Cherylann Gregory, RN, BSN

Oncology nurses help improve patient outcomes through their dedication and expertise. 

It was 1983 when I moved to Ann Arbor, Michigan, and started a new nursing position working midnights as a “float nurse.” I had not been there long when I was directed to “float” to the oncology unit. I was not pleased with this assignment as I had no idea what an oncology nurse was and was unsure of how to take care of cancer patients. As I received report, my assignment included a gentleman diagnosed with metastatic bone cancer. He was in extreme pain and being transported to radiology for evaluation of a possible fractured hip. We needed to move him from his bed to the transport cart. I could see in his eyes his pain, anxiety, and a feeling of helplessness.

What I witnessed next defined the course of the next 30 years of my oncology nursing career. I watched as a team of nurses prepared the transport cart so that it would not be such a hard mattress for him to lie on. As they prepared to lift him, they smiled at him with reassurance that he was in the best of hands and he would not feel any pain. This team of nurses then lifted this gentleman as if he were on a cloud and transferred him with such gentleness and the most compassion I had ever seen. I worked with this team of oncology nurses that night, listening to their conversations, feeling their true dedication. I wondered, who were these nurses? Where did they come from? What kind of training did they receive to be so caring, compassionate, and knowledgeable? The most important question I asked myself was, “How can I become one of them? I want to be an oncology nurse! ”

An oncology nurse provides care for cancer patients. The practice of oncology nursing encompasses the roles of direct caregiver, educator, consultant, administrator, and researcher. It extends to all settings where patients experiencing cancer receive health care, education, and counseling.

Debby J., RN, OCN, states, “Working in oncology can be sad, but it is so rewarding to be able to help the families through such trying times. I love the interaction with patient and family. Our care is very personal. You are not just in and out of their lives.”

Jeanne S., RN, OCN, writes, “Oncology nursing is a call that not many nurses can answer. There’s something amazing about being an integral part of a patient’s journey through his or her cancer treatment. I have treated so many brave patients who face cancer head-on with all of the determination and will that it takes to endure a very trying part of their lives. Through all of the ups and downs of their treatment, the nurse caring for them becomes one of their lifelines and sometimes the only constant they have in that raging sea of uncertainty. I get a strong sense of pride knowing that as an OCN [oncology certified nurse] I have the knowledge and skill it takes to help those patients navigate safely through that raging sea.”

“People have asked how I can do it and I simply say that my patients humble me. They allow me to be a part of something bigger than myself, to see the strength and perseverance it takes to take every day as another day, to engage themselves in the battle against something that scares even the strongest of individuals.”

The role of the oncology nurse developed following the 1971 National Cancer Act. This act was the stimulus for a comprehensive program focused on reducing the incidence, morbidity, and mortality of cancer. As cancer survival rates began to improve, nursing experienced an opportunity that expanded roles and acknowledged the importance of professionalism in oncology nursing. Educational programs that focused on oncology were developed as a specialty nursing area.

The practice of oncology nursing now spans from prevention and acute care through rehabilitative and palliative supportive care. Oncology nurses work in specialties such as hematology/oncology, radiation therapy, surgical oncology, bone marrow transplant centers, and palliative care. These specialty areas have expanded even further into biotherapy, breast oncology, gynecologic oncology, head and neck oncology, and cancer genetic counseling.

The practice of oncology nursing requires a cancer-specific knowledge base and demonstrated clinical expertise in cancer care beyond that acquired in a basic nursing program. The oncology nurse actively participates in professional role development including continuing education, quality assessment and improvement, and the review and clinical application of research findings. Oncology nurses demonstrate their competency by becoming a chemotherapy certified nurse, an OCN, an advanced OCN (AOCN), or a certified pediatric oncology nurse (CPON).

Oncology nursing practice includes inpatient or outpatient settings in hospital systems or community cancer center settings, home health care, hospice, public health, and community nursing. These nurses develop private practices, work at physicians’ offices, and teach at schools of nursing.

Oncology nurses care for the sickest of the sick, which can be very stressful and emotionally difficult. These nurses get to know their patients over the years and develop their own family unit. If the treatment doesn’t help, the oncology nurse shares in the patient’s disappointment; if the nurse cannot access their vein, he/she feels the patient’s discomfort and despair. Being close to so many patients, it can become very difficult when one of their patients dies after helping them through months or years of treatment. When patients invariably become friends, losing them is never easy.

