M&D Clinical Corner: Community Pharmacist’s Guide to Pharmacy-administered Injectables.

The Clinical Corner is a monthly feature that highlights a variety of important pharmacist topics that is written by Morris & Dickson’s staff pharmacist, Paula Belle (RPh).

This month’s Clinical Corner will provide an overview of Pharmacy-Administered Injectable Medications including:

• The pharmacist’s role
• Training
• Workflow considerations
• Billing and reimbursement
• Common pharmacy-administered injectables
• Resources for pharmacists

 
The Pharmacist’s Role

• The success of pharmacy-administered vaccinations has the potential to translate to the administration of other medications. ^[1]
• There is a need for increased patient access to medication administration services (MAS) for many medications that require administration by a healthcare professional. ^[1]
• There are also many self-administered medications that patients and caregivers are expected to administer at home that may present challenges that can be alleviated by a highly accessible healthcare provider that  provides MAS. ^[1]
• This is especially true for long-acting injectable (LAI) antipsychotic agents. ^[1]
• LAI can be life changing for patients who have trouble adhering to complex administration schedules for oral versions of antipsychotics. ^[1]
• About half of schizophrenia patients do not take their medications as prescribed. ^[1]
• This leads to clinical relapses the cause stress for the patients and hospitalizations that increase costs for the healthcare system. ^[1]
• Despite many patients preferring LAI over oral products, uptake in the U.S. is limited. ^[1]
• Pharmacists are uniquely positioned to address some of the challenges to clinic and office based MAS that currently exist by ^[1]:
  • Offering more extensive hours of operation.
  • Offering locations near patient’s homes.
  • Being equipped to handle and maintain a large medication inventory.
  • Offering a high level of medication expertise.
  • Offering a  delivery method that is the same as a patient’s flu shot and offers a reduction in the stigma that may arise when a patient has to visit a certain type of clinic.

Training

• To achieve and maintain competence for MAS, pharmacists should be trained and knowledgeable in  ^[2]:
  • Disease pathophysiology.
  • Medications utilized.
  • Patient management.
  • Proper administration techniques for medications offered.
  • Responses for emergency events.
  • Patient concerns.
• Pharmacists should maintain competence to provide MAS via professional development. ^[2]
• The legally required training for a pharmacist to administer medications varies by state. ^[1]
• Some states specify the exact training required while other states leave it to the professional responsibility of the pharmacist to act in the best interest of their patients and administer only medications for which the pharmacist is appropriately trained.^[1]
• The National Alliance of State Pharmacy Associations (NASPA) recommends that training for pharmacists desiring to administer medications be obtained from an ACPE accredited program and contain the following elements ^[1] :
  • Administrative technique (may be obtained via a separate program)
  • Dosing and storage requirements
  • Patient Education
  • Patient engagement regarding the condition and symptoms being treated
  • Reduction of stigma
  • Patient support networks
  • Side effect management
  • Relevant comorbid conditions
  • Appropriate policies and procedures
  • Documentation procedures
  • Communication procedures
  • Referral procedures
• Similar to initial training, the requirements for continuing education for pharmacist medication administrators can vary by state. ^[1]
• Pharmacist should consult their individual state regulations for training  guidance when considering MAS programs.

Workflow Considerations

Staff Workflow Considerations

• Success of a pharmacy-based MAS program is ensured by all pharmacy team members involvement and execution of assigned roles. ^[2]
• Pharmacy staff members support the pharmacist and can manage many aspects of the MAS program. ^[2]
• APhA conducted a survey that indicated that 56% of MAS programs involved technicians in administrative roles such as ^[2]:
  • Appointment scheduling.
  • Patient intake.
  • Care coordination.
  • Billing.
  • Management of patient assistance programs.
  • Providing patient reminders.
• Student pharmacists and residents can assist by developing educational materials for patients, physicians, health clinics and public health departments. ^[2]

Logistical Workflow Considerations

• Pharmacists should consider whether walk-in patients can be accommodated or if MAS by appointment only will be more efficient and practical for their particular practice.^[2]
• Since the set-up and delivery of MAS can vary, depending on the patients served and the medications administered, technicians should be tasked with managing the paperwork and processes to facilitate efficient workflow. [2] To achieve this, technicians should ^[2]:
  • Allow sufficient time to prepare medications.
  • Assist with assuring that patient education is appropriately delivered.
  • Assist with monitoring patients for any adverse reactions.
  • Facilitate required documentation, communication, and follow-through.
• Privacy may be very important as some medications administered may require gluteal injections. ^[2] 

