient-centered medical homes and accountable care organizations, provide frameworks for integrating pharmacists into broader healthcare teams. These models promote coordinated care, ensuring that pharmacists' expertise is utilized to its fullest potential.
By embedding pharmacists into innovative care models, such as patient-centered medical homes and accountable care organizations, health systems expand their capacity for coordinated, preventive care. Within these structures, pharmacists serve as strategic drivers of transformation, leveraging data, care coordination, and system insight to improve outcomes and advance equity across populations.
What Does a Population Health Pharmacist Do?
Pharmacists trained in population health strategies serve as system-level problem solvers. Their work moves beyond dispensing to include data interpretation, care coordination, risk stratification, and the design of interventions that target both clinical and non-clinical drivers of health.
With the right tools and applied training, population health pharmacists:
Use claims and encounter data to identify high-risk patients and unmet needs
Collaborate with interdisciplinary teams to develop and implement whole-person care plans
Support quality initiatives tied to HEDIS, STAR, and other performance metrics
Address medication adherence barriers, particularly in vulnerable or underserved populations
Integrate pharmacy services into public health models and care management programs
Lead interventions focused on chronic disease prevention, SDOH alignment, and system redesign
Dr. Farmer exemplifies this role. During her tenure as a managed care population health clinical pharmacist, she helped lead equity-focused Medicaid initiatives that aligned pharmacy strategy with performance improvement. Her contributions included designing adherence programs, training clinical and non-clinical teams, and optimizing pharmacy workflows to reduce costs and improve outcomes.
For a deeper look at her work and the impact of Medicaid-aligned pharmacy leadership, visit: How Population Health Pharmacists Improve Adherence.
This role is more than clinical; it is strategic, equity-focused, and essential to value-based care. Population health pharmacists transform care delivery by applying clinical insight within system frameworks to improve outcomes at scale.
What Is the Role of a Pharmacist in Addressing Health Disparities?
Pharmacists are uniquely positioned to recognize and act on social needs that impact patient health. By integrating social determinants of health (SDOH) tools, screening protocols, and collaborative workflows, pharmacists reduce barriers, promote equity, and improve population-level outcomes.
Dr. Farmer collaborated with SDOH specialists and national corporate teams to design and implement enterprise-level screening assessments across Medicaid populations. Her key contribution involved leading the integration of these tools into both clinical and nonclinical population health workflows, working closely with analytics, IT, and clinical operations teams to ensure alignment with NCQA and CMS health equity measures.
She is currently authoring a book that explores how pharmacy professionals advance health equity through structural humility, system-level action, and social justice-informed care. Drawing from lived experience and leadership in population health, the book highlights how pharmacists close gaps by translating equity principles into practice.
This commitment reflects pharmacy’s expanding role in population health, where pharmacists bridge clinical care with social insight. As a pillar of population health pharmacy, addressing SDOH is more than a clinical necessity; it is a strategic pathway to justice-driven, whole-person care.
Whole-Person Assessments in Pharmacy Practice
As pharmacists assume more upstream and population-level roles, whole-person assessments provide a vital tool for understanding patients beyond clinical indicators. These structured tools assess physical health in conjunction with behavioral, social, and environmental factors that influence overall well-being.
A recent review published in The Milbank Quarterly highlights models designed for action, cultural relevance, and system alignment to drive equitable outcomes.¹ One such example is the Whole Person Health Score, a framework that incorporates multiple domains of health, including emotional, social, and financial well-being, to inform person-centered interventions. For pharmacists, tools like this expand opportunities to align care with SDOH, uncover unmet needs, and guide upstream interventions that reduce disparities.
Population health pharmacists apply both clinical pharmacy skills and whole-person insight to identify risks, guide treatment choices, and close care gaps at scale. Pharmacy teams applying these models gain stronger positioning to support risk stratification, care planning, and cross-sector coordination, which are key functions of value-based, population health pharmacy practice.
The Social-Ecological Model: Systems Thinking in Action
The Social-Ecological Model (SEM) emphasizes the importance of whole-person approaches by acknowledging that factors beyond individual behavior influence health. Pharmacists applying SEM consider layers of influence from family systems to organizational policy when developing care plans and interventions. This framework supports the pharmacist’s expanding role in shaping structural and social conditions that impact population-based care delivery.
Population Health Management: Turning Data Into Direction
Effective population health pharmacy hinges on understanding data sources such as:
Claims and encounter data
HEDIS and STAR performance metrics
Medication adherence and utilization patterns
Social risk indices
Lab and EHR trends
Pharmacists equipped with these insights deliver targeted, cost-effective interventions that align with clinical and operational priorities. By turning data into direction, pharmacists help health systems prioritize resources, close care gaps, and support value-based transformation.
While population-level data helps prioritize interventions and measure performance across systems, it takes more than metrics to deliver equitable care. To truly improve outcomes, pharmacists must also understand the individual behind the data. That’s where whole-person assessments play a critical role in pharmacy practice. These are tools that translate population strategy into person-centered action.
