Best Practices for an Alternative Site of Care


Troy Trygstad, PharmD, MBA, PhD; Adrienne Cervone, PharmD; and Tripp Logan, PharmD, detail how to manage claims, inventory, and upfront hurdles in setting up an alternative site of care to administer long-acting injectable medications.

Troy Trygstad, PharmD, MBA, PhD: Any issues after you get a successful claim adjudication as far as paperwork or anything like that? So, you’ve got the paperwork back as a best practice—maybe not as regulation but a best practice—to the prescriber. You successfully adjudicated a claim with the insurance company. Any other paperwork that needs to be worried about? In Pennsylvania?

Adrienne Cervone, PharmD: Right, right. If there were any adverse effects, we would absolutely file those. We would file them with the manufacturer as well, as we would just report it as any adverse effect, but that’s the extent of the paperwork.

Troy Trygstad, PharmD, MBA, PhD: Now, these medications aren’t necessarily cheap and if you’re a small pharmacy, inventory is always difficult, so there’s carry cost. How are you addressing that? Do you sort of do just-in-time inventory? If you’re 100%, I guess you can predict your inventory pretty well and when to order it. Is that the idea? Specialty, in general, in a small-town pharmacy can be very difficult to get into that space for lots of reasons but if for no other reason than just the expense of carrying those medications and inventory, are there any concerns? So, what are your thoughts there as a thriving pharmacy in a small town?

Adrienne Cervone, PharmD: It is very scheduled so we only order on demand. So, we only order whenever the patient is due for their shot. We do have to coordinate with specialty pharmacies in the instance that we don’t have the contract and it’s a specialty fill only. But we will have the patient sign whatever HIPAA document is necessary so that we can act on their behalf and contact the special pharmacies and have it delivered to us. Because if you think about this, we had a little bit of resistance from some of the specialty pharmacies saying that they didn’t want to deliver to us. And I just kept going higher up, higher up, higher up until I got somebody on the phone that I could say, “From pharmacist-to-pharmacist, are you telling me that you want to hand a box of medication with 3 needles to somebody with schizophrenia?” And then it hit home.

Troy Trygstad, PharmD, MBA, PhD: Three low-gauge needles.

Adrienne Cervone, PharmD: Yes.

Troy Trygstad, PharmD, MBA, PhD: Right, sure. Well, that’s resonating. So, Tripp, you’re contemplating getting into this space.

Tripp Logan, PharmD: It’s an intriguing space and it’s where we should be.

Troy Trygstad, PharmD, MBA, PhD: So, what scares you?

Tripp Logan, PharmD: The first thing is we’re unsure about the state’s requirements, and so that’s something that with some research and legal assistance, you figure that out. The next is, somebody has already given those. And so, who am I taking those away from? That’s what we’ll internally have to figure out.

Troy Trygstad, PharmD, MBA, PhD: Or somebody’s not giving them.

Tripp Logan, PharmD: And that’s true.

Adrienne Cervone, PharmD: I was definitely going to say that. We were worried about that, too.

Troy Trygstad, PharmD, MBA, PhD: They’re sitting in a cupboard somewhere perhaps, right?

Tripp Logan, PharmD: Sure.

Adrienne Cervone, PharmD: Right, and they’re not being administered. And I think that more people would be on them if there was a known outlet to administer the medication. I truly believe that because that’s what happened in our little town.

Troy Trygstad, PharmD, MBA, PhD: So, what else scares you?

Tripp Logan, PharmD: Well, cost is definitely an issue. You know from a small-pharmacy owner’s standpoint, there are so many factors in the purchasing of expensive medicine, from inventory cost to reimbursement time from the third party to what it does for your wholesaler buy plan. And so, there are a lot of factors there that would need to be worked through. Because if not, it could actually end up costing you money in order to do that. So, from the financial standpoint, it’s something that’s scary.

Troy Trygstad, PharmD, MBA, PhD: What about the physician and other types of prescribers in your community, do you feel like you have to go out and educate them?

Tripp Logan, PharmD: I don’t. That part, to me, is not as scary because they’re…

Troy Trygstad, PharmD, MBA, PhD: Not the scary part.

Tripp Logan, PharmD: Right. Where we’ve spent a lot of time educating in, outside of both of our pharmacy practices, all pharmacies aren’t the same; we’re different. We already get the most complicated people in 2 counties. So, I don’t think that part would be as hard. It’s actually the mechanics, the inner workings of it—the purchasing, the legal, the education of our staff, the training of the actual injection—like how are we going to do that? Just the mechanics of it.

Troy Trygstad, PharmD, MBA, PhD: Those are achievable.

Tripp Logan, PharmD: Absolutely, oh yes.

Troy Trygstad, PharmD, MBA, PhD: So, if we brought you back 6 months from now, you’d be successfully doing that.

Tripp Logan, PharmD: Sure, yes.

Troy Trygstad, PharmD, MBA, PhD: We’re going to hold you to that.

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