In this episode, Dylan McCabe and Reece Norris interview Jenn Charron, VP of Clinical Services with NHIA. We discuss the differences between the home infusion service model and the in-office and stand-alone Infusion Center model. To learn more about NHIA and their mission, visit www.nhia.org.
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Transcript: The difference between home infusion and the infusion center with Jenn Charron
Dylan McCabe: WeInfuse podcast, episode number 13. Welcome to the WeInfuse podcast, my name is Dylan McCabe and each week we give you a behind the scenes look at the infusion of practice for the standalone infusion suite of the provider office fusions and our goal is to take the confusion out of infusion, especially as it relates to the differences between ambulatory infusion center or the standalone infusion suite or the provider office that does infusion and home infusion and home health there’s confusion around those issues, which is why I’m excited to have on our program this week our special guest named Jenn Charron. She’s a VP of clinical services with the NHIA, the National Home Infusion Association and she’s going to just shed some light and put the pieces of the puzzle together on the differences between these major different types of practices. There are different types of patient access involved, there are different barriers to entry involved, there is different billing involved, there really are completely different business models involved between the infusion suite, the home infusion practice and home health and we’ll just talk about how they’re related, how they’re interconnected and how they are vastly different all at the same time. So without further ado, let’s listen into the interview with Jen Charron, here we go. Okay. Welcome to the show and as I mentioned, we do have a special guest, Jenn Charron, VP of clinical services with the national home infusion association, NHIA for short. So Jenn, thanks for being on the show.
Jenn Charron: Great. Thanks for having me, excited.
Dylan McCabe: We also have our typical co-host, Mr. Reece Norris, one of the founders of WeInfuse.
Reece Norris: Good morning and good to be here.
Dylan McCabe: So we’re excited to have Jenn on the program because her specialty obviously is the national home infusion association and a lot of people that, especially people that want to get into the infusion practice really don’t know the difference between home infusion, the provider office that has an infusion practice, the standalone infusion suite, the difference between that and a hospital where people get infused in the hospital, all these different things and there are a lot of moving parts and then even talking about home infusion and home health, there just seems sometimes there’s confusion and our tagline with WeInfuse is we like to take the confusion out of infusion.
Jenn Charron: Good luck with that.
Dylan McCabe: So Jenn, no pressure, but we want you to clear all that up today. Before we jump into all that, why don’t you just share with our listeners just kind of your background and how you got into the NHIA and into infusion in general?
Jenn Charron: Sure. So I’ve been a nurse for about 20 years. I’ve done everything from ICU to adult daycare and about 15 years ago, I actually took a job as an infusion nurse working for a home health care agency and then shortly after I fell in love with home infusion, for sure, caring for the patients at home and then went to work as a director of nursing for a home infusion provider in New Hampshire. I worked there for about eight years when I left, I was the chief operating officer of their programs. We had three pharmacies in Maine, New Hampshire and Massachusetts 5083 pharmacies, so that’s the type of pharmacy that services home infusion providers. When I left there, we were building a 503B, which is more like a manufacturing to support our industry. So it was a non-profit owned by 40 hospitals in New England. So a lot of great experience there, I had worked actually with NHIA on their EGG committee, since starting there have been to their conferences and then when this opened up, I was really excited to be able to kind of, I think really bridge that gap between home infusion, home health and really work on a national scale to promote home infusion, which is something that I’m very passionate about.
Dylan McCabe: That’s great. So you’ve really, have an extensive background in this and you’ve been a nurse and now you’re a lot more on the business side with this non-profit and it’s just amazing. I know, even before we came in here, just talking about the NHIA, it sounds like your heartbeat and I don’t want to get ahead of it, but it sounds like your heartbeat is really just helping to equip people involved in home infusion and especially as always just helping patients get access to some of these life changing drugs.
Jenn Charron: Yeah. So there are a lot of regulations associated with home infusion. We have a lot of things happening in the market and really what our focus at NHIA is to advocate for home infusion for patients and for industry, but also to educate our industry, not just our home infusion providers, but working with groups like yours, about what are the difference with the home infusion and how we collaborate home health providers; so really trying to be that center of collaboration.
Reece Norris: So we’re really glad to have you on Jenn, because I think one of the questions we get quite a bit and I was even saying this before we got in here. We actually got an email last night, just folks not understanding the different classes of trade between home infusion pharmacies, which we also sometimes short call home infusion. So home infusion pharmacies, home health care agencies, where nurses are going to the home and then also the infusion center and the infusion center can be for our purposes is really the provider based physician or nurse practitioner based infusion center and there’s a ton of overlap between them, but they are different and distinct classes of trade and I think one of the things we try to communicate to our constituents at WeInfuse is to make sure they keep everything in the right bucket, even though there’s a lot of crossover and synergy between all the different classes of trade, it is very important. So Dylan opened up with that. I’m super excited that our audience can now really hear those differences and if I misspeak, correct me; I know the infusion center really, really well. Sometimes I know enough to be dangerous in the home infusion side. So for our audience, the home infusion pharmacy, that’s where you’re shipping drugs to the home, correct?
