Transcript Home Infusion Therapy: A Primer for Pharmacists

Home Infusion Therapy: A Primer
PSHP 47th Annual Assembly
Lawrence Carey, PharmD
Associate Chair, Department of Pharmacy Practice
Temple University School of Pharmacy, Philadelphia
Clinical Consultant
Jefferson Home Infusion Service, Philadelphia
Lawrence Carey, PharmD
PSHP 2015
1
Conflicts of Interest Disclosure
I have no conflicts of
interest to disclose.
Lawrence Carey, PharmD
PSHP 2015
2
Objectives for Pharmacists
• Explain the concept of home infusion practice.
• List three tasks associated with completion of
a successful home infusion referral.
• Define the process of care planning.
Lawrence Carey, PharmD
PSHP 2015
3
Objectives for Technicians
• Recite the number of home infusion
pharmacies currently in operation.
• List four parenteral therapies commonly
provided at home.
• List three intravenous catheter types used to
provide home infusion therapy.
Lawrence Carey, PharmD
PSHP 2015
4
Assessment Question 1
Which of the following patient scenarios would
likely not be considered appropriate for home
infusion?
a) 23 year old patient with osteomyelitis; needs to
complete 6 weeks of antibiotics
b) 53 year old ventilator-dependent, in the ICU, on
4 intravenous therapies, including pressors
c) 65 year old end-stage cancer patient unable to
swallow oral medications
d) 66 year old ulcerative colitis patient requiring longterm nutritional support
Lawrence Carey, PharmD
PSHP 2015
5
Assessment Question 2
Which of the following catheters would likely be
considered acceptable to complete 2 more
weeks of antibiotics for an endocarditis?
a) PICC
b) Chest wall port
c) Hickman tunneled catheter
d) Triple lumen catheter inserted in jugular without
suturing
Lawrence Carey, PharmD
PSHP 2015
6
Setting The Table
Lawrence Carey, PharmD
PSHP 2015
7
Definition of Home Health Care
Services provided to acutely or chronically
ill, or injured patients at their residence
according to a plan of treatment
prescribed by a physician.
Lawrence Carey, PharmD
PSHP 2015
8
Definition of Infusion Therapy
• The administration of parenteral drugs and
biologicals in a patient’s home, either by the
patient, friends/family, or trained nursing staff
– Always initiated by a prescription from a qualified
physician who is overseeing a patient’s care
– Successful provision of care usually involves a vast
array of clinicians and support personnel
IDSA: http://www.idsociety.org/Home_Infusion_FAQs/#sthash.4d86IznN.dpuf
Lawrence Carey, PharmD
PSHP 2015
9
Home Infusion Therapy: The Numbers
• Home infusion therapy market
– Approximately $9-11 billion
• Number of USA home infusion pharmacies
– Approximately 1,500 infusion pharmacy locations
• Market segments grow about 15% each year
– This number is changing as infusion suites and
physician offices are doing more business
National Home Infusion Association (www.nhia.org)
Lawrence Carey, PharmD
PSHP 2015
10
Types of Home Infusion Providers
• Hospital based
– Usually larger teaching institutions with a robust
home care presence
• Corporate based
– Used to be specialized companies; now expanding
to more traditional pharmacy corporations
• i.e., Walgreens Home Infusion
• Independent
– “Mom and Pop” pharmacies
Lawrence Carey, PharmD
PSHP 2015
11
The “Core Four” Major Therapies
• Anti-infectives
• Nutrition
– Parenteral
– Enteral
• Chemotherapy
• Pain management
– Intravenous
– Subcutaneous
Lawrence Carey, PharmD
PSHP 2015
12
Other Therapies Provided
• Hydration, antiemetics,
CSFs
– Post chemotherapy
• Inotropics
– Heart failure
• Immunotherapy
– IVIG
• Corticosteroids
• Chelation
– Iron overload
• Inhalation therapy
– Anti-infectives for
infections secondary to
cystic fibrosis
• Specialty therapies
• Catheter care
– Multiple sclerosis
Lawrence Carey, PharmD
PSHP 2015
13
The Referral Process
Lawrence Carey, PharmD
PSHP 2015
14
Patient Selection & Eligibility
• Determine appropriateness of candidacy
– Not all consults become patients of a home
infusion service
– Lots of factors to consider (i.e., geography)
• Determine primary caregiver
– We’ll teach almost anybody
• Assess for type of venous access device
(i.e., catheter)
ASHP 2013 Guidelines on Home Infusion Pharmacy Services: www.ashp.org
Lawrence Carey, PharmD
PSHP 2015
15
Patient Selection and Eligibility
• Before patient is taken onto service,
consider
– Medical stability
– Functional status
– Motivation
– Reliability
– “Trainability”
Lawrence Carey, PharmD
PSHP 2015
16
Patient Selection and Eligibility
