CCPP Module 11, Section 1: Selecting Target Populations for Collaborative Care
MODULE 11: PATIENT IDENTIFICATION AND RISK STRATIFICATION

Section 11.1: Selecting Target Populations for Collaborative Care

From Volume to Value: Mastering the Art of Clinical and Financial Triage.

SECTION 11.1

Selecting Target Populations for Collaborative Care

Learn to identify high-impact disease states and patient groups where pharmacist-led interventions deliver the highest clinical and financial return on investment.

11.1.1 The “Why”: The Proactive Imperative and the Principle of Clinical Leverage

In the ecosystem of community pharmacy, your expertise is often deployed reactively. A patient arrives with a prescription, a problem, or a question, and you respond with world-class skill. The workflow is largely dictated by the queue—a “first-come, first-served” model of intervention. While essential for public safety and access, this model limits your ability to proactively manage the health of the most vulnerable patients in your community. You are an expert at handling what walks through the door, but you have limited control over who walks through the door.

Stepping into a collaborative practice role requires a fundamental paradigm shift from this reactive stance to a proactive, population-focused strategy. Your most valuable and finite resource is no longer the inventory on your shelves; it is your clinical time and cognitive effort. In a health system, a clinic, or an accountable care organization, you are responsible for the well-being of a defined panel of patients. It is simply not possible to provide the same intensive level of management to every single person. Therefore, the most critical strategic decision you will make is not what to do, but where to do it. Where you choose to focus your efforts is the single greatest determinant of your success and your value to the organization.

This brings us to the core concept of this section: Clinical Leverage. Clinical leverage is the principle of applying your finite resources at the points in the system where they will generate the greatest positive impact. It’s about finding the patients, the disease states, and the medication-related problems where a pharmacist’s intervention can produce a disproportionately large return on investment—not just financially, but in improved patient outcomes, enhanced quality of life, and reduced healthcare utilization. It is a deliberate and data-driven form of clinical triage. Instead of simply serving the next person in line, you are systematically identifying the patients who are most likely to end up in the emergency department, to be readmitted to the hospital, or to suffer a catastrophic adverse drug event, and you are intervening before it happens. This section is your masterclass in developing that strategic vision.

Pharmacist Analogy: Triaging the High-Risk Medication Shelf

Imagine a busy Monday afternoon in your pharmacy. The prescription queue is long. A basket contains a refill for atorvastatin for a stable patient. Another basket holds a new prescription for warfarin 7.5 mg daily for an 85-year-old patient also taking amiodarone. Which one commands more of your cognitive energy?

Your professional training has hardwired you to perform an instantaneous risk assessment. The atorvastatin refill is routine; it requires your standard, meticulous safety check. The warfarin prescription, however, sets off alarm bells. It’s a high-risk medication, a non-standard dose, in a vulnerable patient, with a major interacting drug. You don’t just verify it; you interrogate it. You stop the workflow, pull up the patient’s full profile, calculate their CrCl, check their last INR, and immediately call the prescriber to discuss the dose and the interaction. You are applying disproportionate effort to this prescription because you know it carries a disproportionate risk.

This instinct is the very foundation of population health management. Now, expand that thinking from a single prescription to an entire patient panel of 5,000 lives.

  • The atorvastatin patient is like the thousands of stable, low-risk individuals in your panel. They need good care, but not your intensive, minute-to-minute management.
  • The warfarin patient represents a high-risk sub-population. They are the patients with uncontrolled diabetes and an A1c of 12%, the heart failure patients just discharged from the hospital on 15 medications, the COPD patients with multiple ED visits in the last year.

Selecting target populations for collaborative care is the process of systematically identifying all the “warfarin patients” within your larger group. It is about using data and clinical judgment to find the individuals and groups where your focused, proactive intervention can prevent the most harm and generate the most good. You already possess the core skill of risk triage; this module will teach you how to apply it at scale.