Despite all the challenges, every nurse who works with cancer patients shares the common denominator of passionate care, determined to enhance the quality of their patients’ lives.

Today we are experiencing many victories in the fight against cancer. Patients are surviving cancer and living longer. Oncology nurses have played a significant role in this success. They are side by side with their patients, assisting them with the management of their therapy and side effects, through the good and the bad.

Thank you to all the oncology nurses who continue to give hope to their patients and keep smiling! 

 is founder and president of the Specialty Pharmacy Nursing Network (SPNN) and has more than 30 years of experience as an oncology/infusion nurse. Cherylann serves on the 

Articles

A Tribute to Oncology Nurses

Successful at-home administration of specialty medications requires extensive preparation and constant assessment of the patient's response by the specialty therapy nurse.

	As a patient prepares to receive a specialty therapy in the home care setting, many aspects of his or her care need to be coordinated. Along with the physician and specialty pharmacy staff, specialty therapy nurses are key members of the patient’s therapy care team. The specialty therapy nurse has advanced education, training, and expertise in the administration of drugs and biologics. 

	For 13 of the past 14 years, Gallup polling has shown that nurses are ranked the most trusted professionals in America—and for good reason.

 Nurses work face to face with the patient and family, taking the time to explain and teach, and also hold the hand of any patient who needs reassurance. 

	Multiple components are involved in conducting a specialty therapy visit in the home care setting. These consist of the pre-visit preparation, the visit, troubleshooting, and the post visit care. Each step encompasses a multitude of tasks and assessments required to complete the administration successfully. 

	Prior to the visit taking place, the nurse verifies that the patient has received the drug, supplies, and equipment. The nurse asks which support persons will attend the visit for medication administration training and if any language barriers exist that may interfere with the therapy administration or education. 

	Upon arrival at the patient’s home, an inventory of medication, supplies, and equipment is performed by the nurse. The nurse educates the patient on pro-per storage of supplies and medication. Most likely, the supplies are still in the box that the specialty pharmacy shipped them in. The nurse assists the patient in removing the supplies and equipment. The delivery ticket is used to educate the patient on how to identify the supplies and the quantity needed for the reorder prior to the next delivery. 

	The nurse reviews any documentation that requires the patient’s signature with the patient. Instruction is initiated on the patient’s disease, therapy, the potential risks and benefits of therapy in the home care setting, and the plan of care. Once the patient acknowledges that he or she understands the information, the nurse obtains the patient’s consent for care.

	To initiate a visit in the home, the nurse performs a patient assessment. The patient is evaluated for dehydration and symptoms of cold, flu, or infection. The patient’s emotional status is assessed for readiness to learn and receive the therapy. Any issues, concerns, or symptoms that need to be addressed prior to the start of therapy are evaluated and reported to the pharmacist and/or physician. 

	The home is assessed to determine whether the environment is conducive to learning and administration of the therapy. The nurse must identify potential barriers that could interfere with the therapy and assess how to remove those barriers prior to the start of therapy. Examples of barriers are small children, animals, inadequate lighting, and disruptive family members. 

	The nurse then proceeds to establishing intravenous (IV) access prior to the preparation of the drug. Once IV access is established, the nurse begins the reconstitution, preparation, and administration of the therapy. Depending on the therapy, reconstitution could be simple or very complex. Adequate time must be taken to properly reconstitute the drug in the home environment. 

	Once the drug is reconstituted and prepared, the nurse obtains baseline vital signs (VSs) and begins the administration per protocol. The patient is monitored throughout the entire administration and assessed for any side effects or adverse events, with dosage adjustments made per protocol. 

	One complication that could delay therapy initiation or extend the therapy visit is unsuccessful venous access via a peripheral or central venous access device. It may be necessary to reschedule the visit if the problem cannot be resolved immediately and requires further follow-up.

	Adverse reactions to the therapy require that the nurse make quick decisions on the course of action. It may be necessary to slow down or briefly stop the infusion before restarting or to administer additional medications before continuing with the therapy.

	If the patient experiences a serious adverse reaction, the nurse must then initiate the emergency plan by discontinuing therapy, dialing 911, and administering medications to treat anaphylaxis. 