Jenn Charron: Yeah. Typically. Yeah. And you know, we talked a lot about the crossover. A lot of our home infusion providers actually do have infusion suites or they work collaboratively either within not providers suites, but where they might have them inside their pharmacy already. But yeah, typically how our home infusion pharmacy works is we get the referrals from all different physician offices, hospitals might come from home care and then we compound the medications, put them together, very simplified with their supplies and then that gets shipped out to the patient either UPS or drivers, couriers and then typically the patient after they’ve been trained, then will infuse that medication on their own. There are a lot of differences with that, some of the Remicades or some of the biologics a nurse would actually go out and infuse the medication in the home, they insert the line, stay during the infusion and do that right at the home. But many things like antibiotics, hydration, the patient have a somewhat permanent line of vascular access and we train them to infuse their medications on their own and then the nurse would go out once a week do a dressing change, might draw labs, assess a patient more frequently if needed, but really a lot of what we’re doing is a lot of independence for the patient, which is fantastic for them to go back to their regular lives and feel that they have control over what they’re doing.
Dylan McCabe: That is so interesting. Out of the things that you mentioned, just going back to your experience, what would you say today’s your main area of expertise?
Jenn Charron: So I think it really is the compounding, home infusion compounding is a little different from where you might see and even in a hospital area where we’re compounding a week’s worth of drug and it’s really the compounding itself is specific to each individual patient. So some things that are considered with that is how long is the drug stable, what’s the method of administration that the patient can do. So some patients will be on a pump, some will use elastomerics, some will be IV push. So what has to happen is this full assessment of the patient with the whole team and then the pharmacist actually does the type of compounding and develops kind of the way that it needs to be compounded specific to the patient and then we have technicians who do the compounding and the pharmacist oversees it. But I think the biggest thing is that sterile compounding expertise and something that over the last two years really NHIA has started to try to promote, we had our sterile compounding clinic last year at the conference, we had clean rooms, we had TPN compounders. We had people compounding and doing medications and a full week long program just on sterile compounding and with the regulatory changes, that’s even more important for us this year.
Reece Norris: So for our audience out there, home infusion pharmacies are subject to pharmacy, pharmacy regulations, they’re shipping drugs to the home of the therapeutic areas. Again, Jen, stop me here if I’m wrong, the therapeutic areas are typically antibiotics, TPN hydrations, occasionally biologics…
Jenn Charron: Yeah, biologics, we’re doing a lot of biologics in the home now. I think when everything went, especially on the commercial payer side, they started moving patients from hospital infusion suites to either physician office practices infusion suites or the home. So we’re seeing a tremendous amount of biologics now done in the home and IG is another one that we do a lot of and then the other one that we talked about earlier is I inotropes. So we have patients at home on inotropes therapy, their bridge to transplant, heart transplants sometimes end of life. So there’s a lot of complexity about what’s happening in the home for patients.
Reece Norris: Great. And so for our audience, you know, so if you have an infusion center, a lot of those drugs that she just mentioned are also administered in that infusion center. So it’s just a matter of making sure you’re crossing your T’s and dotting your I’s in terms of keeping those classes of trade separate when you’re billing cost and your inventory separate, so a pharmacy has its own inventory when you’re in one bucket and then the infusion center, if it’s truly a physician office or a nurse practitioner and infusion center will have its own inventory as well. So again, keeping those buckets separate, and again, I want to distinguish the National Home Infusion Association from the National Infusion Center Association, which we call NICA. So there’s NHI and NICA, both are incredible organizations and both advocate for patients and providers. And again, lots of synergy, lots of crossover here, but we actually at NICA, I’m a board member there, we work a lot with the NHIA on multiple issues. (inaudible) left because I’ve been working with him on quite a few things, but I know other members of your team as well.
Jenn Charron: Honestly, one of the biggest things we worked on was this issue in New Hampshire, where we had Brian there testifying, Connie Sullivan testifying, I testified and that was really, again, just shows the crossover between home infusion and hospital or infusion suites of all kinds and the board of pharmacy really came down, it was going to affect hugely patient access in the state of New Hampshire and so that banning together, I think really brought NICA and NHIA a lot closer even just in how we’re aligning. Some of the regulatory things that are coming may affect physician practices for compounding. So there’s also this kind of back and forth between that as well. So there are a lot of synergies there.
