Overview of services

Ben Smith
Associate Chief Pharmacy Officer Population Health and Ambulatory Services

The Population Health and Ambulatory Services consists of clinical pharmacist services in ambulatory endocrinology, gastroenterology, neurology, rheumatology, and primary care clinics.  Additionally, a team of population health pharmacy technicians and clinical pharmacists provide Population Health Pharmacy Services across Duke Health’s accountable care organization (ACO) and clinically integrated network (CIN), Duke Connected Care (DCC).

The specialty clinic pharmacists provide collaborative medication management and clinical support to their clinic staff and providers.  When applicable, these pharmacists become credentialed as clinical pharmacist practitioners (CPPs) to provide collaborative medication management services.  Specialty conditions served include, but are not limited to, diabetes, gender medicine, hepatitis C, inflammatory bowel disease, multiple sclerosis, memory disorders, movement disorders (including Parkinson’s disease), osteoarthritis, rheumatoid arthritis, and lupus.  Additionally, Population Health and Ambulatory Services collaborates with all other Duke Health specialty ambulatory clinic pharmacists based in other Department of Pharmacy divisions. Examples of these clinical services include transplant, interstitial lung disease, anticoagulation, and oncology.

CPPs practice at Duke Family Medicine and the Duke Outpatient Clinic (internal medicine), the two main Duke Health primary care teaching clinics. Services at these sites include chronic disease management for conditions such as diabetes, hypertension, and anticoagulation.  Additionally, the clinical pharmacists serve as valuable resources for the medical residents, attending providers, and clinic staff.

Population Health Pharmacy Services includes initiatives to improve quality measure performance and to improve transitions of care.  This team is based out of the Duke Population Health Management Office (PHMO) and serves as a resource to Duke Health and DCC providers, staff, and care managers.  The pharmacy technician team assists in valuable initiatives such as overcoming medication access barriers, clarifying medication regimens, and improving medication adherence.  The population health clinical pharmacists provide clinical pharmacy advice, proactive quality measure outreach, transitions of care activities, and embedded primary care population health services.  Additionally, the pharmacists collaborate with specialist physicians on population health initiatives for conditions such as diabetes, chronic kidney disease, peripheral arterial disease, geriatrics, cardiology, behavioral health, and palliative care.

The embedded Population Health Primary Care pharmacist program consists of clinical pharmacist practitioners (CPPs) embedded in Duke Primary Care practice sites providing services to improve chronic disease management for conditions such as diabetes, hypertension, and coronary artery disease. Additionally, these pharmacists conduct proactive population health initiatives for their clinic sites and serve as a clinical pharmacy resource for providers and staff.


Resources for navigating formularies and preferred pharmacies has been compiled by the Population Health Pharmacy services team and can be found here.