Long-Acting Injectable Medications: Serious Mental Illness

Troy Trygstad, PharmD, MBA, PhD, and Adrienne Cervone, PharmD, share insight into the benefits of an alternative site of care for treating patients with serious mental illness with long-acting injectable medications. Adrienne Cervone, PharmD, details step-by-step how pharmacists can start an alternative site of care for administering these medications.

Troy Trygstad, PharmD, MBA, PhD: So, Adrienne, I’ve been told, by a little birdie, that you have an interesting practice model that’s growing across the country, as an alternative site of care. Do you want to tell us what an alternative site of care is in your world, and what that looks like?

Adrienne Cervone, PharmD: Yes. I truly believe that it takes pharmacy and it kicks it up a notch. Because we’ve all wanted to just take the medicine and put it in our patient’s mouth and say, “Just take this, you will feel better if you take this medicine,” right? But, what we do is normally, we would get the medicine covered. We would fight an insurance or maybe have a paid claim on the first try and celebrate. But normally we would counsel the patient and send them on their merry way and hope that they’re going to actually take the medicine.

But what we do now is we get the medicine covered, and then we call to schedule an appointment and have them come in for the shot. We give them a reminder call, they come into our pharmacy and we have a private room in the back of the store and we actually administer the medicine. But it doesn’t stop there because now we communicate it back to the prescribing physician, and it’s a fax-back program and that’s what all of our doctors really prefer. We’re very flexible so if they wanted to call, we would absolutely call. But we fax the screen sheet that we’ve created for each of the long-acting injectables to that physician’s office. So, now they have proof that their patient has their medicine.

Troy Trygstad, PharmD, MBA, PhD: I’m going to stop you there because one of the objectives I think is really important is to walk the average pharmacy through what this looks like, because as you told me before we started, this is not nearly as intimidating as some might seem it to be. So, when you say fax back and screening, what does that mean?

Adrienne Cervone, PharmD: So, whenever a patient is prescribed a medicine, we make sure that there’s no contraindications. We make sure that the medicine is safe for them. So, all of those questions that you would normally counsel about and really just go over with a patient, we put it in writing. And we ask the patient very simple questions, like what other medications are you on? Just in case they don’t get everything filled at your pharmacy. What supplements are you taking? Have you ever had a concern with diabetes? These questions that are very specific to these types of medications. That’s our screen sheets.

Troy Trygstad, PharmD, MBA, PhD: So, then the fax back is?

Adrienne Cervone, PharmD: It’s that screen sheet, once we’ve actually given the shot. So, we document where on the patient we’ve given the shot, the date, the lot number, and expiration of the actual shot. And we date it and we send it to the doctor’s office so that for their next appointment, the doctor has it in their hand that the patient received the medicine. So, not only do we follow up with the patient and ask about adverse effects, but now the doctor has a real record of the patient taking their medicine. Because they can write the prescription and the patient can maybe get it filled, but we don’t know that they’re actually taking it. But now, there’s a record.

Troy Trygstad, PharmD, MBA, PhD: That sounds like a real double win for the prescriber. Not only then am I actually getting a screen pharmacy—it sounds like an enhanced service—but then you’re getting information back into the practice. So, I’m not only writing the prescription, I’m getting a screening on it, and information back to me in the physician’s office. Is this something that you just came up with or is this a state regulation?

Adrienne Cervone, PharmD: We have been immunizing patients for 11 years now. And the best way for us to communicate with the prescribing physician, if they ask for a specific vaccine, was to prove to them that we gave it. And so, when these long-acting injectables came out, I instantly got in touch with our local mental health providers and asked if this was something that they were going to write for. Because, of course, I looked it up and saw that Pennsylvania had no limitations on this, so we were able to inject them. And I said, “If you’re game, I’m game,” and so we started. And it is intimidating because they’re gluteal shots.

Troy Trygstad, PharmD, MBA, PhD: So, the administration was intimidating at first.

Adrienne Cervone, PharmD: Very.

Troy Trygstad, PharmD, MBA, PhD: So, let’s walk through from the beginning. You say, “I want to do this, I’m allowed to do this,” what are the first 3 steps?

Adrienne Cervone, PharmD: See if the local doctors are going to prescribe it. That would be number 1.

Troy Trygstad, PharmD, MBA, PhD: Or local doctors are aware of therapy and so on and so forth.

Adrienne Cervone, PharmD: Absolutely. Let them know that if they want to prescribe it, we will provide the means for it. Because that was so important. We found out that there was a physician who wanted to write for it, but it was just overwhelming to manage it in the office. We said, let us manage it. We already have got a good program going.