11.1.2 The Quadruple Aim: Your Strategic Compass for Population Selection

Before diving into specific diseases or patient types, we must establish our guiding principles. In modern healthcare, all initiatives, including pharmacist-led clinical services, are measured against the framework of the Quadruple Aim. This framework is your strategic compass. When you propose a new service or decide where to focus your efforts, your rationale must be anchored to one or more of these four cardinal points. Your ability to articulate your value in this language is crucial for securing resources, gaining buy-in from leadership, and demonstrating your impact.

1. Improving the Patient Experience

Enhancing the quality of care, patient satisfaction, and access to services.

2. Improving Population Health

Improving clinical outcomes and preventing disease for a defined group of people.

3. Reducing Per Capita Costs

Lowering the total cost of care through efficiency, prevention, and optimization.

4. Improving Provider Well-being

Reducing burnout and improving the practice environment for the healthcare team.

Masterclass Table: Linking Pharmacist Interventions to the Quadruple Aim
Quadruple Aim Domain Pharmacist-Led Service Example How You Articulate Your Value
1. Improving Patient Experience Comprehensive Medication Management (CMM) for Polypharmacy Patients
  • “By creating a single, reconciled medication list and a simplified dosing schedule, we reduce patient confusion and anxiety, directly improving their experience and satisfaction with our clinic.”
  • “Our one-on-one CMM sessions empower patients by improving their health literacy, making them active, confident participants in their own care.”
  • “We act as a single point of contact for all medication-related questions, simplifying navigation of the complex healthcare system for our most vulnerable patients.”
2. Improving Population Health Diabetes Management CPA
  • “Our service will target patients with an A1c > 9%. By initiating and titrating evidence-based therapies like GLP-1 RAs and SGLT2is per protocol, we will demonstrably lower the average A1c in this high-risk population, reducing long-term complication rates.”
  • “We will ensure 100% of our diabetic patients with comorbid HF or CKD are on a guideline-directed SGLT2 inhibitor, directly improving cardiovascular and renal outcomes for this cohort.”
3. Reducing Per Capita Costs Transitions of Care (TOC) Service for Post-Discharge HF Patients
  • “The average cost of a heart failure readmission is over $15,000. By focusing on post-discharge medication reconciliation and optimization, our service is projected to reduce 30-day readmissions by 25%, generating significant direct cost avoidance for the health system.”
  • “We will optimize diuretic regimens to prevent unnecessary ED visits for fluid overload, another major source of avoidable costs.”
  • “We will manage prior authorizations and formulary conversions for high-cost heart failure medications, ensuring timely access while minimizing medication-related expenditures.”
4. Improving Provider Well-being Anticoagulation Management Service
  • “Our service offloads the complex and time-consuming tasks of warfarin dosing, DOAC renal dose adjustments, and peri-procedural bridging from our primary care physicians. This frees up their time to focus on complex diagnostics and other aspects of patient care, reducing their administrative burden and burnout.”
  • “By managing all anticoagulation-related patient calls and pharmacy clarifications, we reduce interruptions to the provider’s day, improving their efficiency and job satisfaction.”

11.1.3 High-Impact Disease States: The “Big Four” Clinical Opportunities

While a pharmacist can add value to almost any patient’s care, certain chronic disease states are exceptionally well-suited for CPA-driven management. These conditions are typically complex, medication-intensive, costly, and have clear, measurable metrics for success. They represent the “sweet spot” for demonstrating your clinical and financial worth. We will refer to these as the “Big Four.” For any new or expanding collaborative practice service, one of these four areas is almost always the perfect place to start.

Deep Dive: Diabetes Mellitus (Type 2)

Why it’s a High-Impact Target: Diabetes is the quintessential pharmacist-managed disease. The sheer prevalence, the complexity of the medication regimens, the high cost of therapies, the need for frequent monitoring and dose adjustments, and the clear link between glycemic control and long-term outcomes make it a perfect fit for a CPA. The treatment landscape is evolving at a breathtaking pace, with new guidelines emphasizing cardiovascular and renal risk reduction. Primary care providers often struggle to keep up. A pharmacist who is a true diabetes expert can become an invaluable force multiplier in any clinic.

