Ford Research Group
Community pharmacists offering injectable naltrexone services reported five pre-injection best practices: (1) patient scheduling before the appointment, (2) benefits coordination, (3) extended patient consultation, (4) conducting the urine drug test, and (5) behavioral health consultations. Descriptions and best practices associated with all pre-injection activities are provided.
A critical change to the workflow related to the activities associated with scheduling the injectable naltrexone appointment, calling to remind patients of their appointments, establishing procedures for walk-in clients, and developing, as necessary, a transportation plan. Approximately 90% of the pharmacies, that completed the cost calculator, currently offer an injectable naltrexone service to both new and returning patients. This task is typically completed by the pharmacy technician. A description of these scheduling best practices is below.
Scheduling of patients is a critical component of establishing the injectable naltrexone service in the pharmacy. The process includes who will be responsible for scheduling the patients and determining how far in advance appointments will be accepted.
If only one pharmacist is trained to provide injectable naltrexone, it is important to ensure that pharmacy staffing is sufficient during scheduled appointments to minimize workflow disruptions and ensure that other customers can be served. Scheduling advanced appointments is necessary if naltrexone is not routinely stocked, but also allows the pharmacy to verify that the injectable naltrexone is in stock and, if not, order it before the patient arrives for their appointment. By scheduling appointments, the community pharmacist can contact the prescriber to determine if treatment changes have occurred (e.g., naltrexone is no longer warranted). Reminder calls can also reduce disruptions to the pharmacist workflow, prevent medication ordering, and potentially reduce unnecessary costs.
Walk-in clients are a frequent occurrence, but such patients can create a workflow disruption if they arrive unscheduled and there are insufficient pharmacy staff resources to cover duties so that the pharmacist can attend to the patient in a timely manner. Again, establishing pharmacy procedures (including scheduling) for walk-in patient can effectively mitigate potential disruptions.
It is important to determine if transportation to the pharmacy represents an issue for clients who would come to the pharmacy for injectable naltrexone. If so, there is a need for pharmacy staff to work with patients on solutions so there is no interference with treatment success. As a result, a best practice for pharmacies would be to develop a transportation plan. Such a plan may involve offering vouchers for public transportation or ride share services, providing information to clients about available transportation options, or having a protocol in place to confirm patient appointments for local transportation services (e.g., medical transport).
Benefits coordination occurs more frequently for new patients (compared to returning patients) in pharmacies that offer injectable naltrexone services. These activities typically focus on determining the clients’ insurance status and/or co-pays associated with injectable naltrexone and then discussing costs with the client. If necessary, pharmacy staff may help the client obtain discount cards to cover medication costs. In pharmacies offering an injectable naltrexone service, the pharmacy technician typically completed the activities associated with benefits coordination.
Pharmacist training provides them with the skills to consult with patients about their medications, including about medication interactions and side effects. In pharmacies that provide injectable naltrexone services, extended patient consultation focuses on activities to help the patient understand the benefits and risks associated with naltrexone, provides information about available resources, obtains informed consent, and offers educational resources. Such pharmacist-led consultations always occur with new patients but are not as frequent with returning patients.
Urine drug testing is completed in 75% of the pharmacies offering injectable naltrexone services. Typically, the pharmacist coordinates these services but, in some pharmacies, it is a shared responsibility with the pharmacy technician. Pharmacies that provide urine drug testing will have lab agreements in place. Administering a urine drug test involves the costs of obtaining the supplies (urine cup/panel), drug test interpretation, and lab monitoring and/or management. Specific activities include, but are not limited to, having the patient sign permissions for the urine drug test, providing the patient with the testing kit and showing them the restroom, waiting for results, and sending the urine sample to the outside lab to confirm results.
Behavioral health consultations do not always occur within a pharmacy offering an injectable naltrexone service, with about 60% of community pharmacies providing such consultations. Pharmacies that do not offer behavioral health consultations typically do not have a private consultation room or a collaborative practice agreement with a behavioral health specialist.
In pharmacies that provide this service, the client is taken to the private consultation room and shown how to use the video technology (often a tablet device) to connect with the behavioral health specialist. The pharmacist or pharmacist technician will initiate the video conference with the behavioral health specialist and then leave the room. Once the meeting between the client and the behavioral health specialist is complete, and if the patient agrees to get a naltrexone injection, the client will leave the room to get the pharmacist. The pharmacist will enter the room and confirm the order with the behavioral health professional and will then leave the room to prepare the injection.