On The Cover
Sonya Collins
An estimated 61.2 million U.S. adults are over the age of 65 years. Advancing age brings not only the likelihood of more chronic diseases and prescription medications, but also increasing barriers to care, including cost, transportation, and a health care system that’s more difficult to navigate. In many rural communities, it’s not physicians or clinics reducing these hurdles for older adults. It’s pharmacists.
Pharmacists who see their patients every month—or as often as every week—are spotting problems earlier, simplifying complex regimens, and stitching together fragmented care.
From rural North Dakota to small-town Kentucky, they’re packaging medications, screening for risky drugs, frailty and fall risk, and even bringing vaccines to patients’ living rooms. Along the way, they’re confronting the structural barriers—reimbursement, workforce constraints, and a headlong rush to mail order—that too often push older adults through the cracks.
Care for older adults is different
As chronic care patients get older, their needs become increasingly complex.
Nearly 80% of adults over age 65 years have two or more chronic conditions, according to a 2025 study published in Preventing Chronic Disease. The conditions are mounting while the body is by nature growing more frail.
Roughly half of adults over age 65 years take five or more medications every day. As many as a quarter of them take 10 or more. Polypharmacy comes with increased risk for adverse effects, falls, and morbidity and mortality due to non-optimized medication therapy. The latter is estimated to cost $528.4 billion a year.
Preventable morbidity is compounded by the fact that so many older adults struggle to afford their care or may have to choose between health care and proper nutrition. According to the Commonwealth Fund 2023 Health Care Affordability Survey, more than one in five Medicare beneficiaries has delayed or skipped care due to costs. The same amount said that health care costs made it hard to afford food and utilities.
Pharmacists are well positioned to help address some of these needs while improving access to care and helping older adults navigate a complicated system.
Closing gaps born of fragmentation
Fragmented care is an unfortunate hallmark of the American health care system, and older adults are among those most likely to suffer its consequences.
A 2022 study in the Journal of General Internal Medicine quantified fragmentation in care and the associated consequences for older adults. The researchers found that fragmented care was associated with more visits to a provider and more emergency department visits. Fragmented care leaves patients vulnerable to medication errors. Each transition in care raises the risk for unintentional medication discrepancies, research shows.
Fragmentation in care is acutely felt in rural areas, where access to both general internists and specialists can be scarce. Forty million rural Americans live in primary care professional shortage areas, and one in five of them is 65 years or older. In the absence of medical providers, older adults turn to their community pharmacists.
“Patients visit their pharmacies at least two times more, if not more frequently, than they do their primary care providers,” said Elizabeth Skoy, PharmD, who practices at Thrifty White Pharmacy and directs the Center for Collaboration and Advancement in Pharmacy (CCAP) at North Dakota State University.
Both Thrifty White and the CCAP have built programs around this reality.
Pharmacists at Thrifty White complete multiple components of the Medicare wellness visits for older adults who may not be able to get to a physician’s office. This addresses a major gap in care for older adults as fewer than 60% of Medicare beneficiaries complete their wellness visit every year.
The CCAP deploys student pharmacists to rural pharmacies, where older adults make up the majority of the patient population, to screen for and help address social barriers to health, such as inability to pay for medications or utilities and lack of transportation to the pharmacy or physician’s appointments. Older adults in rural areas are more likely than their urban counterparts to forego health care due to lack of transportation, according to HRSA’s Rural Health Information Hub.
CCAP student pharmacists also perform routine BP checks and refer urgent cases.
“One student checked a patient’s blood pressure and, because it was so high, had a loved one take them directly to an emergency room,” Skoy said. “They were having a heart attack. So that was potentially a life saved.”
The CCAP also piloted community-pharmacy screening for potentially inappropriate medications. “We found that over 80% of our patients had potentially inappropriate medications prescribed through their pharmacists,” she said.
Routine medication reviews are critically important for older adults as polypharmacy increases the risk of adverse drug effects, including falls and cognitive impairment, harmful drug interactions, and drug–disease interactions. Deprescribing, research consistently shows, reduces the proportion of patients taking potentially inappropriate medications and with potential prescription omissions and reduces adverse drug events.
“Our primary focus is deprescribing,” said Kim Croley, PharmD, a pharmacist at Laurel Senior Living Communities in London, KY.
Croley unravels prescribing cascades and consolidates duplicate therapies. She noted that it is important to pay special attention to the inevitable decline in liver and kidney function that comes with aging, saying, “We double check there’s not a dose adjustment needed and cap acetaminophen at 3,000 mg/day.”
Screening for fall risk and frailty
About a third of community-dwelling older adults experience a fall every year. Half fall more than once. Fall risk– increasing drugs are a significant risk factor. Polypharmacy in general raises the risk for hospitalization due to a fall, according to Zaninotto and colleagues’ 2020 study in BMJ Public Health, which said that 40% of falls among older adults are preventable.
Whenever any resident of Laurel Senior Living has a fall, a pharmacist completes a root-cause review. “We go back and look at every medication to see if they are on anything that could increase risk for falls,” Croley said.
Gait and grip strength can also be surrogates for frailty and indicators of overall health among older adults.