Masterclass Table: The Pharmacist’s Value Proposition in Diabetes Care
Common Clinical/Financial Challenge The Pharmacist-Led Intervention (Your CPA in Action) Measurable Outcomes (How You Prove Your Value)
Persistent Hyperglycemia (A1c > 9%) Under a CPA, you can independently initiate and titrate insulin (basal and bolus), GLP-1 Receptor Agonists, and oral agents according to a pre-approved protocol, overcoming clinical inertia.
  • Percent of targeted patients achieving A1c < 8%
  • Average reduction in A1c across the managed panel
  • Reduction in ED visits for hyperglycemic crisis
Suboptimal Cardiorenal Protection You proactively screen all diabetic patients for comorbid Atherosclerotic Cardiovascular Disease (ASCVD), Heart Failure (HF), or Chronic Kidney Disease (CKD) and initiate guideline-directed SGLT2 inhibitors or GLP-1 RAs.
  • Percent of eligible patients prescribed an SGLT2i/GLP-1 RA
  • Reduction in MACE (Major Adverse Cardiovascular Events) rates over time
  • Slowing of GFR decline in the CKD cohort
High Medication Costs & Access Barriers You are the expert in formulary navigation. You manage prior authorizations, convert patients from expensive branded drugs to clinically equivalent preferred agents or biosimilars, and connect patients to assistance programs.
  • Total drug spend reduction for the diabetes medication class
  • Patient out-of-pocket cost reduction
  • Medication possession ratio (adherence) improvement
Risk of Hypoglycemia You conduct comprehensive reviews to identify and de-prescribe high-risk medications like sulfonylureas and sliding-scale insulin in older adults, replacing them with safer, more effective therapies. You provide intensive education on hypoglycemia recognition and management.
  • Reduction in documented hypoglycemic events
  • Decrease in sulfonylurea prescribing rates
  • Reduction in ED visits or hospitalizations for hypoglycemia
Identifying the “Low-Hanging Fruit” in Your Diabetes Population

When starting a diabetes service, don’t try to boil the ocean. Focus on these high-yield patient profiles first to demonstrate quick wins:

  1. The High A1c Cohort (A1c > 9%): These patients are at the highest immediate risk. Run a report for this group and start scheduling visits. They have the most to gain from intensive management.
  2. The “Cardiorenal Gap” Cohort: Identify all diabetic patients with a documented history of ASCVD, HF, or CKD who are NOT on an SGLT2 inhibitor or GLP-1 RA. This is a massive opportunity to implement guideline-directed medical therapy.
  3. The Basal Insulin-Only Cohort with High A1c: Patients whose A1c remains high despite a good basal insulin dose are prime candidates for intensification with a GLP-1 RA or prandial insulin—a classic case of clinical inertia you can solve.
  4. The High-Risk Hypoglycemia Cohort: Target patients over 65 who are still on a sulfonylurea (especially glyburide) or on a sliding scale insulin-only regimen. De-prescribing these agents is a major safety victory.

Deep Dive: Heart Failure (HFrEF & HFpEF)

Why it’s a High-Impact Target: Heart failure is a malignant disease with a prognosis worse than many cancers. It is also the number one cause of hospitalizations for adults over 65 and a primary target for readmission reduction programs. The treatment paradigm for HF with reduced Ejection Fraction (HFrEF) is built on a “four-pillar” medication foundation that is complex to initiate and titrate. Patients are often on a dozen or more medications, making polypharmacy and adverse events the norm. A dedicated pharmacist is not just helpful in this population; they are essential for achieving optimal outcomes.

