An Inside Look at the Opportunity of Long-Acting Antipsychotic Medications

While pharmacists continue to wait for provider status, states continue to expand their scope of practice one service at a time. In most cases, an expansion of scope means an expansion of profit, and by now most pharmacies have taken advantage by offering nontraditional services like immunizations and point-ofcare testing. But pharmacies are still catching up on one overlooked opportunity to expand their scope and profit. Recently, states across the country have authorized the administration of long-acting injectables (LAIs), which mostly comprise antipsychotics such as Invega, Abilify, Aristada, and Risperdal.

For patients, the ability to get these injections at the pharmacy can be life changing. Pharmacies are easily accessible and help increase adherence, which is essential for patients on antipsychotic meds.

″I feel it’s important for pharmacists to be involved with mental healthcare services,″ said Leighton N. Mascari, pharmacist at Bremo Pharmacy, which has served the Richmond, Virginia community since 1976. ″We’ve been able to offer different services to patients just by having them come through our doors and connecting them to care.″

Bremo Pharmacy has offered LAIs for more than 20 years, when Virginia first gave pharmacists authority to administer the drugs. The majority have been given at their long-term care location, where there has always been a clear need. But during the pandemic the retail location saw a large influx of LAI patients when psychiatric offices stopped allowing patients to come in for administration. The pharmacy now administers up to 25 LAIs a month on average.

Hashim Zaibak, owner of Hayat Pharmacy, has provided LAIs for about three years and is already administering up to 30 injections every month. After discovering that several of his patients were looking for a place to get their injections, he started carrying them. ″They used to pick up their injection from Walgreens and CVS, and they didn’t know what to do with it. And they go to the doctors, and the doctors are busy,″ he said. ″So patients approached us and we thought this would be a good opportunity.″

As with many other services, reimbursement varies across health plans, whether it’s Medicare, Medicaid, or private insurers. But in all, Zaibak said that the reimbursement for these drugs is better than traditional prescription medications.

Just as important, offering LAIs helps increase your total script count, sometimes by a large margin. ″That patient doesn’t just give us their injectable prescription,″ Zaibak said. ″When they transfer it to us, they transfer their whole profile.″

In addition, you can earn an administration fee for each injection, paid for by a manufacturer or by the patient. Bremo and Hayat both have patients who pay the fee out of pocket if they aren’t able to get patient assistance from the manufacturer. Bremo Pharmacy is exploring alternative ways to get paid for the service. It recently established a collaborative practice agreement with a provider so the pharmacists can bill for their time. So far, this seems to be the best approach not only because it provides payment for the administration, but also because it has opened the door for further services, like measuring blood pressure, weight, and waist circumference. ″That’s really important for the administration of LAIs because they can create a lot of metabolic effects,″ Mascari said. ″And the providers have been very excited that we do that.″ They also perform Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for extrapyramidal side effects and involuntary movements that can occur with the long-term use of LAIs.

Keys to success

Electronic care plans have been instrumental in Bremo’s LAI offering. ″E-care plans are very helpful for documentation and follow up with providers,″ Mascari said. If a patient has an adverse side effect or has questions the pharmacy can’t answer, they can document it in the plan for the provider. The e-care plan also keeps track of appointments, so pharmacists are prepared and make sure patients don’t miss their injection. ″In this population, adherence is not always easy,″ she said. ″So keeping up with patients and knowing when they’re due for their medications is very important.″

The pharmacy also leans on other technology, like their HIPAA-compliant scheduling system that automatically texts reminders to patients.

Medication synchronization significantly helps protect cash flow even when carrying LAIs, which can be expensive. Although Bremo keeps some LAIs in stock based on prescribing patterns, it primarily orders when the patient is due to pick up their medications for the month, making it easy to align inventory with demand.

It’s the same at Hayat Pharmacy. The scheduled maintenance combined with synchronization minimizes the holding costs even for the most expensive of these drugs. ″After a while you get to know some of the fast movers and you can keep some of those on the shelf, but also at the same time those medications are administered every four weeks, every six weeks, every eight weeks so they’re not really an emergency,″ he said. ″You don’t really have to keep a large quantity in stock.″

Mascari said educating employees is paramount, especially for these types of medications. ″Working in mental healthcare, you have to know that you’re serving a different variety of patients.″ Staff should have a good understanding of the antipsychotic medications, such as their varying intervals, and they should know what to do if they can’t answer a question or if a patient misses their appointment.

Unless you get buy-in from the staff, it’s going to be a difficult road. ″That’s not just true with this project but with any project you do,″ Zaibak said. ″If you get employees who really care, you can make this a very successful project.″

Part of Hayat’s success hinges on the reputation it has built in the community over time. Manufacturers, patients, and providers have come to regard the pharmacy highly, which means they readily recommend Hayat for the healthcare services that matter. Part of that reputation has come from the lengths they go for their patients, like driving to patients’ homes to administer the injections. ″People know that we care, that we’re willing to go the extra mile, literally,″ Zaibak said. ″It’s a win-win relationship. We help them and they help us.″

Bremo Pharmacy also has great relationships with prescribers because of how thoroughly they take care of their patients and how consistently they improve outcomes. ″We’ve had some patients that are historically not adherent to the medications become more adherent through their relationship with us,″ Mascari said. ″I take extra time to check on how they’re doing personally.″

Requirements

To administer the injectables, you’ll need a separate room. ″You do need the private area because sometimes it goes into the gluteal part of the body,″ Zaibak said.

Although all the drugs are intramuscular, there may be subtle differences in the preparation and administration, such has how long or how strongly to shake it. Mastering the different requirements simply takes a few minutes online. ″The manufacturer websites are phenomenal,″ Zaibak said. ″You watch a video and usually within a minute you’ll know how to do it.″

Every pharmacy should check with their state board of pharmacy to see if they have authority to administer LAIs. At least 11 states do not, and 4 require a collaborative practice agreement.

More to know

In the time Zaibak has been offering LAIs, he’s often encountered a fear of working with patients who are on antipsychotic medications, with a particular concern for safety. ″The fear is invalid,″ Zaibak said. ″The safety concern is exactly the same with patients who need these medications versus patients who don’t need these medications.″

Mascari said she wished she knew that LAIs were such a need in her community retail locations before the pandemic revealed it. ″We wish we had started this service a long time ago,″ she said. ″We feel that it would have benefited even more patients over the years.″

But even in the brief time she’s offered LAIs at Bremo Pharmacy’s retail locations, it’s been more than worth it. ″It’s been a very rewarding service for us as pharmacists and for the patients, being able to help them.″

---