	Documentation is completed during the home care visit to validate the patient’s status while receiving the therapy. Post therapy, the nurse assesses whether the patient is alert and oriented, has stable VSs, has provider and emergency contact information readily available, and understands the potential of delayed adverse events requiring immediate medical attention.

	At the conclusion of the visit, the nurse submits the appropriate documentation to the specialty pharmacy and physician and notifies them of any issues or concerns that require further follow-up.

	Many times, the length of the visit is estimated in relation to the type of therapy and dosage; however, no one can predict what the specialty therapy nurse will encounter in the home care setting. At every phase of the visit, the nurse may encounter an issue, concern, or barrier that will need to be addressed in order to move forward with the therapy. It is also important to realize that the nurse is solo in the home with only telecommunication for support. The specialty therapy nurse must use good judgment, have keen assessment skills, and be able to react under pressure. 

		Nurses remain most trusted professional in America, Gallup survey says. Advance Healthcare Network for Nurses website. http://nursing.advanceweb.com/news/National-News/Nurses-Remain-Most-Trusted-Professionals-in-America-Gallup-Survey-says.aspx. Published December 5, 2012. Accessed March 1, 2014.

Hands-on Care in the Home Setting

With proper instruction from specialty infusion therapy providers, self-administration in the home setting is a feasible option for many patients and can greatly improve quality of life.

	Self-administration is a viable and feasible option for patients with chronic diseases requiring administration of intravenous (IV) medications. According to Healthy People 2020, chronic diseases are the leading cause of death and disability in the United States, and in 2008 a reported 107 million Americans—almost 1 out of every 2 adults 18 years or older&mdash;has at least 1 of the 6 repor-ted chronic illnesses.

 Barriers to health care services impact a patient’s ability to receive needed intravenous medications required to treat their chronic disease state. Lack of access to physician offices, clinics, or infusion centers (alternate sites) can lead to unmet health needs, delays in receiving appropriate care, missed doses, and hospitalizations that could have been prevented.

	A problem identified for nursing is the fact that without self-administration, the barriers to health care access and incidences of re-hospitalizations cannot be minimized. More importantly, limited access to health care services further impacts overall physical, social, and mental health, which directly impact quality of life (QOL).

 Limited QOL activities can have a long-term effect on a person’s well-being. Since 1997, the National Health Interview Survey has collected data rela-ted to limitations on daily activities. In 2006, 5.5% of adults aged 18 to 44 years had a limitation of activity and 32.6% of non-institutionalized adults 65 years and older, had a limitation of activity.

	Research conducted so far has just begun to scratch the surface of self-administration at home versus alternate site infusions and the impact on quality of life. An important research and clinical direction involves improving QOL of persons with chronic or rare diseases. This can be accomplished by understanding the relationship between self-administration and improved QOL.

	A literature review (CINAL, PubMed, and EBSCO Host) was conducted and articles in peer-reviewed journals, which addressed QOL, self-administration, and rare and chronic disorders, were selected, reviewed, and summarized. There was a limited amount of information available on the subject, which emphasizes the need for research in this area. Previous studies have shown that patients who are adherent to protein-replacement therapies for other types of chronic diseases, such as factor VIII for hemophilia and intravenous immunoglobulin for patients with antibody deficiencies, have better outcomes.

	Focused efforts of specialized infusion nurses provide an opportunity to educate and train patients to better manage chronic disease, which may benefit overall health and QOL.

 Several articles have cited the positive outcomes of learning self-administration as it relates to QOL measures. In the article “Replacement IgG Therapy and Self-Therapy at Home Improve the Health-Related Quality of Life in Patients with Primary Antibody Deficiencies,” the authors reported that self-administration at home improves health-related quality of life and treatment satisfaction by empowering the patient and families—facilitating being able to work or study, improve family relations, increase flexibility and sense of self-control among the patients and families, and improve their daily life situation.

 Factors cited as being of importance for high health-related QOL and treatment satisfaction nestled around coping abilities or how patients manage their condition and treatment.

	Although this article examined health-related QOL outcomes of patients before and after treatment with IgG replacement therapy, findings also suggested that being able to self-administer at home instead of visiting the hospital increases treatment satisfaction of both adult patients and their families, resulting in increased flexibility, independence, and sense of control.

 Self-administration allows for greater flexibility, increased convenience, and increased QOL as well as decreasing cost associated with travel to an alternate site. Furthermore, it is associated with a low incidence of cannulation failure and may preserve veins more effectively than alternate site care.