Masterclass Table: The Pharmacist’s Value Proposition in Heart Failure Care
Common Clinical/Financial Challenge The Pharmacist-Led Intervention (Your CPA in Action) Measurable Outcomes (How You Prove Your Value)
Failure to Initiate/Titrate the “Four Pillars” of HFrEF Therapy You manage a protocol to systematically initiate and titrate all four pillars of Guideline-Directed Medical Therapy (GDMT): 1) ARNI/ACEi/ARB, 2) Beta-Blocker, 3) MRA, and 4) SGLT2 inhibitor, pushing patients to target doses as tolerated.
  • Percent of HFrEF patients on all four pillars of therapy
  • Percent of patients at >50% of target dose for Beta-Blockers and ARNIs/ACEi/ARBs
  • Reduction in all-cause mortality and HF hospitalizations
High 30-Day Readmission Rates You run a transitions of care service, performing inpatient medication reconciliation, providing discharge counseling, and conducting follow-up calls within 72 hours to address discrepancies, access issues, and side effects.
  • 30-day HF-specific and all-cause readmission rates
  • Reduction in medication errors post-discharge
  • Improved patient-reported understanding of their medication regimen
Fluid Overload & Symptom Management You manage a diuretic titration protocol, teaching patients how to self-monitor daily weights and symptoms and adjusting their loop diuretic dose via telephone or patient portal messages to maintain euvolemia.
  • Reduction in ED visits or urgent care visits for dyspnea
  • Number of diuretic dose adjustments made without a physician visit
  • Improved quality-of-life scores (e.g., KCCQ)
Risk of Hyperkalemia and Renal Dysfunction You are the expert at navigating the fine balance of RAAS inhibitors and MRAs. You proactively monitor potassium and renal function, manage dose adjustments, and initiate potassium binders when necessary to maintain patients on life-saving GDMT.
  • Percent of patients maintained on target doses of ARNI/MRA without significant hyperkalemia
  • Reduction in therapy discontinuations due to lab abnormalities
Critical Pitfall: Ignoring HFpEF

For decades, there was little effective therapy for Heart Failure with preserved Ejection Fraction (HFpEF). This has changed dramatically. SGLT2 inhibitors are now guideline-recommended for this population, and MRAs have also shown benefit. Many providers are not yet in the habit of prescribing these agents for HFpEF. Creating a service that specifically identifies HFpEF patients and recommends initiation of an SGLT2 inhibitor is a massive, cutting-edge opportunity to improve outcomes in a previously untreatable population.

Deep Dive: Hypertension & Dyslipidemia (ASCVD Risk Reduction)

Why it’s a High-Impact Target: While seemingly less complex than diabetes or heart failure, ASCVD risk reduction is the bedrock of population health. The sheer volume of patients with hypertension and dyslipidemia is immense. The medications are generally inexpensive, but adherence is often poor, and therapeutic inertia is rampant. The downstream costs of inaction—myocardial infarction, stroke—are catastrophic. Pharmacist-led services are consistently proven to be one of the most effective strategies for achieving blood pressure and lipid goals. This is a high-volume, high-impact area perfect for demonstrating consistent value.

Masterclass Table: The Pharmacist’s Value Proposition in ASCVD Risk Reduction
Common Clinical/Financial Challenge The Pharmacist-Led Intervention (Your CPA in Action) Measurable Outcomes (How You Prove Your Value)
Uncontrolled Hypertension Following a CPA protocol, you initiate and titrate antihypertensive agents, combining medications with different mechanisms of action, and coaching patients on home blood pressure monitoring to achieve guideline-based targets.
  • Percent of patients achieving target blood pressure
  • Average reduction in systolic and diastolic BP
  • Increased use of combination therapy
Statin Underutilization and Intolerance You identify all patients with ASCVD, diabetes, or high LDL who should be on a statin but are not. You manage “statin intolerance” by systematically trialing different statins, adjusting doses, and providing intensive education to overcome perceived side effects. You add ezetimibe or initiate PCSK9 inhibitors for high-risk patients per protocol.
  • Percent of eligible patients prescribed appropriate intensity statin therapy (a key quality metric)
  • Average percent reduction in LDL-C
  • Number of patients successfully treated for statin intolerance
Poor Medication Adherence You are a master of adherence. You identify barriers (cost, side effects, regimen complexity), switch patients to once-daily formulations, consolidate to combination pills, and utilize 90-day supplies and auto-refill programs to improve the Proportion of Days Covered (PDC).
  • PDC scores for statin, RAAS inhibitor, and hypertension medication classes (a major Medicare Star Rating metric)
  • Improvement in BP and LDL control correlated with improved adherence

