Pharmacist-led community network approach addressing social needs and adherence (Connect AF)

Social determinants of health (SDOH) are nonmedical factors that impact health outcomes and medication use. As national initiatives and value-based care models prioritize SDOH interventions, pharmacists are uniquely positioned to support these efforts. However, evidence describing pharmacist-led SDOH screening, particularly through collaborations between health-system and community pharmacists, remains limited.

To learn how community pharmacists address SDOH-related care gaps among patients with atrial fibrillation (AF) and how vertically integrated partnerships can strengthen these efforts through the Connect AF program.

Connect AF was developed through partnership among Community Pharmacy Enhanced Services Network USA (CPESN), UNC Health Pharmacy, Pfizer, and Blue Cross Blue Shield North Carolina. Pharmacists administered an adapted SDOH questionnaire to 75 AF patients receiving care at UNC Health and filling oral anticoagulants at 5 North Carolina CPESN pharmacies. Domains assessed included housing instability, transportation, mental health, food insecurity, community support, safety, and utilities. Pharmacists provided referrals, facilitated resource navigation, documented patient engagement, and completed pre- and post-program feasibility and acceptability surveys.

Connect AF represents a first-of-its-kind alignment between a health-system, community pharmacies, a payer, and an industry partner to gain insights on pharmacist-driven SDOH strategies for AF patients.

Data were analyzed descriptively using frequencies and percentages.

Connect AF fostered a collaborative learning environment that enabled each partner to contribute insights, expertise, data, and resources aligned with their role. Mental health (28%), housing instability (20%), and transportation barriers (20%) were most prevalent. Though 16% of patients screened shared needs, most expressed uncertainty about engaging with referred resources (75%). All pharmacists reported strong confidence and intent to continue providing SDOH-related support.

Connect AF demonstrates how pharmacists can address SDOH-related care gaps and provides a scalable model for cross-sector collaboration to enhance patient care coordination.