**1. Introduction**

Findings from the 2009 and 2014 National Pharmacist Workforce Surveys in the United States revealed five segments of pharmacists: (1) medication providers, (2) medication providers who also provide patient care, (3) other activity pharmacists, (4) patient care providers who also provide medication, and (5) patient care providers [1,2]. The findings from 2009 and 2014 showed similar patterns with approximately 40% of U.S. pharmacists devoted primarily to medication providing, 40% contributing a significant portion of their time (typically, 20% or more) to patient care service provision, and the remaining 20% contributing most of their time to business/organization management, research, education, and other health-system improvement activities.

The findings from 2009 and 2014 suggested that there remained a need for, and segmen<sup>t</sup> of, pharmacists devoted to specialty practices, dispensing, and patient care services, which are delivered at the point-of-care [2]. At that time, increases in the number of pharmacy graduates per year helped the pharmacy profession meet medication provision needs while, at the same time, expand capacity for new roles in patient care [2]. However, the relatively large cohort of pharmacists trained in the 1970s (capitation years) was retiring at this same time [3], and their contributions needed to be replaced (see Figure 1). Consequently, there still was not a substantial surplus of pharmacists that could have been engaged in more intense advancement of pharmacists' patient care service provision [4]. A recent commentary by Lebovitz and Eddington [5] pointed out that, although pharmacist training focused on clinical knowledge and increased student enrollment during those years, employment in more patient-focused jobs had been minimal.

Since the time the 2009 and 2014 workforce surveys were conducted, considerable shifts in health services and pharmacist roles in the United States have occurred. For example, the pharmacy profession now performs two distinct types of activities: (1) medicine access and supply, and (2) pharmaceutical care [6]. Work system and process designs for medicine access and supply respond to formal requests from prescribers to supply products and associated services as instructed. In contrast, pharmaceutical care involves work systems and processes that focus on decision-making about medicines therapy and planned consultations between pharmacists, prescribers, and patients that facilitate the aim of improving health outcomes [6]. Baines and colleagues described a "blended pharmacy practice" work system and process design that currently is being used as the pharmacy profession attempts to fulfill both types of activities, often in the same location.

**Figure 1.** Number of Pharmacist First Professional Degrees by Year of Graduation (1965–2018) with Trend Line. Source: 2017-2018 Profile of Pharmacy Students – American Association of Colleges of Pharmacy, AACP.

Furthermore, the pharmacy profession in the United States is close to gaining provider status, which would provide Medicare coverage for certain pharmacist services in health professional shortage areas or medically underserved areas [5]. Also, changes in laws allowing immunizations, medication therapy management, and collaborative practice agreements are opening up patient-focused jobs for pharmacists. Frogner and colleagues [7] proposed that health care delivery overall is being reorganized to achieve greater value, improve access, integrate care among settings, advance population health, and address social determinants of health. To accomplish this, there is a need for telehealth, the application of digital technology, team-based care, and community-based delivery models [7]. In their commentary, Frogner and colleagues specifically mentioned pharmacists as playing integral roles and the need for changes in their scope-of-practice regulations [7].

Recent market-driven shifts have moved community pharmacy practice from the traditional "locational convenience" strategy to one in which pharmacies are "being organized by their capacity to operate as health care access points that provide and are reimbursed for patient care and public health services" [8–12]. Also, health-system pharmacy practice has been changing from largely acute care models to more comprehensive integrated care models [13] through horizontal integration with clinics and medical centers so that medication and medical costs can be combined in risk portfolios and meet pay-for-performance goals [14].

Vertical integration is affecting pharmacy practice, as well. Insurance companies, wholesalers, manufacturers, integrated delivery networks, pharmacy benefit managemen<sup>t</sup> companies, pharmacies, clinics, and medical centers are integrating in order to (1) provide coordinated services at a lower cost, (2) improve access to services, (3) leverage data, and (4) bear financial risk for the health outcomes of patient populations [9,14–17].

A special issue in the journal *Pharmacy* focused on pharmacist services and provides further evidence of recent changes in health services and pharmacist roles. In that special issue, Urick and Meggs described the post-pharmaceutical care era and the shift in focus from product to the patient [18]. Ascione proposed the need for pharmacists to be better team members in newly emerging collaborative care and integrated health systems [19]. Goode and colleagues provided a comprehensive categorization of community pharmacy-based patient care services within medication optimization, wellness and prevention screenings, risk assessments, chronic care management, acute care management, patient education, care transitions, and public health domains [20]. Other articles

in the special issue further described innovative organizational collaboration [21,22], comprehensive medication managemen<sup>t</sup> [23,24], transitions of care [25,26], public health initiatives [27–29], and tailored patient-centered care and assessment [30–33]. These are just some examples of the changes in health services and pharmacist roles.

To help make these transitions, significant changes in work systems and processes are being developed, including (1) tech-check-tech processes [34–36], (2) patient-tailored packaging and delivery [37], and (3) technological advances [37]. It appears that the "blended pharmacy practice" work system and the process design described by Baines and colleagues [6] continue to evolve. New ways of delivering products, managing inventory, and reimbursing for product costs are being developed. At the same time, new ways for recruiting and connecting patients with practitioners, achieving patient outcomes, organizing space for patients to receive services, and being reimbursed for value-based outcomes are being developed. These significant changes are likely to influence the types of work activities performed by pharmacists and the time they devote to these activities [2]. This, in turn, will necessitate changes for pharmacy workforce support personnel as they augmen<sup>t</sup> the roles that pharmacists and pharmacies will serve in health care.

In light of the expansion of pharmacist roles and congruen<sup>t</sup> changes in systems of care provision, our goal was to repeat the segmen<sup>t</sup> analyses conducted in 2009 [1] and 2014 [2] using data from the 2019 National Pharmacist Workforce Survey [38]. As was done in 2009 and 2014, the segmentation analysis was based upon pharmacists' time devoted to medication providing (their traditional role) and to patient care services (their emergen<sup>t</sup> role). A segmentation approach identified key clusters (segments) of the pharmacist workforce and provided a description of their characteristics so that projections could be made regarding future pharmacy profession capacity as cohorts of pharmacists exit the workforce and newly trained pharmacists join the workforce. In addition, the findings were interpreted within the context of the future scope of practice changes that could a ffect roles filled by pharmacists and pharmacy workforce support personnel.

### **2. Study Objectives**

The overall goal for this study was to repeat the segmen<sup>t</sup> analysis of the pharmacist workforce conducted in 2009 [1] and 2014 [2] using data from the 2019 National Pharmacist Workforce Survey. The objectives were to:

