Allison Beatty, PharmD, BCPP
Clinical Pharmacy Practitioner
Southern Arizona Veterans Affairs Healthcare System
Tucson, AZ
With considerations/contributions from: Alex Heyfetz, PharmD
Dr. Allison Beatty is currently a mental health clinical pharmacy practitioner with the Southern Arizona Veterans Affairs Healthcare System. She currently practices in the area of Primary Care-Mental Health Integration, but has a strong background in inpatient psychiatry. She has dealt with long-acting injectables frequently and coordinated with outpatient clinics for administration. She is a member of AAPP and serves on the Resident and New Practitioner Committee.
Establishing clinics that coordinate and administer long-acting injectable antipsychotics (LAIAs) is a great way to provide additional services that may improve patient outcomes, while increasing the visibility and value of the pharmacy profession. The setting may vary (a community pharmacy, a Veterans Administration health care system, or an ambulatory clinic) but there are some general principles that can make the process smoother. Prior to initiating a new service, you must capture your market. Consider completing a needs assessment to ensure your service can, and will, be utilized by the teams and providers you work with. For example, in a community pharmacy setting, if you find yourself dispensing LAIAs to offices for administration, perhaps the office may also have the need for your administration abilities, and this could help build your patient panel. Advertising the service and what benefits it may provide is crucial for getting patients in the door.
First Things First: Iron Out the Specifics
While logistics may be boring, they are a good place to start. You will need to secure appropriate clinic space. A private area to counsel patients and administer the injections is necessary. Several LAIAs are administered via the gluteal route, so discretion and privacy are important. You will also want to ensure you have proper storage space and materials for reconstitution of any LAIA (medication refrigerators, temperature logs, gloves, etc.). Additionally, you will need to research any legal requirements in your particular state (are pharmacists able to administer LAIAs in your state?) and navigate appropriately.
Next, determine which LAIAs you will administer. If the clinic will offer to administer all available LAIAs, additional setup is required. For example, olanzapine pamoate (Zyprexa Relprevv™) requires patients to be observed for 3 hours post-injection in a facility with ready access to emergency services, so ensuring the infrastructure is in place to accomplish this would be needed. Perhaps you will want to expand the service to include non-antipsychotic LAIs such as naltrexone and buprenorphine in the future. These considerations should be addressed prior to starting the clinic.
How will you manage your stock of LAIAs? Which formulations will be kept on hand, and which will be ordered for patient-specific administration? Your answers will depend on the volume of your clinic and the profile of medications you administer. For example, our clinic keeps stock of fluphenazine decanoate and haloperidol decanoate, since multi-dose vials are available and several patients receive these injections every 2-4 weeks. All other LAIAs are ordered on a per patient basis. Having a stock of medications that are fast-movers may improve your efficiency and patient satisfaction, however this must be weighed with the cost of injections and their potential to expire before use.
Organization is Key
Once the particulars of the clinic are ironed out, the organizational aspect takes precedent. Having a systematic approach to an injection clinic is so important to ensure it runs smoothly and provides optimal benefit to both patients and providers. Assigning a single person to function as the coordinator will help keep everything streamlined. It is equally important to have well-documented clinic specifics for the inevitable times the coordinator is unavailable.
Setting a process and sticking to it is key to success. Below is an example of the process utilized in an ambulatory clinic within a Veterans Affairs system.
A master Excel sheet is kept with all patients that receive a LAIA. The information that is included on this sheet is:
Patient specific medication information – LAIA, dose, frequency, and route.
Schedule information- Last injection given and next injection due
Patient specifics – Prescriber, other important treatment members (ie: nurse case
manager) and any other monitoring that may be due (such as lipid panel).
Every Thursday, the head coordinator goes through the Excel sheet and identifies any injections that are due the following week. The LAIAs are then processed/adjudicated that day for the following week. Doing this the week before is crucial, as it allows time to fix any potential issues that may come up (such as no refills remaining, dose changes, stock issues, insurance rejections or prior authorizations needed).
In this example clinic, patients typically have a clinic appointment scheduled for their injection, or the injection will be taken to their residence by a nurse case manager for administration, so communication with the appropriate team member is typically the next step. In a clinic where patients are coming in on their own, it would be prudent to set up a reminder system to call the patient before their injection. Offering appointments may be beneficial, but also allowing walk-ins at any time the injection is due may improve patient adherence by providing flexibility.
Implement a process for documentation after injections are administered. At a minimum, the coordinator should update whatever system is in place to track when injections are due and provide appointment reminders to the patient. In the example clinic, the coordinator reviews the week’s injections every Friday and updates the Excel sheet with injections given as appropriate. Notes are also entered in the electronic chart regarding administration and any additional necessary information may be included in this note (such as side effects, symptom burden, or treatment recommendations) and appropriate team members are alerted to these notes for coordination of care.
Final Considerations
Final steps to establishing your clinic will depend on the setting. For example, in an ambulatory clinic, it may be important to figure out reimbursement/payment (see Dr. Ott’s article for more information on establishing a billing system). Additionally, if your clinic is in a space where you can offer additional services within the clinic, such as metabolic monitoring with point of care testing, incorporating this in to your initial planning will be beneficial. Ensure patients have adequate follow-up, as you are able, to ensure patients are receiving appropriate provider follow-up and oversight.
Utilizing LAIAs can be great for patients (improved adherence, better outcomes), yet there are barriers to widespread use. Employing pharmacist’s unique abilities and skill sets to help break down these barriers, these types of clinics can create more access for patients to receive LAIAs.
