LAI in solo/small private practice

[spaceydaisy]

Logistically, how does that work? Do you prescribe and have a pharmacy administer the injection or do you stock the medication in your office? Or do you just avoid/refer out to larger practices?

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[Merely]

Avoid

 

[Laradd]

Care to elaborate?

 

[Ironspy]

Care to elaborate?

Patients needing a LAI are often too sick to be seen in solo practice as they require additional services (case management, Sw etc) and often have Medicaid which is difficult to navigate without a billing specialist

 

[whopper]

You can on occasion get someone on LAI that is stable enough for a private practice but this is rare. If you want to do injections you need to likely (it depends on the state) get all the bureaucratic stuff out of the way such as registering with the appropriate authorities to get a sharps container, pay someone for their disposal, and then establish who is doing the injection, you or someone else.

Storage of the med is also an issue. You're going to have to familiarize yourself with all the local laws on storing meds and the specific LAI instructions such as putting it in a refrigerator or not.

The issue with doing the injection yourself is several see a psych patient exposing their buttocks to you as a boundary violation and would recommend someone like a nurse do it. The problem there is you likely have so few patients needing a LAI it's not cost-effective for you to have a nurse to do it.

 

[Armadillos]

My understanding is some retail pharmacies will administer a LAI if you order it.

 

[whopper]

In addition to LAI you occasionally get someone who needs a depot Naltrexone injection.
You are correct. Many pharmacies will do it but from my experience these are the exception, not the majority. Out of all of the ones in the area I only of know of 3 that do injections.

Thankfully one of them is one in my buildling.

 

[Sushirolls]

I'm solo and attempting to offer this. I had a discussion with a pharmacy who asked their higher ups if okay, and they said they would be willing to administer them at one location only.
To date, I've yet to get connect with any vivitrol starts or continuation.
I am willing to take on early psychosis / young schizophrenia to get stablized before greater symptoms take over. I currently have 2 possibly 3. One is likely not going to be good fit and needs the higher level of care. The other might just be appropriate for this practice, but currently is stable on oral. Third is unclear diagnosis.

For psychosis spectrum if initial consult they truly belong with other practice venue I will refer, but if there is a reasonable chance with my office, I'm willing to try. Positively these young patients have involved and supportive parents, too.

I won't do the injections personally as others above have noted reasons to avoid.

I'm optimistic about the future of the SubQ buprenoprhine preparations and hope to have this done by the pharmacists, too.

In summary, I have 0 patients actively getting injections at the moment.

 

[whopper]

The main problem I've had with the injections are that none of them minus the typical antipsychotic injections are cheap. So then if I prescribe them I don't know if the insurance will pay for it and then they play the game of not answering to me or the patient if it'll be paid by insurance. Then the pharmacist doesn't want to order the medication unless he/she is reasonable confident insurance will cover it cause then they paid about $1000 for a LAI that's sitting in their pharmacy gathering dust.

 

[NickNaylor]

Our inpatient group just had a discussion about this yesterday as our very large and very well-resourced outpatient practice has a hard time continuing LAIs that are started in the hospital setting. Even with patients that are generally higher SES with insurance coverage and an army of staff to assist with PAs and other bureaucratic hurdles, we were told that for most patients it's not possible to continue LAIs started in the hospital for one reason or another, and usually not for clinical reasons (e.g., lack of efficacy, side effects, etc.). I should note that these are second-generation LAIs, not first-generation, so if we stuck with haloperidol and fluphenazine perhaps we would have a different experience.

I mention that just to say that it is likely much harder to do this in the private practice setting. I do know that there are some docs in our community that routinely use LAIs - including second-generation agents - but they are relatively few and far between.

While things like storage and administration are worth thinking about, my understanding of things is that it is extremely difficult to even get to that point unless the patient has the cash to pay very high copays or the cost of the injection altogether. For what it's worth, when I was in residency we had some patients pick up the LAI from a pharmacy that we sent the prescription to and bring the whole dosing package to clinic where it was administered by one of our RNs if it was an agent that wasn't on the formulary. That seemed to work pretty well but introduces some uncertainly (e.g., actually picking the medication up, not losing it, not leaving it in a hot car for several days, etc.).

 

[whopper]

In community mental health centers they have the LAI thing down. They have enough patients on LAIs for it to be worth it to them to order them without much risk of it going to waste, the people on the pharmacy end know what to do on their end to get the stuff paid for, Medicaid is more understanding with this type of thing cause people with severe mental illness tend to sink to the bottom SES then getting Medicaid.

With private insurance it's different, and with private offices where the majority of patients have private insurance you almost never get someone needing an LAI. Happens but of over the 1,000 patients I have less than 5 of them are on one.

As mentioned above, and as Nick expanded upon, the problem getting these meds require an infrastructure. That of the psychiatrist needing to provide the injection that many do not want because of local regulations that will require them to pay more money to keep an LAI on-site, possible boundary violations, private insurance not being clear if they'll pay for it, a lack of available knowledge if local pharmacies could do in the injections instead of the psychiatrist, a hesitancy for usual pharmacies to want to carry an LAI because they too have so few patients that use them and people often times needing an LAI aren't reliable in picking them up mixed with the extremely high cost.

What I do is the pharmacist in my building does injections. We worked it out with him. What another psychiatrist I know does is he hired an NP to do the injections and he can maintain this practice because he has enough LAI-Naltrexone patients for it to be cost-effective.

 

[dl2dp2]

I know someone who does this. She treats mainly younger women with SMI who also have well off parents. This has worked pretty well so far. The logistics aren't difficult--buy syringe from a medical supplier and ask the patient to bring the medication into the office and do it on the arm.

I do injections all the time in my private office but I'm an addiction psychiatrist (i.e. Vivitrol/Sublocade). Not a big deal. Order from specialty pharmacy and deliver at the visit. Or if you are a larger practice buy and bill (and make a small profit for your trouble). Vivitrol is relatively common now in private offices.

 

[Merovinge]

I agree sluox. Both major 2nd generation LAIs (Abilify, Invega) are deltoid capable and super easy to give. Patients get prior approval trivially easily if they have significant hospitalization histories, and even with just 1 I get them approved 4 out of 5 times. Both packages are really setup for ease of use, the patient/family just needs to call the pharmacy and they usually pick it up minutes before coming to the appointment.

I've physically administered a couple dozens and had absolutely zero issues with it impacting the patient relationship. If anything, I think more patients prefer having their psychiatrist physically give it versus having someone else as it feels like you are "doing" something. That said, in my current practice I have so much nursing access that I let them take care of it for work flow issues.

 

[futuredo32]

Write a prescription for it and the patient picks it up and a nurse at their PCP's office administers the injection