Troy Trygstad, PharmD, MBA, PhD: Yes, we hear the same thing about medical-assisted treatment, right? So, the reason it’s so difficult in rural areas is the same reason there’s a lot of pharmacies that aren’t yet long-acting injectable sites. It’s sort of fear of the unknown, right? And so, you say, “I’m going to put together description of service. I’m going to go to the providers, or the prescribers.” And then what? You order the medicine?

Adrienne Cervone, PharmD: We make sure that it’s covered. We get it covered. We help them along with the prior authorizations. And I know that seems like a simple service but it helps because now we’re providing the doctor with the form. We get the diagnosis, we help them fill it out, and then they can fax them in on their own. So, we actually help.

Troy Trygstad, PharmD, MBA, PhD: Wow, so you’re enabling their preauthorization process.

Adrienne Cervone, PharmD: We are, we are. And that’s the biggest part of the battle right there: getting the medication covered. Then we have to really make sure that the patient is comfortable with this type of administration. Because it’s new, and it’s still new. There are still some patients who have no idea that there are options for this.

Troy Trygstad, PharmD, MBA, PhD: So, again, paint the picture. You’re here to do the service, you’ve ordered it, you did some training or not associated with the injection, or…?

Adrienne Cervone, PharmD: Well, this is where it gets fun.

Troy Trygstad, PharmD, MBA, PhD: OK, let’s do the fun part.

Adrienne Cervone, PharmD: So, who knows just how to give a gluteal shot? Because it’s not taught whenever pharmacists are taking their training for immunizations.

Troy Trygstad, PharmD, MBA, PhD: I haven’t run across those subjects yet.

Adrienne Cervone, PharmD: Right. We learned how to give a shot in deltoid or subQ, right? Now, there’s this new class of medicine and they’re gluteal shots. So, we turned to YouTube. We turned to YouTube and the best videos are from the Army, whenever they gave gluteal shots in the 80s. And so, we just got comfortable with that by watching these videos, and that’s how we taught ourselves how to do this.

Troy Trygstad, PharmD, MBA, PhD: So, you gained 1 person or the whole staff is comfortable with this process? You found a location, a room then, for it as well. You administer onsite. You go offsite to administer at all?

Adrienne Cervone, PharmD: There’s no need yet for us to do that because they are all much more local to us. The physician is right in town so they come right in for their appointment and usually come to see us later afterwards or before their appointment. But at this point, we are on site for these types of injections. They come to us.

Troy Trygstad, PharmD, MBA, PhD: So, I put together the service. I have a conversation with prescribers in the community. I have a room. I learn how to administer gluteal shots. Tell us about your first one.

Adrienne Cervone, PharmD: I think I was shaking like a leaf because it’s this unknown. Because you draw, you’re ready, everything is ready. The patient is comfortable and the medicine’s there and you draw it up and all of a sudden, there’s 2 mL of liquid and we’re used to, at most, giving 1 mL shots. So, now you’ve doubled the amount of liquid that you have to inject into this person who has no idea. I don’t know if they’re going to feel it. I don’t know if it’s going to burn because it’s the very first shot, and there’s no real-life information anywhere. This was years ago, by the way. But I gave the shot and the patient did not feel the shot. The patient did not feel the shot. They didn’t flinch. And he put me at so much ease—because he didn’t feel the shot—that any time that I start a patient off with that, I tell that story. I say, “You’re not going to feel this. I’m going to give it to you, you’re going to have a band-aid on, and you’re going to be done.” And nobody feels it any more, they really don’t.

Troy Trygstad, PharmD, MBA, PhD: My sense is you’re getting some professional gratification out of this service, that you feel like you’re helping folks that have challenges. Tell me what it has been like now that you’ve been doing it for a while as part of your practice. What do you get out of it from professional fulfillment or can you give us an anecdote about a patient you’ve had where you think the service was really important or made a difference?

Adrienne Cervone, PharmD: We watched these patients change. And when I say we’re a small pharmacy, there’s only 3 or 4 of us on staff at the most on the busiest days. And so, we know all of these patients. We know them by name, we know their dog’s name. And when they start on this medicine, they’re usually put on this medicine because they’re not taking their oral meds very well. And they’re quiet and they’re kind of backwards, and we watch them come out of their shell. And we’re at the point now, where they’ve been on it a couple of years, jovial. You would never know that these patients are on this type of medicine. You would not know. And we watched that change. So, yes, it is very gratifying, and not just to me but for my staff as well, from bringing them out front to asking how their holiday was; they’re very interactive. And we’ve even watched other medications being dropped because they’re actually taking this medicine. So, we lessen other medications with that, which is amazing to see.