Deep Dive: COPD & Asthma

Why it’s a High-Impact Target: Respiratory diseases are a leading cause of ED visits and hospitalizations, often triggered by exacerbations. The core of management rests on medication therapy delivered via complex inhaler devices. Improper inhaler technique is epidemic and is the number one cause of treatment failure. Furthermore, the guidelines for escalating and de-escalating therapy are nuanced. This combination of high utilization and technique-dependent therapy makes it an ideal domain for pharmacist intervention. Your expertise in patient education and device training is a unique and powerful tool.

Masterclass Table: The Pharmacist’s Value Proposition in Respiratory Care
Common Clinical/Financial Challenge The Pharmacist-Led Intervention (Your CPA in Action) Measurable Outcomes (How You Prove Your Value)
Frequent Exacerbations and Over-reliance on SABA You perform a comprehensive assessment to determine if the patient is on the correct controller therapy. Under a CPA, you can escalate therapy (e.g., adding a LAMA to an ICS/LABA in COPD) or ensure proper use of SMART therapy in asthma. You de-prescribe unnecessary SABA refills.
  • Reduction in ED visits and hospitalizations for exacerbations
  • Decrease in the number of SABA canisters dispensed per year
  • Improved scores on symptom questionnaires (e.g., CAT, ACQ)
Incorrect Inhaler Technique This is your superpower. You provide hands-on, teach-back education for every inhaler device. You use placebo devices to allow patients to practice and provide corrective feedback until mastery is achieved. This is often the single most effective intervention.
  • Demonstrated improvement in technique scores at follow-up visits
  • Correlation between improved technique and reduced exacerbations
High Cost of Inhaled Medications You are an expert on respiratory formularies. You navigate prior authorizations and help select the most cost-effective device and medication combination that meets the patient’s clinical needs, including the use of authorized generics or preferred brands.
  • Reduction in medication costs per patient
  • Improved adherence due to reduced out-of-pocket expenses

11.1.4 High-Risk Patient Populations: Identifying Vulnerability Beyond Diagnosis

Focusing on disease states is a powerful top-down approach. However, an equally valid and complementary strategy is a bottom-up approach that identifies patients based on patterns of medication use or healthcare utilization that signal high risk, regardless of their primary diagnosis. These cross-cutting populations often represent the most complex and vulnerable individuals in your panel, and they are frequently falling through the cracks of a fragmented healthcare system. Targeting them allows you to address medication safety at its most critical junctures.

Target Population: Polypharmacy

Why it’s a High-Impact Target: Polypharmacy (often defined as the use of 5, 10, or even 15+ chronic medications) is not a disease, but it is a powerful independent predictor of negative health outcomes. It is a marker of clinical complexity and a fertile ground for adverse drug events, drug interactions, prescribing cascades, non-adherence, and high costs. A patient on 15 medications is seeing multiple specialists, none of whom may be looking at the full picture. The pharmacist is the only professional uniquely trained to step into this role, acting as the master coordinator of the medication regimen.

The Polypharmacy Patient is Your Bullseye

If you were to choose only one single population to target to demonstrate maximum value, it would be patients on >15 chronic medications. A comprehensive medication review (CMR) in this cohort will always yield significant, actionable interventions. It is the highest-yield activity a clinical pharmacist can perform.

Masterclass Table: The Pharmacist’s Value Proposition in Polypharmacy
Common Clinical/Financial Challenge The Pharmacist-Led Intervention (Your CPA in Action) Measurable Outcomes (How You Prove Your Value)
Adverse Drug Events (ADEs) & Prescribing Cascades You perform a systematic review to identify medications that may be causing side effects being treated with other drugs (e.g., a CCB causing edema treated with a diuretic). You identify opportunities to de-prescribe the offending agent.
  • Number of prescribing cascades identified and resolved
  • Reduction in fall rates, ED visits for dizziness, or other ADE-related events
Therapeutic Duplication & Lack of Indication You meticulously review the patient’s entire medication list from all sources (EHR, claims data, patient report) to identify duplicate therapies from different prescribers and medications with no clear, current indication (e.g., a PPI started in the hospital 5 years ago).
  • Number of unnecessary medications discontinued
  • Direct cost savings from de-prescribing
Regimen Complexity & Non-Adherence You are the architect of simplification. You consolidate medications into combination products, switch from multiple-daily to once-daily formulations, and align refill dates to create a regimen the patient can actually follow.
  • Reduction in total pill burden
  • Improved adherence (PDC scores)
  • Improved patient-reported confidence in managing their medications

