Medical providers often don’t know how to best include community pharmacists within team-based care. Physiatrists or rehabilitation doctors know how to do this and they know how to deliver the fitness and functional outcomes that are transforming the future of value-based care.

The centers for disease control recommends that clinical pharmacists should be elevated within care teams to help patients better self-manage their medications, conditions, lifestyle and social barriers. The CDC also recommends that these teams include community health workers.

Payors, like Medicare, are implementing strategies that improve overall health while reducing overall costs. These strategies must include evidence-based strategies that prevent relative frailty and dementia while improving relative fitness.

Relative fitness versus relative frailty serves as the best overall measure for overall health.

Aging patients who are relatively fit require less ER visits and hospital care than those that are frail. They require overall less healthcare services in general.

Primary care teams do not currently have the capacity to measure, monitor or treat the modifiable primary determinants for frailty and dementia. 80% of these determinants require the self-management of:


Pre-frail and frail patients at risk for falls, dementia and hospitalization can now receive telehealth support from a prevention team of physiatrists and pharmacists at home. This telehealth support is initiated by a telehealth facilitator who visits the patient wherever they reside.

Patients receive a rehabilitation medicine consult that identifies any barriers effecting fitness and functional capacity like pain. The physiatrist then prescribes a self-management care plan and pharmacy team support for:

In addition, patients receive specialized telehealth tablets for home that enable the physiatry-pharmacy teams to deliver frailty prevention utilizing best practices from cardiac rehabilitation, pulmonary rehabilitation and the Lancet commission for dementia prevention.

Pharmacists can finally get paid for delivering clinical care as crucial members of a NEW telehealth prevention care team.