How Pharmacists Use Telepharmacy to Improve Access and Care Strategy
As population health pharmacy continues to evolve, telehealth, especially telepharmacy, offers a practical way to scale pharmacist-led interventions. Whether through real-time medication counseling, remote verification, or care planning, pharmacists utilize remote care platforms to deliver services that rely on clinical pharmacy skills to identify risks, enhance adherence, and facilitate care coordination.
"So, how do pharmacists work remotely?” Programs like the North Dakota Telepharmacy Project and Iowa’s TelePrEP demonstrate how pharmacists expand access to pharmacy services by connecting with patients in low-resource settings to improve medication access, address SDOH, and deliver timely interventions.⁵ ⁶ These models illustrate how digital tools support population health strategies in action.
Embedding telepharmacy services into population health workflows allows pharmacy teams to strengthen continuity, expand access, and deliver outcomes-based care at scale. Dr. Farmer has designed and led multiple telepharmacy programs that advance these goals in managed and HIV care settings, where she has also trained peers to lead with the same strategic focus.
Pharmacy Benefit Design and Formulary Management
Population health strategies must address benefit design barriers that prevent equitable access to medications. Pharmacists play a pivotal role in shaping:
Evidence-based formulary decisions
Streamlined utilization management
Medication therapy management (MTM) integration
Coverage policies that improve access for high-risk populations
These actions are especially impactful in Medicaid programs, where pharmacist-led strategies directly improve adherence and reduce disparities. Again, we explore this idea further in our blog article, How Population Health Pharmacists Improve Adherence, highlighting how pharmacy benefit design, when guided by experienced pharmacists, serves as a catalyst for long-term health improvement.
How Pharmacists Lead in Healthcare Policy and Population Health
Pharmacists trained in population health are increasingly influencing policy at local and state levels. Their work supports:
Medicaid and Medicare transformation efforts
Public health program development
Payment model innovation
Cross-sector equity initiatives
Dr. La Kesha Y. Farmer’s leadership across California Medicaid initiatives illustrates how pharmacists shape scalable, system-ready care models. As a key contributor to policy design, she advised department leaders on pharmacy-related strategies to improve medication access and reduce disparities. Her work included guiding benefit alignment across managed care plans, developing performance-linked pharmacy metrics, and integrating pharmacist-led solutions into public health infrastructure.
These efforts helped inform policies that prioritized population outcomes, equity, and pharmacy’s role in value-based care delivery.
How Pharmacists Lead Quality Improvement in Pharmacy Practice
Ongoing evaluation is essential for sustaining impact. Population health pharmacists engage in:
Rapid-cycle quality improvement
Implementation science
Disparity audits and equity dashboards
Pharmacy-led outcomes research
These activities help ensure care delivery remains effective, equitable, and aligned with population needs. Guiding frameworks, such as NCQA’s Health Equity Accreditation and the CMS Framework for Health Equity 2022–2032, support the development of equity dashboards and disparity audits, helping pharmacists design strategies that align with national quality and equity goals.
Although some U.S. federal health equity initiatives, including components of the CMS Framework, face political challenges in 2025, advancing equity remains essential across the healthcare sector. Pharmacy professionals lead quality improvement by designing solutions that close gaps, regardless of shifting policy.
To align with long-term priorities, follow the World Health Organization (WHO), which prioritizes health equity as a core element of population health and universal care delivery.
These strategic approaches come to life through pharmacist-led programs that translate quality goals into measurable community impact.
How Do Pharmacists Improve Population Health?
At aPHP, we answer this question through lived experience and applied strategy.
Dr. Farmer’s work as a population health clinical pharmacist in California’s managed care system demonstrated how pharmacist-led programs reduce costs and improve outcomes for high-risk populations.
These case studies reflect the same approach, where pharmacists apply population-level insights, clinical acumen, and systems thinking to deliver value-based results. It’s the foundation of every aPHP training, designed to prepare pharmacy teams for the real-world impact on population health.
Examining successful population health pharmacy initiatives provides valuable insights into the impact of this approach on community wellness. One notable example is the Asheville Project in North Carolina, which focused on improving the management of chronic conditions such as diabetes and hypertension. Pharmacists worked closely with patients to provide medication therapy management, education, and support. The results were remarkable, with significant improvements in clinical outcomes, reduced healthcare costs, and enhanced patient satisfaction.
Another successful initiative is the Michigan Pharmacists Transforming Care and Quality (MPTCQ) program. This program aimed to integrate pharmacists into primary care teams to improve medication management for patients with chronic diseases. Pharmacists conducted comprehensive medication reviews, identified gaps in care, and collaborated with other healthcare providers to optimize therapy. The program resulted in improved disease control, reduced hospitalizations, and cost savings for the healthcare system.
In California, the California Right Meds Collaborative (CRMC) demonstrated the impact of population health pharmacy on underserved populations. Pharmacists provided culturally competent care to diverse communities, addressing barriers to medication adherence and promoting health equity. The initiative led to improved health outcomes, increased access to care, and enhanced patient engagement.