Gait speed has been positively correlated with survival in several studies of older adults. Grip strength has been described as a biomarker for overall health. Research has shown it has positive correlations with overall strength, upper limb function, and bone density and is negatively correlated with risk of fall or fracture, malnutrition, cognitive impairment, depression, sleep troubles, diabetes, multimorbidity and overall quality of life. Grip-strength tests can be used alone or in conjunction with other measures to identify older adults at risk of poor health status.
North Dakota’s CCAP has trained pharmacists to test handgrip strength, “which has been attributed to some worsening of chronic disease,” Skoy said. Some pharmacists perform gait screenings in older adults as well and refer them to specialists when necessary.
“Adding a PIMs, gait or handgrip strength onto an MTM may add 5 to 10 minutes but can make a big impact,” Skoy said.
Meeting needs of older adults
Just Meds, an independent pharmacy in Martins Ferry, OH, takes advantage of Medicare’s Long-Term Care at Home model, which allows community pharmacies to bill LTC-level dispensing fees for home-based patients who require the same level of medication support as facility residents. Through this program, the pharmacy provides individual dose packaging to older adults and delivers them to patients’ homes at no extra cost.
“We want people to be able to live in their homes and have as much independence as possible,” said Just Meds pharmacist Matthew Rafa, PharmD.
It’s not just medications he delivers to older adults’ homes. Rafa takes vaccines right to their doors as well.
But transportation isn’t the only barrier to care that pharmacists may help address for older adults. Cost is a serious concern for older adults, too.
Within a subset of its older adult patient population, Just Meds is taking an innovative approach to saving patients money. The independent pharmacy is piloting pharmacogenomic testing for psychoactive medications to streamline therapy and try to reduce costs.
“What if someone’s on a medication that works great, but it costs 100 bucks a month, and there’s something else that could get them the same benefit at a fraction of the cost?” Rafa said.
Based on available research, Just Meds can expect to get good results.
A 2019 study published in the Journal of Geriatric Psychiatry and Neurology found that pharmacogenomic-guided prescribing of psychoactive medications for adults over age 65 years led to savings of more than $3,000 a year and one fewer prescription per year.
The human antidote to mail-order confusion
Mail-order pharmacy provides convenience for a lot of patients, but there are real downsides for older adults. One of them being further isolation that many older adults already feel.
“This is a generation that wants to talk to someone,” Rafa said. “They’re getting pushed through medical offices, being put on hold at the pharmacy.”
In our increasingly automated, contact-less health care system, Ijeoma Uwakwe, PharmD, owner of WilsonValue Drug Store in Wilson, NC, sees the fallout daily. She describes a longtime patient for whom she provided blister-packaged prescriptions—until the patient was pushed to mail order.
“Within 3 months, she called me crying,” Uwakwe said.
Uwakwe did the extra legwork to bring the patient’s prescriptions back to her pharmacy, but the tug-of-war continued. “[The mail-order pharmacies] call the providers directly and get the prescription back,” she said.
She managed to get this patient’s prescriptions back once again, but she’s not always successful, which simply means she continues to serve the patients for free.
When older adults receive devices by mail, invariably they come to Uwakwe to learn how to use them—sometimes repeatedly.
Uwakwe has former patients who have now completely transferred to mail order, including to receive their Dexcom G7.
“Who do they come to when they don’t know how to use it? Their local pharmacist. Then they say, ‘Can we come back in 10 days so that you can apply it again?’ I don’t receive any payment for that,” she said.
But she never turns away an older adult seeking help. She knows that the older adult members of her community need a local ally.
An untapped area of patient care
Pharmacists are already demonstrating what comprehensive chronic care for older adults can look like: timely screenings, safer medication regimens, fewer falls, and care delivered directly to the doorstep.
For innovative pharmacists who can find a path to reimbursement, chronic care for older adults is an untapped market where they can excel. Quick geriatric screenings for potentially inappropriate medications, fall risk, grip strength, and gait can be added to MTM visits. Pharmacists can offer adherence packaging, device education and at-home delivery of medications, vaccines, and preventive screening.
But older adult patients themselves may argue that the responsibility for their care shouldn’t rest on the shoulders of a few entrepreneurial or out-of-the-box-thinking pharmacists. All pharmacists need resources to make their care of older adults widespread, reimbursable, and sustainable. Older adults require a system that meets them where they are, and pharmacists are showing that such a system is within reach. The next step is to fully recognize and support the value they bring, so that no older adult has to navigate their most vulnerable years without a knowledgeable ally at their side.
“We do far more than just counting pills,” Uwakwe said. “We are there for the community.” But, she added, “We could be doing more if we were compensated for it.” ■
All eyes on the Rural Health Transformation Program
By the time this article is published, CMS will have approved or denied state’s applications for funds in the Rural Health Transformation Program, which is aimed at expanding health care in rural areas. According to CMS, all 50 states submitted proposals.
The Rural Health Transformation Program, which was included in the One Big Beautiful Bill Act, appropriated $10 billion per year for 5 years for rural health. CMS has indicated that half of the funds are designated for states whose applications are approved, and the other half will be awarded to states based on their plans and perceived impact. The goal of the program is to strengthen rural health care across the country and “empower states to transform the existing rural health care infrastructure and build sustainable health care systems that expand access, enhance quality of care, and improve outcomes for patients.”
Be on the lookout for how pharmacists and payment for pharmacists’ services will be part of how states expand health care through this program and make it more accessible for patients in rural America. ■