How Implementing Clinical Pharmacists, Community Health Specialists Could Prevent Hospitalizations

A panel featured during the NAACOS Spring 2026 Conference featured 3 experts discussing different methods of encouraging more preventive medicine through the use of technology and incorporating community health workers and clinical pharmacists into the health care system, which are some strategies that have seen promising results in preventing hospitalizations in the US.

Clinical Pharmacists Play Role in Medication Adherence, Improved Outcomes

Anjali Kakwani, PharmD, BCPS, CACP, pharmacy manager and clinical pharmacy specialist for accountable care organizations at Atlantic Health, began the session by explaining the role of clinical pharmacists in value-based care. Atlantic Health, whose accountable care organizations (ACOs) are primarily located in New Jersey, has incorporated a clinical pharmacy team into their health services. Clinical pharmacists, said Kakwani, provide comprehensive pharmacy services for medication optimization. Clinical pharmacists have specialized training and education in addition to their license.

Comprehensive medication management is “a patient-centered approach to optimizing medication use, improving patient outcomes delivered by a clinical pharmacist or clinical pharmacy specialist,” said Kakwani. “And you’re working in collaboration with everyone: with the patient, with primary care, with the specialist, with the specialist that’s hard to get in touch with, [and] with the specialist that’s easy to access.” Clinical pharmacists help to create an individualized care plan with the patient and follow up with them to determine the efficacy of the plan and to ensure the individual is following the plan.

This service is effective in patients with chronic obstructive pulmonary disease, according to research conducted by Kakwani.¹ Hospital readmissions were reduced from 21.7% to 11.8% through 30 days and from 19.6% to 4.7% through 90 days. Medication management has demonstrated a 5:1 to 9:1 return on investment from 2022 through 2024, according to Kakwani.

“You can see, year over year, we’re continuing to improve these medication adherence metrics…and we are doing that by practicing shared decision-making and empowering our patients and unburdening our providers,” she said.

Kakwani emphasized that clinical pharmacists can bring value to health systems and should be incorporated into other health care systems across the nation.

Technology Can Help Deliver Care With Ease

Rob Fields, MD, MHA, executive vice president and chief clinical officer for Beth Israel Lahey Health, focused on the promise of technology in health care and how it may help in delivering quality health care. He primarily focused on his organization, a health system that is primarily located in eastern Massachusetts and southern New Hampshire.

Fields emphasized that technology should be implemented for a purpose, whether that is artificial intelligence (AI) or any other form of technology. He explained that leaders need to solve 4 problems in health care: revenue compression, the supply-demand problem due to the aging population, not destroying the workforce by addressing these problems, and preserving humanity in the care provided. “That’s hard, but it will require technology to do it. You have to make sure that the technology you employ solves 1 or more of those problems,” he said.

Beth Israel has incorporated a remote patient monitoring program featuring clinical pharmacists. Although the technology is not new, said Fields, the program allows for patients to bring blood pressure cuffs home and measure their blood pressure over time, with clinical pharmacists offering guidance and collaboration with the primary care physician. A virtual primary care practice, where the primary location of care is virtual, has also been started with online appointment scheduling, triage after hours, and offering weekday evenings and Saturdays for appointments. AI, he said, will be the next phase of how access will change in the care model.

“Whatever you design, you have to design the scale; otherwise it just won’t matter for the purposes of your population and for a contract,” Fields concluded.

Community Health Workers Improve Population Health

Tori Bratcher, MA, system vice president of population health operations at Trinity Health, discussed how community health workers could improve population health and prevent hospitalizations in the last presentation of the panel. Trinity Health, which is a Catholic health system that is present in 25 states across the country, specifically focused on reducing the readmission rates in heart failure in those dually enrolled in Medicaid and Medicare, as this population was driving hospitalizations.

Trinity Health started looking toward community health workers in 2022, forming a team of 3 departments for reducing preventable hospitalizations alongside population health providing ambulatory care management services and Trinity Health providing ambulatory medical care while community health workers provided social care.

The population health care team, she said, was made up of a registered nurse care manager who focused on the medical side, a community health worker who focused on the lived experience, and the provider for the patient. There are now 155 community health workers across the health system, with standard job descriptions and training for each hired worker.

“It’s not been a smooth journey, I would say…it does take a while to see the broader impact of this, but we are starting to see a downward trend when it comes to our preventable hospitalizations for the dually enrolled,” Bratcher said.

Expanding this care model is the next step, primarily to uninsured patients, to get them connected to a federally qualified health center or a safety net clinic.

The incorporation of professionals in health care to address complications that occur outside of the primary care physician’s usual care can help to bridge gaps in health care and improve value through the prevention of deterioration in health overall. Implementing the use of clinical pharmacists, community health workers, and technology across health systems has helped to improve outcomes in various health systems, indicating potential avenues for health systems across the country to increase value and prevent hospital visits in their own health care practices.

Reference

1. Kendra ME, Kakwani A, Uppala A, et al. Impact of a COPD care bundle on hospital readmission rates. J Am Pharm Assoc (2003). 2023;63(1):269-274. doi:10.1016/j.japh.2022.10.002