• Once initial assessment done AND patient is
deemed acceptable for taking onto your
service, consider
– Visual acuity and manual dexterity
– Available support system
– Safe home setting
– Appropriate insurance coverage
Lawrence Carey, PharmD
PSHP 2015
17
Venous Access Devices
Lawrence Carey, PharmD
PSHP 2015
18
Centrally-Placed VADs
• Peripherally inserted central catheters (PICCs)
– Most common, easiest to place
• Tunneled
– Broviac, Hickman, Groshong
• Other brands available for specific needs
• Implantable ports
– Chest (common) or arm (rare)
• Non-tunneled = non-preferred
Lawrence Carey, PharmD
PSHP 2015
19
PICC
www.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdf
Lawrence Carey, PharmD
PSHP 2015
20
Tunneled Catheter, Implanted Port
www.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdf
Lawrence Carey, PharmD
PSHP 2015
21
Ambulatory Pumps and
Innovative Devices
Lawrence Carey, PharmD
PSHP 2015
22
Pumps: Moog Curlin, CADD-Solis
www.moog.com, www.smiths-medical.com
Lawrence Carey, PharmD
PSHP 2015
23
Elastomerics: Eclipse, Infusor
www.specials.fresenius-kabi.com/eclipse, www.baxter.com
Lawrence Carey, PharmD
PSHP 2015
24
Care Planning
Lawrence Carey, PharmD
PSHP 2015
25
Carey’s Definition of Care Planning
A collaborative, interdisciplinary
effort to identify goals of therapy
and a framework
to meet those goals.
Lawrence Carey, PharmD
PSHP 2015
26
The Five Tenets of Care Planning
• Constantly review and revise your approach to
providing care for a specific patient
• Identify patient problems
• Set goals to resolve these problems
• Intervene as necessary
• Assessment of whether patient needs are met
Filibeck D et al. AJHP 1999:56:1348-49.
Lawrence Carey, PharmD
PSHP 2015
27
Miscellaneous Issues
Lawrence Carey, PharmD
PSHP 2015
28
Paying The Bills
• Accreditations
– The Joint Commission
– Accreditation Commission for Health Care (ACHC)
– Community Health Accreditation Program (CHAP)
• Insurance
– Medicare Part B (DME-given therapies)
– Medicare Part D (drug only – no supplies or
services)
Lawrence Carey, PharmD
PSHP 2015
29
Considerations for Your Institution
• Space
– Need more than just an IV room
• Staffing
– Need 24/7/365 coverage of pharmacists
• A lot of this time is spent on call
– Also need nurses, technicians, delivery drivers,
intake/billing personnel
• Capital costs
– Pump purchases and rentals are expensive
Lawrence Carey, PharmD
PSHP 2015
30
Back to Assessment Questions
Lawrence Carey, PharmD
PSHP 2015
31
Assessment Question 1
Which of the following patient scenarios would
likely not be considered appropriate for home
infusion?
a) 23 year old patient with osteomyelitis; needs to
complete 6 weeks of antibiotics
b) 53 year old ventilator-dependent, in the ICU, on 4
intravenous therapies, including pressors
c) 65 year old end-stage cancer patient unable to
swallow oral medications
d) 66 year old ulcerative colitis patient requiring longterm nutritional support
Lawrence Carey, PharmD
PSHP 2015
32
Assessment Question 1
Which of the following patient scenarios would
likely not be considered appropriate for home
infusion?
a) 23 year old patient with osteomyelitis; needs to
complete 6 weeks of antibiotics
b) 53 year old ventilator-dependent, in the ICU, on 4
intravenous therapies, including pressors
c) 65 year old end-stage cancer patient unable to
swallow oral medications
d) 66 year old ulcerative colitis patient requiring longterm nutritional support
Lawrence Carey, PharmD
PSHP 2015
33
Assessment Question 2
Which of the following catheters would likely be
considered acceptable to complete 2 more
weeks of antibiotics for an endocarditis?
a) PICC
b) Chest wall port
c) Hickman tunneled catheter
d) Triple lumen catheter inserted in jugular without
suturing
Lawrence Carey, PharmD
PSHP 2015
34
Assessment Question 2
Which of the following catheters would likely be
considered acceptable to complete 2 more
weeks of antibiotics for an endocarditis?
a) PICC
b) Chest wall port
c) Hickman tunneled catheter
d) Triple lumen catheter inserted in jugular without
suturing
Lawrence Carey, PharmD
PSHP 2015
35
Summary
• Home infusion therapy is here to stay…and
will likely continue to grow
– Need to diversify your practice as physician-based
infusion suites are impacting the industry
• Motivated, clinically-interested pharmacists
can thrive and collaborate interprofessionally
• SOMEONE in your institution is providing
these services….why not you?
Lawrence Carey, PharmD
PSHP 2015
36
Questions?
Lawrence Carey, PharmD
PSHP 2015
37