	Administration of infusion therapy in the home setting is not a new concept, nor is teaching self-administration; however, the role of the specialty infusion nurse has expanded from not only teaching how to administer medication but how to obtain IV access. As the health care continuum continues to shift to include evaluation of patient-centric outcomes and utilization of health care dollars, research into the effectiveness of self-administration should be an area of focus for specialty infusion therapy providers. 

	1. General health status. Healthy people 2020 (fact sheet). Healthy people 2020 website. www.healthypeople.gov/2020/default.aspx. Published November 15, 2011.

	2. Access to health services. Healthy people 2020 (fact sheet). Healthy people 2020 website. www.healthypeople.gov/2020/default.aspx. Published October 30, 2012.

	3. Gregory C, Landmesser L, Corrigan L, Mariano D. Feasibility of home infusion and self-administration of nanofiltered CI esterase inhibitor for routine prophylaxis in patients with hereditary angioedema and characterization of a training and support program. 2013. Manuscript submitted for publication.

	4. Gardulf A, Nicolay U. Replacement IgG therapy and self-therapy at home improve the health-related quality of life in patients with primary antibody deficiencies. 

	5. Dagen C, Craig T. Treatment of hereditary angioedema: items that need to be addressed in practice parameter. 

. 2010;6(11):1-7. www.aacijournal.com/content/6/1/11.

Virginia Strootman, RN, MS, CRNI, has been a nurse for 26 years and an infusion nurse for the last 23 years. She is currently a patient liaison with NPS Pharmaceuticals, Bedminster, New Jersey, providing advocacy for patients with rare and chronic disorders.

Cherylann Gregory, RN, BSN, is founder and president of the Specialty Pharmacy Nursing Network (SPNN) and has more than 30 years of experience as an oncology/infusion nurse. Cherylann serves on the

Self-Administration of Intravenous Medications

How aware are specialty pharmacists regarding the legal and ethical implications related to the home care nurses they hire? Here are some professional issues facing nurses as they work in tandem with specialty pharmacists.

Nurses are required to abide by laws and regulations when practicing nursing. Not abiding by the code of ethics could cost the nurse his or her nursing license and result in a malpractice suite. The nurse has the responsibility to practice within his/her scope of care. How aware are specialty pharmacists regarding the legal and ethical implications related to the home care nurse they hire? This article touches on some important professional issues that nurses encounter while providing specialty therapies in the home.

At the time of the initial patient and home assessment, it is the nurse’s responsibility to assess and report to the physician and pharmacy the following: 1) the patient’s ability to receive the medication; 2) who will be administering the therapy; 3) is the home environment safe and appropriate for the care; 4) any specific interventions required to accomplish the expected outcomes; and 5) evaluation of the patient’s support system. Once the plan of care is established, the nurse provides instruction to the patient and caregiver(s) regarding the patient’s particular disease and treatment in order to help the patient achieve an agreed-upon plan of care.

It is important for the specialty pharmacy to coordinate care with a nurse who best understands the patient’s culture and background to meet the needs of the patient. Differences among nurses, including their level of education, years of work experience, type of work experience, and level of cultural competence (cross-cultural sensitivity) all influence care delivery to some extent.

The legal considerations connected with delivering care in a patient’s home are similar to those of care delivered in health care facilities, but have additional aspects. A common legal nursing consideration in specialty pharmacy is “first dosing.” Home care agencies are reluctant to administer first dosing in the home or blood products due to the legal liability. Specialty pharmacies may request first dosing and blood products in the home to expedite the delivery of services.

What is important to understand from the nursing perspective in the home setting is that the nurse may be the only person available to attend to the patient experiencing the anaphylactic reaction and must make emergency medical decisions. It is essential for the nurse to follow processes, protocols, and standards of practice to keep free of legal liability. Not all nurses are prepared for such an occurrence, which puts both the nurse and the agency at risk.

Another common legal consideration with regard to the nurse’s encounter, while administering therapies in the home, involves the knowledge or suspicion of abuse of a member of the family. This has little to do with the actual administration of the drug, but definitely falls under the legal liability of the nurse’s license to report to proper authorities.

Nurses often encounter ethical implications which are closely tied to legal implications in the home care setting. The patient is in his or her own residence and has the legal right to do as he or she chooses. The nurse may arrive to administer a therapy for a patient and find that the patient is consuming drugs or alcohol. The nurse must evaluate the liability if he/she provides the service versus the ethical implication if the nurse does not.

