Payers, Health Systems, and Pharmacies Partner to Fill SDOH-Related Gaps

Through various partnerships in the Connect AF initiative, key stakeholders were able to demonstrate the immense role community pharmacists play in addressing gaps in care related to social determinants of health (SDOH), according to a study in the Journal of the American Pharmacists Association (JAPhA).¹

“Researchers and practitioners are increasingly interested in pharmacies as a healthcare setting to deliver SDOH interventions to address community needs and improve health and well-being,” wrote the authors of a study published in Preventive Medicine Reports.² “This interest is warranted: among all health care settings, pharmacies have the best reach to US residents, are more easily geographically accessible to patients, and are frequented more often.”

The Connect AF program specifically forged a novel alignment between the Community Pharmacy Enhanced Services Network USA, UNC Health Pharmacy, Pfizer, and Blue Cross Blue Shield of North Carolina. This vertical integration allowed pharmacists to screen 75 patients with atrial fibrillation (AF) using an adapted tool focused on eight domains, including housing instability, food insecurity, and interpersonal safety.¹

The study found that mental health barriers were the most prevalent social need at 28%, followed by housing and transportation issues, both at 20%.

READ MORE: The Pharmacy Rewards Program Improving Outcomes Through Key Partnerships

These findings are particularly critical for AF management, as nonmedical factors account for an estimated 84% of modifiable contributors to health outcomes. Recent meta-analyses confirm that pharmacist-led interventions in AF care significantly improve clinical results, including a 35% reduction in strokes and a 24% reduction in major bleeding events compared to usual care.^1,3

Because oral anticoagulant adherence is vital for stroke prevention, pharmacists are uniquely positioned to bridge the gap between clinical necessity and the social adversities that often lower adherence.¹

However, the path to integrating these services is not without obstacles. A national survey of 578 pharmacists revealed that while nearly all respondents spend time addressing social barriers, only 31% reported having the adequate staff capacity to do so effectively.²

This capacity gap is most pronounced in high-volume settings, whereas independent community pharmacies were more likely to report having the staffing and flexibility to step out of the traditional dispensing workflow. The CDC emphasizes that addressing these social determinants is essential for achieving health equity, yet many providers feel they lack the specific resources or training to manage complex social needs.^2,4

The necessity for SDOH training extends even into the most acute settings. Educators in critical care suggest that the intensive care unit may actually be an optimal setting to identify social needs, as the critical care team often has days or weeks with vulnerable patients to understand the social context behind a clinical crisis.⁵

Just as critical care trainees must learn to navigate the relationship between social factors and critical illness, community pharmacists require targeted training, such as Mental Health First Aid, to handle sensitive screenings involving substance use or interpersonal safety.^1,5

Building sustainable programs also requires navigating complex funding and trust issues within marginalized communities. Historical inequities and structural racism have created deep-seated mistrust in government-led health efforts, necessitating partnerships with trusted local organizations, according to Healthy Security.⁶

Success stories like the Rhode Island Health Equity Zones show that braiding multiple funding streams can support community-led priorities, but such models are often difficult to replicate due to administrative burdens.

Looking forward, the Connect AF pilot suggests that while screening is a vital first step, the future of pharmacy practice lies in closed-loop referrals. Because most patients in the study were uncertain about engaging with social resources on their own, researchers advocate for the integration of community health workers or the training of pharmacy technicians to provide the follow-up and navigation support that pharmacists may not have the capacity to deliver.¹

By aligning the expertise of health systems, payers, and accessible community pharmacies, the profession can shift toward value-based care models that treat the patient's social environment as a core component of their clinical success.

“Purposeful establishment of partnerships between health systems and community-based pharmacy practices strengthens care coordination, advancing shared goals while enhancing outcomes for patients facing social care needs,” concluded authors of the current study.¹ “Connect AF underscores the critical value of empowering community pharmacists to address health inequities, aligning seamlessly with the shift toward value-based reimbursement models and away from traditional fee-for-service approaches.”

READ MORE: Independent Pharmacy’s Adaptability Through Reform, Closures, and Technology

REFERENCES

1. Liang D, Witkowski M, Abolins N, et al. Pharmacist-led community network approach addressing social needs and adherence (Connect AF). JAPhA. 2026;66(4):103123. https://doi.org/10.1016/j.japh.2026.103123

2. Meehan KA, Waters AR, Wangen M, et al. Not just about pills: findings from a national survey of pharmacists to understand their views on addressing social determinants of health. Prev Med Rep. 2025 Jan 28;51:102991. doi: 10.1016/j.pmedr.2025.102991.

3. Tonin FS, Tsuyuki RT, Fernandez-Llimos F, et al. The role of pharmacists in the management of patients with atrial fibrillation: a systematic review and meta-analysis. Can Pharm J (Ott). 2025 Aug 31;158(6):351-367. doi: 10.1177/17151635251365148.

4. Social determinants of health (SDOH). CDC. January 17, 2024. Accessed June 11, 2026. https://www.cdc.gov/about/priorities/why-is-addressing-sdoh-important.html

5. Ramadurai D, Salazar EG, Reddy A. The need to address social determinants of health during critical care training. ATS Sch. 2022 Nov 15;3(4):518-521. doi: 10.34197/ats-scholar.2022-0057VL.

6. Auerbach J, Chen AT. Strengthening the partnerships that promote health equity and social justice. Health Secur. 2023 Sep;21(S1):S42-S46. doi: 10.1089/hs.2023.0012.