Target Population: Transitions of Care

Why it’s a High-Impact Target: The moment of discharge from a hospital is one of the most dangerous points in the healthcare continuum. Patients are sick, confused, and sent home with a completely new and often complex medication list. Unintentional discrepancies between the inpatient and outpatient medication lists occur in up to 70% of patients, and these discrepancies are a leading cause of adverse events and hospital readmissions. A pharmacist-led TOC service that “bridges” this gap is one of the most well-studied and effective interventions for improving safety and reducing costs.

Masterclass Table: The Pharmacist’s Value Proposition in Transitions of Care
Common Clinical/Financial Challenge The Pharmacist-Led Intervention Measurable Outcomes
Medication List Discrepancies You perform a “best possible medication history” on admission and a meticulous medication reconciliation on discharge, comparing the hospital MAR to the patient’s home list and the new discharge summary to identify and resolve conflicts.
  • Number and severity of medication discrepancies identified and resolved
  • Reduction in post-discharge ADEs
Patient Confusion & Lack of Understanding You provide dedicated, teach-back based discharge counseling at the bedside, focusing on the most critical changes. You provide simplified medication schedules and action plans. You then conduct a follow-up call 2-3 days after discharge to answer questions and reinforce learning.
  • Patient satisfaction scores
  • Improved scores on medication knowledge assessments
Access & Adherence Barriers You proactively address access issues before the patient leaves the hospital. You confirm prior authorizations are in place, that copays are affordable, and arrange for meds-to-beds delivery or ensure the first fill is waiting at their community pharmacy.
  • Primary medication non-adherence rates (percent of new scripts not picked up)
  • 30-day all-cause readmission rates

11.1.5 Financial & Operational Drivers: Aligning Clinical Goals with Business Objectives

In an ideal world, you would select target populations based purely on clinical need. In the real world of healthcare, however, “no margin, no mission.” The long-term sustainability and growth of your clinical services depend on your ability to align your interventions with the financial and operational priorities of your organization. This means understanding how the health system or clinic gets paid and which quality metrics they are being judged on. By targeting patient populations that directly influence these key performance indicators (KPIs), you transform your role from a “cost center” to a “value generator.” This is the key to securing FTEs, resources, and a permanent seat at the table.

Masterclass Table: Aligning Pharmacist Services with Value-Based Care Models
Payment Model / Quality Program Key Performance Indicators (KPIs) That Matter How to Target Your CPA Population to “Move the Needle”
Medicare Star Ratings (Part C & D)
  • Medication Adherence (Triple-Weighted): Proportion of Days Covered (PDC) >80% for Statins, RAAS Inhibitors, and Diabetes meds.
  • Statin Use in Persons with Diabetes (SUPD)
  • A1c Control (<8%)
 Targeting Strategy: Run reports to identify patients with PDC scores <80% in the three key adherence classes. Launch a pharmacist-led adherence outreach program targeting these specific individuals with CMRs, 90-day fills, and regimen simplification. This is a direct, measurable way to improve Star Ratings.
Hospital Readmission Reduction Program (HRRP)
  • 30-Day All-Cause Readmission Rates for specific conditions, including Heart Failure, COPD, and Pneumonia.
 Targeting Strategy: Implement a pharmacist-led Transitions of Care service specifically for patients discharged with a primary diagnosis of HF or COPD. Your entire focus is on preventing that readmission through medication reconciliation, education, and post-discharge follow-up.
Accountable Care Organizations (ACOs) / Shared Savings
  • Total Cost of Care: Reducing avoidable ED visits and hospitalizations.
  • Quality Metrics: BP control, A1c control, preventative screening.
  • High-Cost Drug Utilization.
 Targeting Strategy: Focus on the highest-cost, highest-utilizing patients (the top 5%). These are typically individuals with multiple, uncontrolled chronic conditions like diabetes and HF. A CMM service for this “rising risk” population can generate huge ROI by preventing even a single hospitalization.
Speaking the Language of the C-Suite: How to Propose Your Service

