It’s no secret that our health care system is increasingly shifting the site of care to the patient’s home. Infusion therapy is the among the specialized services that can be delivered in the home, safely and effectively—but it requires a nurse’s care. For decades, home infusion pharmacy and home care nursing have been interconnected. Today, that intersection is growing and the need for highly skilled home infusion nurses has never been stronger.
Where Infusion and Home Health Meet
Delivering high-quality infusion therapy to patients in their homes requires highly skilled field to be a vital part of the clinical care team. Nurses serve an important role as the “eyes and ears” in the home—particularly at the beginning of each patient’s treatment journey. They educate patients and family members, explaining the medication regimen and infusion devices—all the while coaching independence and reiterating safety precautions and procedures. As treatment progresses, they assess patient response to therapy and remain alert to signs of complications, troubleshoot problems, answer questions, and offer encouragement. The infusion nurse is indeed a critical member—and often the most recognizable face—of the care team. Yet, not all nurses are employees of the home infusion organization that’s quarterbacking patient care. For a variety of reasons, the majority of providers—even those with their own nursing staff—rely on outside agencies to provide at least some of the nursing services needed to cover their entire patient census. In addition to skilled nursing visits, Medicare-certified home health agencies are licensed to provide an array of services that can be billed to Medicare’s Part A program, such as physical therapy, occupational therapy, speech therapy, social work and so on. Also referred to as Visiting Nurses Associations, or VNAs, these organizations are typically the go-to for outsourced nursing services because they can accept qualified Medicare patients in addition to commercial insurance patients.
Three Business Models
Some infusion providers base their business model strictly on pharmacy services and don’t provide their own nursing. Others offer this service, but still outsource nursing care to cover some gaps. Examples might include times of high-volume referrals or patients that live outside the nursing service area. Regardless of the model, successful patient care requires careful coordination among the multi-disciplinary care team. There are a couple different ways the relationship between home infusion providers and nursing agencies can be structured. The simplest version is where the infusion pharmacy provides the medications and supplies and the nursing agency provides care in the home, which typically consists of patient education and weekly follow-up visits for lab draws and dressing changes. The home infusion provider is responsible for clinical monitoring and stays in contact with the patient to check on their progress and arrange for the delivery of supplies and medication. Each provider submits its own claim and is reimbursed separately. Contracted arrangements are often necessary when a commercial payer wants to bundle the payment and reimburse only one provider. In that case, the home infusion provider takes the referral and agrees to pay the nursing agency a pre-determined amount per visit amount. Agencies submit an invoice and nursing notes monthly to the infusion provider. A third type of arrangement involves “pass-through billing,” where the home infusion provider takes the referral and submits the claim, but at intake the patient signs two sets of paperwork, so he or she is technically on service with both providers.
Necessary Competencies
Even before the relationship begins, infusion providers need to determine with which agencies they wish to partner. Nurses are on the front lines of patient care and essentially represent the home and specialty infusion provider, so clinical competency is a chief consideration. The most important factors are the background, skill level and training of the nurses. Infusion providers often employ some sort of assessment (see Exhibit 1). They may also want to interview nursing managers or conduct site visits. For their part, infusion providers will often perform in-service trainings for specialized skills that they desire (i.e., disconnecting chemotherapy), to familiarize nurses with complex equipment (i.e., new infusion pumps), or to share protocols (i.e., for new drugs as they come to market). Exhibit 1. Nursing Agency Assessment Items
- State license number
- Accrediting body
- Insurance plans accepted/Medicare certification
- Geographic area serviced
- After-hours/on-call process
- Specialty programs (pediatric, cardiac, etc.)
- Number of infusion nurses on staff
- Number of chemo-qualified nurses on staff
- Training procedures for clinical staff
- Experience with the following skills and therapies:
- Peripheral IV insertion
- PICC/Midline line care
- PICC/Midline line removal
- Implanted ports—access and care
- Tunneled central venous catheter care (i.e. Hickman, Groshong)
- Non-tunneled central venous catheter care
- Intraspinal catheter care (epidural and intrathecal)
- Implanted pump refills
- Subcutaneous infusion therapy
- Hypodermoclysis therapy
- Central venous access device declotting with alteplase
- Venous blood draws
- Blood sampling from central venous access devices
- Hydration therapy
- Total parenteral nutrition therapy
- IV antibiotic/anti-infective therapy
- Parental pain management
- Intraspinal pain management
- IVIG therapy (intravenous immune globulin)
- IV steroids
- Inotropic therapy (Dobutamine, Dopamine, Milrinone)
- Biologic infusions
- Chemotherapy
- 5FU and methotrexate
- First dose in the home policy
The Best Partners
With so many relationships, how does an infusion provider decide which nursing agency to partner with for an individual referral? A variety of factors come into play as providers triage each situation. The first three are skill level with infusion patients, cost-per-visit and agency rating. From there, the decision has a great deal to do with patient specifics, such as diagnosis, prescribed therapy, vascular access device, and pump set up. Providers want to know that an agency has the skills and training best suited to take care of the patient, if they are in the right geographical location, and—the ultimate factor—availability. Delivering quality patient care requires a great deal of coordination, and when the care team is made up of individuals from different organizations, that task is all the more challenging. Typically, infusion providers, intake coordinators and team pharmacists coordinate care from the start of therapy, following the patient, managing care, and communicating directly with the agency. Many infusion providers send the agency a copy of the pharmacy plan of treatment that outlines physician orders and patient teaching sheets for each type of therapy. Agencies are sometimes tasked with getting authorization from the pharmacy for each infusion visit. Other times, an agency is authorized for a certain number of visits up front and contacts the pharmacy if they believe more are needed. Good partners communicate on protocols in order to deliver care that results in positive clinical outcomes and reduced readmissions. Infusion providers appreciate agencies with strong communication channels. Even though their pharmacists and patient care reps are checking on the patient via phone and assessing their lab values, they are interested in obtaining as much additional clinical information as possible. Homecare nurses are in a position to notice critical issues, such as change in status, or adverse drug reactions and side effects. Ultimately, good communication is indicative of a solid relationship.
Sharpen Your Agency’s Home Infusion Nursing Skills
Developing a highly skilled home infusion nursing workforce requires access to the latest clinical resources and education programs. NHIA’s Home Infusion RN Essentials Program is designed to enhance the capabilities and competencies of home infusion nurses. This special one-day program takes place Sunday, March 10, 2019, as a precursor to the 2019 Annual Conference. Join industry experts and dig into advanced concepts such as:
- Ig therapy (SC and IV)
- Home administration of biologics
- Management of acute infusion reactions
- Catheter occlusions
Additional NHIA 2019 conference programming for home infusion nurses includes:
- Going the Distance: Optimizing Central Line Dwell Time in the Pediatric Patient
- The Prevention of CLABSI: Utilizing Technological Advancements in Infection Prevention to Protect Patients
- Medical Cannabis: Introduction and Evidence
- New Parenteral Drugs, Biologics and Biosimilars—Indications and Administration Guidelines
- Effective Pain Management and Practical Considerations in the Era of the “Opioid Epidemic”
- Outcome Data ED visits—Using NHIA’s Standard Definitions for Home Infusion
- Case Study: Transitioning IV Staff Education to an Online Learning Model
NHIA Now Offers a Nursing Provider Membership
When home infusion pharmacies and home infusion nursing providers work together as full partners, they can improve patient experience, achieve positive patient outcomes, and reduce health care costs. Learn more about how an NHIA nursing provider membership can support the growth of your organization and the development of your home infusion nursing team.