 
Billing and Reimbursement

• Pharmacy payment for MAS services can derive from several payer types. ^[2]
• In an APhA survey from 2017, of 31 pharmacies providing MAS services, 74% were being reimbursed. ^[2]
• For the majority of MAS pharmacy programs payment came from patient self-pay or enrollment with specific pharmaceutical manufacturers. ^[2]

Sources of Reimbursement for Medication Administration Services

• The number of payers is expected to increase as the number of pharmacists providing MAS increases. ^[2]
• Some medications are paid only through the medical benefit. ^[2]
• Payment from health plans  continues to develop. ^[2]
• Pharmacist inclusion in payer networks can be challenging to navigate due to varied processes, forms, guidelines for participation and rules for processing claims. ^[2]
• Pharmacists should be proactive with payers to determine ^[2]:
  • If and how pharmacy claims are recognized.
  • Clarification of billing processes that are required by the payer.
  • The billing codes that the payer will recognize.
  • Any other requirements such as prior authorizations and submission instructions.

Common Pharmacy-Administered Injectables

• In numerous states, pharmacists can currently administer a variety of medications, including ^[3]:
  • Antipsychotics
  • Anticoagulants.
  • Immunological agents.
  • Erythropoietic/hematopoietic agents.
  • Androgen.
  • Calcium regulators.
  • Vitamin B12.
  • Naltrexone.
  • Antineoplastic agents.
• APhA provides a list of example medications that are appropriate for administration by pharmacists at this link: https://aphanet.pharmacist.com/sites/default/files/files/MASmedicationsforadministration.pdf

Resources for Pharmacists

• A continuing education program with 3 modules that provide an overview of the delivery of MAS in a community pharmacy as well as injection administration techniques is available at: https://ebusiness.pharmacist.com/PersonifyEbusiness/Shop-APhA/Product-Details/productId/355997982
• Information on state-specific laws and regulations (updated 2021)  that pertain to pharmacy-based medication administration can be found at: https://naspa.us/wp-content/uploads/2022/02/NASPA-med-admin-maps-Dec-2021.pdf
• APhA offers “Practice Guidance for Pharmacy-Based Medication Administration Services “ at: https://aphanet.pharmacist.com/sites/default/files/files/MASPracticeGuidance(1).pdf
• An example of a MAS patient intake form is available at: https://aphanet.pharmacist.com/sites/default/files/files/MASpatientintakeform.pdf
• An example pharmacist referral to physician form is located at:https://aphanet.pharmacist.com/sites/default/files/files/MASpatientreferralform.pdf
• An example MAS patient information sheet can be found here: https://aphanet.pharmacist.com/sites/default/files/files/MASservicesheet.pdf
• For those states that require a physician protocol, APhA has an example at: https://aphanet.pharmacist.com/sites/default/files/files/MASprotocol.pdf
• An example of an informed consent form is located at: https://aphanet.pharmacist.com/sites/default/files/files/MASinformedconsent.pdf
• Find an example patient appointment card at: https://aphanet.pharmacist.com/sites/default/files/files/MASappointmentcard.pdf
• Follow-up letter from pharmacist to prescriber example is located at: https://aphanet.pharmacist.com/sites/default/files/files/MASprescriberfollowup.pdf

Sources

1. National Alliance of State Pharmacy Associations and College of Psychiatric and Neurologic Pharmacists. State Policy Recommendations for Pharmacist Administration of Medications. 2017 [cited 2023 March]; Available from: https://naspa.us/wp-content/uploads/2017/04/Medication-Administration-Meeting-Report-FINAL.pdf.
2. American Pharmacists Association. Practice Guidance for Pharmacy- Based Medication Administration Services. 2017 [cited 2023 March]; Available from: https://aphanet.pharmacist.com/sites/default/files/files/MASPracticeGuidance(1).pdf
3. American Pharmacists Association and National Alliance of State Pharmacy Associations. Practice Insights: Pharmacy-Based Medication Administration Services Summit. 2022 [cited 2023; Available from: https://indianapharmacy.org/files/Practice%20Insights_APhA%20and%20NASPA_Medication%20Administration%20Services%20Summit%20(1).pdf.