When you ask for a new pharmacist FTE, you need to present a business case, not just a clinical one. Frame your proposal using their language:

Poorly Framed Request: “I would like to start a diabetes clinic to help patients get their A1c under control.”

Powerfully Framed Proposal: “Our organization’s Medicare Star Ratings are currently at 3.5 stars, largely due to poor performance on the diabetes-related adherence and A1c control measures. I am proposing a pharmacist-led diabetes management service targeting 200 of our highest-risk patients with an A1c over 9%. Based on published data, a dedicated pharmacist can lower A1c by an average of 1.5% and improve medication adherence by 15-20 percentage points. Achieving these targets would directly move our Star Rating to a 4.0, resulting in an estimated quality bonus payment of over $2 million. The service would more than pay for itself in the first year through shared savings and improved quality metrics.”

11.1.6 Synthesis: Building Your Population Health Action Plan

We have covered a vast amount of strategic ground. The key is to synthesize these different approaches—disease state, patient risk factors, and financial drivers—into a coherent and actionable plan. A successful collaborative practice is not built by trying to do everything at once. It is built by selecting a specific, high-impact target, executing flawlessly, demonstrating overwhelming value, and then using that success to expand your scope and resources. This is how you build a sustainable, respected, and indispensable clinical service.

Your Step-by-Step Guide to Selecting Your First Target Population
1

Analyze the Data: Become a Data Detective

Before you do anything else, get your hands on the data. You can’t manage what you don’t measure. Work with your clinic’s data analyst or quality department to get reports on:

  • Quality Metrics: Where is your organization underperforming? (e.g., HEDIS scores, Star Ratings, ACO quality measures). Look for the gaps.
  • High Utilizers: Who are the patients with the most ED visits or hospital admissions in the past year?
  • Disease Prevalence: How many patients do you have with diabetes, HF, COPD? Who has an A1c > 9% or a recent HF admission?
  • Prescribing Data: Who is on >15 medications? Who is on high-risk combinations?

2

Interview Stakeholders: Identify the Pain Points

Data tells you what is happening, but people tell you why. Schedule brief meetings with key physician leaders, clinic managers, and nurse managers. Ask them one simple question: “What is the biggest medication-related problem that gets in the way of you doing your job and caring for your patients?” You will be amazed at the insights you gather. They might point to uncontrolled hypertension, the administrative nightmare of prior authorizations, or the flood of patient calls about anticoagulation.

3

Find the Overlap: The Nexus of Need

Your ideal target population lies at the intersection of three circles:

  • The Data-Driven Need: A population with clear gaps in care and high costs.
  • The Stakeholder Pain Point: A problem your physician colleagues are desperate to solve.
  • Your Clinical Strength: An area where a pharmacist’s skills are uniquely suited to make an impact.
When you find a problem that exists in all three circles (e.g., poor A1c control, which shows up in the data, is a frustration for physicians, and is a perfect fit for a pharmacist CPA), you have found your starting point.

4

Propose a Pilot Program: Start Small, Win Big

Do not propose a plan to manage all 5,000 patients in the clinic. Propose a highly focused, 6-month pilot program with a clear, measurable goal.
Example: “We will conduct a 6-month pilot targeting the 50 diabetic patients with the highest A1c in the clinic. The goal is to lower the average A1c in this cohort by at least 1.5% and ensure 100% are on appropriate cardiorenal protective therapies. We will track outcomes and present a return-on-investment analysis at the end of the pilot.”