Complex ethical issues are not always addressed in policy statements. Ongoing communication between the nurse and the specialty pharmacy is essential to address problematic situations.

Nurses may experience safety issues in home care requiring immediate attention and vigilance. The nurse does not have security protection readily available if a family member becomes violent toward either the health care worker or the patient. Nurses are required to visit patients in high-crime areas or after dark. Specialty pharmacies need to be aware of the home environment the nurse is going to.

Nurses are held to a holistic responsibility of the patient, family, and home environment once they enter the home. Even though their assigned task is to administer a medication or perform a teaching on behalf of the specialty pharmacy, their nursing license calls upon their knowledge and skills to make decisions in the best interest of the patient while in their presence.

Cherylann Gregory, RN, BSN, is founder and president of the Specialty Pharmacy Nursing Network (SPNN) and has more than 30 years of experience as an oncology/ infusion nurse. SPNN provides a nationwide network of 500 qualified nurses for specialty pharmacies and biotech manufacturers. Services include coordination of care, drug administration, first dosing, education, clinical outcome data collection and reporting, and on-call coverage for specialty therapies. Visit www.spnninc .com for more information.

How aware are specialty pharmacists regarding the legal and ethical implications related to the home care nurses they hire? Here are some professional issues facing nurses as they work in tandem with specialty pharmacists. 

Providing Specialty Therapy in the Home

Specialty therapy nurses can present educational modules that encompass the disease state, symptoms, diagnosis, and treatment of orphan and ultra orphan disorders.

Orphan disorders are defined as a host of conditions that are serious and lifelong, affecting populations of fewer than 200,000 persons. Ultra orphan disorders affect an even smaller population of 20,000 or fewer persons. The majority of these disorders are genetic or have a genetic component. They are extremely rare, creating a lack of awareness by many primary care physicians, specialists, pharmacists, and nurses.

Heredity angioedema (HAE) is an example of a rare ultra orphan disorder with approximately 6000 patients diagnosed in the United States. Individuals diagnosed with HAE experience attacks of swelling of the face, larynx, abdomen, and extremities. These life-threatening attacks are very painful and unpredictable, varying in severity, frequency, duration, and location. Due to the rare nature of this disorder, primary care physicians and specialists may have never encountered it and the symptoms may be unknown to them, sometimes delaying diagnosis by multiple years.

Simply getting a diagnosis often becomes a quest. These patients are misdiagnosed with allergic reactions, appendicitis, or abdominal obstruction. If undiagnosed, a patient experiencing a laryngeal attack would end up intubated or trached until the swelling subsided. Patients with abdominal swelling often have unnecessary abdominal surgeries. The disorder incapacitates an individual for 20 to 100 days a year. Once diagnosed, HAE can be treated both prophylactically and acutely, thus preventing and/or decreasing the frequency of attacks.

Educational awareness plays a key role in expediting an accurate diagnosis, leading to the appropriate treatment for these orphan disorders. Educational awareness also plays a critical role in extending the awareness to the rural setting. Many patients are diagnosed at major medical health care centers and then return home to be followed by their primary care provider who may be unaware of the disease and treatments.

Biopharmaceutical manufacturers face multiple challenges in creating educational awareness for every primary care physician involved with even 1 or 2 patients. Providing the manufacturer with committed educational support is essential to the well-being and quality of life of people with these rare diseases.

Specialty therapy nurses possess an expertise in the orphan and ultra orphan disorders and they are extremely well positioned to provide this ongoing transition of support to the biopharmaceutical manufacturers. They work in several areas of practice, which include clinical research, specialty practices, specialty pharmacies, and home health care agencies. These nurses are mobile, with the ability to carry through educational awareness to the primary care physicians in both rural areas and local emergency departments.

Specialty therapy nurses can target specific physicians and present educational modules that encompass the disease state, symptoms, diagnosis, and treatments specific to the orphan and ultra orphan disorders. With the continuation of the orphan drug development, it’s imperative that the specialty therapy nurses maintain ongoing awareness of the biopharmaceutical market, products in clinical trials, and new products launched.