These case studies highlight the transformative potential of population health pharmacy in enhancing community wellness. By addressing medication-related issues, promoting health education, and fostering collaboration, pharmacists drive meaningful improvements in health outcomes and contribute to the overall well-being of communities.
Workforce Development: A Population Health Pharmacy Priority
To meet the evolving demands of healthcare, pharmacist training must expand to include public health, informatics, and systems-level thinking. As APhA notes, population health requires a reimagined workforce equipped for value-based and community-centered care.³
While pharmacy education may introduce these concepts, few pharmacists gain applied training in population health pharmacy, whether through formal residencies or direct practice experience. That’s where aPHP bridges the gap, delivering specialized instruction led by a population health pharmacist with real-world experience in ambulatory care, managed care, health equity, and system-level transformation.
Structured training helps pharmacists:
Build care coordination and data fluency
Engage with cross-disciplinary teams
Address SDOH across diverse settings
Lead improvement and innovation initiatives
Equipped with population health training, pharmacists are vital contributors to interdisciplinary teams. Dr. Farmer’s expertise drew recognition from population health nurses and physicians, who actively sought her out to inform care strategy and strengthen pharmacist integration in system-level initiatives.
Challenges Facing Population Health Pharmacy
Despite its proven potential, several other challenges must be addressed to fully realize the benefits of population health pharmacy.
One of the primary challenges involves integrating pharmacists into broader healthcare systems. Before 1951, pharmacists often assessed symptoms and compounded treatments directly for patients. However, after the passage of the Durham-Humphrey Amendment, the profession shifted toward a more product-centered focus, and pharmacists were increasingly viewed as dispensers rather than essential members of the care team.
This shift in perception has also influenced how pharmacists are prepared for evolving roles. Although pharmacy curricula have expanded, many practicing pharmacists enter the workforce without exposure to data-driven care or system-based interventions. Addressing this readiness gap requires continued investment in applied training and professional development to align skills with the demands of modern care delivery.
Funding and reimbursement pose additional hurdles. Although value-based care has increased demand for services such as MTM and health education, many community pharmacists lack consistent compensation for this work. Advocacy for expanded reimbursement remains essential to sustain these services in underfunded settings.
Technology and data infrastructure also present challenges. Implementing population health pharmacy models requires investments in digital tools and training for the workforce. aPHP supports pharmacy organizations by collaborating with HR and compliance teams to align workflows with regulatory standards. Ensuring that pharmacists are prepared to utilize data and maintain privacy safeguards is vital for achieving a long-term impact.
Despite these barriers, population health pharmacy continues to evolve, driven by collaborative models and emerging technologies that advance care delivery.
Collaboration & Innovation: Pharmacy’s Expanding Role
Population health pharmacists collaborate with nurse case managers, clinical social workers, and physicians to support patients across care transitions. They also utilize digital health platforms, including remote monitoring tools, to enhance medication adherence and minimize avoidable utilization. These partnerships and technologies empower pharmacists to drive innovation in population health programs, positioning them as key contributors to prevention, risk reduction, and population-level outcomes.
Final Word: Why Population Health Pharmacy Is the Future
Pharmacists are no longer just medication experts; they are health system strategists. With the right tools, they reduce health disparities, improve outcomes, and help shape the future of care delivery.
At aPHP, we train pharmacists to think systemically, act strategically, and transform patient touchpoints. Through population health pharmacy, we are reshaping healthcare, one trained professional at a time.
Begin your transformation today.
Think. Train. Transform.
Explore our upcoming workshops and training modules, and book a session tailored for your team. Visit regularly for new books and resources to support your success in population health.
References
Gold, Marsha, and Douglas McCarthy. “How Are You Doing, Really? A Review of Whole Person Health Assessments.” The Milbank Quarterly, vol. 103, no. 2, 2025, pp. 187–212. https://doi.org/10.1111/1468-0009.12621. Accessed 20 June 2025.
James, Thea. “What Is Upstream Healthcare?” HealthCity – Boston Medical Center, 20 Apr. 2020. HealthCity BMC, www.bmc.org/upstream-healthcare. Accessed 20 June 2025.
Krauss, Zach. “Pharmacy’s Role in Population Health.” American Pharmacists Association (APhA), n.d., https://www.pharmacist.com/Publications/Pharmacy-Today/Article/pharmacys-role-in-population-health. Accessed 02 June 2025.
Nash, David B. "The Population Health Mandate: A Broad View for a Complex Issue." The Governance Institute, 2012.
Rural Health Information Hub. “Telehealth Models for Increasing Access to Pharmacy Services.” Rural Health Information Hub, www.ruralhealthinfo.org.
Utilization Review Accreditation Commission (URAC). Telehealth and Pharmacy Webinar Slides. URAC, Nov. 11, 2021. Accessed 22 June 2025.
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