Reece Norris: Well tell us about your conference, when is it, how do listeners get involved and come to the conference?
Jenn Charron: Yeah, so our conference is March 9th through the 13th this year. We will be at the Gaylord in Kissimmee, Orlando, Florida. So we have a lot of great programs and we’re excited to have you there with us Reece to help explain the infusion suites, kind of the billing side on our group so that we can be able to make that clear. So we’re excited to have you there, but we’re going to have everything from advanced nursing training for home infusion. We’re having our sterile compounding clinic again this year, we’ll have some training inside the expo as well as tabletop exercises and that’s during the whole entire conference as well, separate registration for that. We’ll have our networking event, which I’m sure you had fun out last year as well. I’m making the final changes to that coming up soon. But yeah, it’s really the one area where home infusion providers kind of come together and really my favorite part of it coming as an attendee is it was the only place I could talk about home infusion and everybody knew what I was talking about. It was just so nice. So we’re excited to have everybody back. We have some great news sponsorships actually for our business providers. So it’s going to be an exciting time. We’re looking forward to people coming registration should open next week. You can go to our annual conference website and get all the information there. But yeah, we can’t wait.
Reece Norris: That’s awesome.
Dylan McCabe: That’s great and for people that have never stayed at the Gaylord, they are in for a treat. That’s quite a location you guys picked; and so when you talk about compounding what’s one big thing you would want our listeners to take away around the subject of compounding?
Jenn Charron: Regulations are changing; we had some new release of the USP 797 that came out this summer. We did a webinar on that and on what those changes are to home infusion and then interestingly; we also just had a release as the FDA in sanitary conditions regulations that were released as well. Interestingly they don’t, two federal regulations don’t really agree and so now we’re trying to bridge that gap between two of these regulations for our home infusion providers. But the biggest thing there is the compounding is changing USP 797 and USP 800 are going to go into effect and so we need to prepare our audiences as well as any providers doing any type of compounding office as well.
Reece Norris: So Brian Nike was at NICA told me, and maybe Jen can elaborate here that USP 800 makes it clearer. Is that the right word? I don’t know, clearer. I don’t know what’s proper. But that mixing in the physician office or the provider based infusion center is different than compounding and that there’s some clarity around that. The better clarity around that and USP 800, is that correct?
Jenn Charron: It’s under USP 797 and similar to what we kind of came in contact with as New Hampshire is what is compounding and what is mixing the drug prior to administration. So that was really what we focused on in New Hampshire was that for one dose, for one patient, for basically using right away that that’s going to be really specific in 797 when that is and that does not constitute compounding when you’re doing that. So like we were talking with a Remicade if a nurse is in the home and they’re putting that dose together for that patient to be administered right away that’s different from the 797 and that’ll be physician offices as well.
Reece Norris: And that was just really important, especially for these biologic therapies that are weight based that you have to weigh the patient before you mix the drug and so again, just really makes sense.
Jenn Charron: An expensive one, you really shouldn’t be mixing or starting those until you’re ready to administer it and they also don’t stay stable for very long. So you can’t mix that seven days ahead of time and it is based on the patient’s specific diagnosis and order. So yeah, that is a big, big deal.
Dylan McCabe: So is there a resource that our listeners could go to, to stay on top of these regulatory changes that you mentioned?
Jenn Charron: Sure. Yeah. So we’re actually having a webinar on Thursday that will review those regulatory changes. Again, anything on the NHIA advocacy website updates that and actually we submitted comments from NHIA on the USP 797. So that really has been completed now. But yeah, the webinars, they’re all open access webinars. You can see the one that we actually released in August and then we have another one again on Thursday.
Dylan McCabe: So you’re able to, if you miss it, you can go back and do it.
Jenn Charron: Absolutely, yep. Yeah. You can view those webinars online.
Reece Norris: That’s awesome. I got a question from one of our clients recently about this, so this is a great way for me to point him in this area.
Jenn Charron: Yeah. The other thing that’s really happening too is Medicare payments. So we were talking about this earlier because there’s just not a good payment model for Medicare patients. In the 21st century cures act actually changed some of the payment model or reduce the price of the drug by sometimes more than 90% for providers with the promise of putting a service payment in there like a commercial payer would do and those regulations or those rules where we least actually the summer as well and what they’re saying is they want to require the only day that you can bill is when the day the nurses in the home, which that’s not home infusion like we talked about, patients are infusing the medications by themselves and the compounding on everything that to do with that patient is done throughout the week, so to have one billable day, I mean, that’s just does not work.