Specialty Pharmacy Nursing Network (SPNN) held the first specialty therapy nursing conference in Orlando, Florida, in September, which focused on specialty therapies. It was attended by specialty therapy nurses and specialty pharmacists from across the country. Those who attended received an overall CE program on several orphan and ultra orphan disorders with topics presented by experts in the disease-specific field.

The program was followed by hands-on clinical workshops, which provided drug reconstitution and administration training, along with skills validation. This is one of multiple avenues being created to provide the disease-specific education to the specialty therapy nurses. Biopharmaceutical manufacturers are also collaborating with specialty therapy nurses to provide a branded nursing service model.

Cherylann Gregory, RN, BSN, is founder and president of the Specialty Pharmacy Nursing Network (SPNN) and has more than 30 years of experience as an oncology/ infusion nurse. SPNN provides a nationwide network of 500 qualified nurses for specialty pharmacies and biotech manufacturers. Services include coordination of care, drug administration, first dosing, education, clinical outcome data collection and reporting, and on-call coverage for specialty therapies. Visit www.spnninc.com.

Advances in Specialty Therapy Nursing

To provide complete services to the specialty patient in the home care setting, specialty pharmacies and specialty nurses need to clearly define their individual responsibilities. 

Community-based retail pharmacies were actually the first to provide specialty therapies to patients in their community. Typically, these pharmacies focused on obtaining and delivering the specialty drugs, which took the pressure off patients, saved them money, and even improved outcomes. Today, due to the complex nature, high cost, and competitive business of specialty therapies, expectations have grown beyond the service of just providing the medications to patients.

Expectations now include services that provide prior authorization assistance, supplies, durable medical equipment (DME), lab draws, patient education, and drug administration. These expectations are not inexpensive and come at an additional cost to the specialty pharmacy (SP). The community-based pharmacies that venture into the specialty therapy drug space need to consider these questions: 1) How they will provide these additional services? 2) What additional personnel will they need to provide the services? and 3) Who will pay for these services?

The term “delegation of responsibilities” defines who provides what services between pharmacy and nursing in the home care setting. Often, the community-based SPs assume that nursing provides the infusion supplies and DME, when in reality they do not. In general, the SP is responsible for the drugs, supplies, DME, and lab supplies. Nursing is responsible for teaching, administering, and providing documentation of the therapy given. This creates additional costs of services to the SP.

Physicians evaluate what services the community-based SP will provide in order to meet the needs of its patients. They welcome any assistance the SP can offer them with prior authorization. Obtaining prior authorization can take months. It requires working one-on-one with the physician’s office to obtain all medical information required for the approval. Many times, especially with new therapies, it is initially denied and must go into appeals.

This involves both the SP and the physician. The physician relies on the SP to assist them through this process and to write the script for the drug. It is very time-consuming for both parties and will require additional resources from the SP. The more the SP assists, the more likely the physician will write the script to that SP. Many times, the SP will need to provide a reimbursement expert to assist with this service, again creating additional costs to the SP for services.

Coverage of supplies and DME may involve reviewing and updating the community-based SP payer contracts to include a per diem rate to cover supplies and a DME addendum. The community-based SP may need to enter into an agreement with a medical supply vendor to provide infusion supplies and the DME not normally required with oral or injectable medications. The community-based SP also will need to evaluate if they will buy, lease, or rent equipment for infusions that require pumps or special monitoring devices. This equipment requires special care and maintenance. Renting is usually the preferred method, and the communitybased SP can pass through the cost to the payer if they have the DME as part of their contract.

Labs are also a requirement of many of the therapies. The community-based SP is responsible for providing these supplies at the home for the nurse, and they will need to enter into a contract with a vendor that provides blood-drawing equipment. These “lab in a box” kits, usually sent out by the SP with the drug and supplies, are an additional cost to the SP. This includes not only the cost of the kit, but the shipping of the labs from the patient home to the lab.

Nursing is one of the most costly and time-consuming services for the community-based SP. It is not uncommon for the nursing services to be covered by the SP. Pharmacies spend numerous hours searching for a home care agency to service their patients and bill the payer. The patient’s benefits do not always cover nursing. Often the SP needs to contract directly with infusion nurses or agencies that provide infusion nurses. The nursing services are usually covered out of the margins of the drug.

Community-based pharmacies engaging in SP therapies need to take into account the expectation of services and the delegation of responsibilities in today’s marketplace. If they can prepare for these additional costs of services while meeting the needs of their community, it will give them an edge in the referral process from a local community perspective.