Reece Norris: And again, so those were for home infusion codes for our listeners for the infusion center, that’s billing as a provider or a physician office. That’s Medicare part B as in boy, and then that’s a little different for home infusion and some student I’m trying to make sure our listeners understand that the 21st century cures act really didn’t impact much if at all the infusion center billing as a provider officer, physician office, but both are important issues because both affect patient access.
Dylan McCabe: That’s good. I’m not confused at all. I keep thinking of a maze in my mind, like we’re navigating all these ideas, but yeah for anybody who has any more questions, obviously you can check out our blog, you can give us a call. All this has meant to do is just stimulate some thoughts here. So in all of this, obviously there’s challenges, there’s successes, all the different things that you guys face in the national home infusion association, what would you say has been one of the biggest challenges you’ve seen lately?
Jenn Charron: Yeah, I think the payment mechanism really is a big challenge. Home infusion has been widely accepted by commercial payers, Medicaid and it’s a continued challenge for Medicare beneficiaries to not have a complete payment model on that. When you’re looking at patients I always kind of tell the story of my dad’s 70 years old, he’s out chopping wood and if he gets an infection Medicare is really pointing him towards a skilled nursing facility as the place of choice for him to get his six weeks of antibiotics. That’s just not right and that’s not the highest quality, lowest cost site of care for patients and so I think the payment model is a big challenge for our industry for sure. We can deal with the regulations and certainly we’re really on top of the regulatory piece, but not getting paid for the services that we can provide is only going to decrease access for patients.
Dylan McCabe: So why is that? I mean, if a payer has a choice to send a person to one of these four locations, why would they send them, like you said to a place that’s not as accommodating and even more expensive?
Jenn Charron: You got me. Yeah, I mean, the commercial payers, even Medicare advantage, that’s not their side of care so they do allow some of that. But the Medicare payment really has to be changed and a skilled nursing facility is kind of on one budget, home infusion is another. So trying to cross that and show the savings across two budgets, I think it’s just our two payment areas, it’s just difficult and nothing’s really easy to get past in Medicare.
Reece Norris: So an antibiotic patient, like you just described, if we have a 70-year-old person and they’re getting an infection, they need six weeks of antibiotics, that’s really difficult. I mean, that’s a traditional home infusion patient and not necessarily infusion center, unless they’re open six days a week, seven, I mean, seven days a week, excuse me, for six weeks or during the six week duration, which there’s not many infusion centers that are open that often, not many physicians’ offices are open because you can bill under Medicare part B for those services but the issue is these are antibiotics. Maybe it’s continuous antibiotics…
Jenn Charron: Three times a day, what is a patient going to drive into an infusion suite or a hospital three times a day for that, it’s just, it’s not…
Reece Norris: So there is a gap in coverage there that Medicare is missing and hopefully your advocacy efforts will continue and then we can close that gap.
Jenn Charron: So those antibiotics fall under part D as in dog, so that there is payment kind of for the drugs but again, it’s the services that are not provided where on a commercial payer, the home infusion pharmacy would receive, we call it a per diem, which covers the compounding, the delivery, the supplies, 24 hour on call, all of that and that’s what’s not really covered under the Medicare benefits. So if we can get this passed, the goal is to get this passed under part B, but it also gives us a great framework for expanding that for patients moving forward.
Dylan McCabe: That’s great. That’s great. So for those of our audience that are listening that maybe have a home infusion, a practice, or maybe thinking about starting one, I mean, we do obviously interact with a lot of our customers and people that are interested already having a fusion practice, but maybe also want to add home infusion to that. What’s one piece of advice you would offer to that crowd?
Jenn Charron: Yeah. I think, research it, this is not something to kind of just go into, you really have to research your business model, your market and understand the compounding regulations and that is the big one there. I think I highly recommend coming to the conference, that is the one place that you can get all of that information and from compounding to the billing piece of it, to selling it, to leading in that area, the clinical programs, that’s really the one place that you can actually get a full understanding of what it’s like to be a home infusion provider.
Dylan McCabe: That’s great and feel free to plug the conference all you want because we want people to. I mean, our goal with this podcast is to provide our listeners, we want to use this as a platform to equip people and so this conference clearly is one of the best ways to equip people with interested in or involved already in home infusion.
Jenn Charron: And membership to NHIA, especially if you’re a new home infusion provider, it’s all based on revenue. So if you’re not doing a lot in home infusion right now it’s really inexpensive to become a member, but as a member, you get access to Connie Sullivan, myself, Bill Noise, Sharon and it is as easy as shooting us an email or picking up the phone, we’re all very available to be able to help kind of fare it out some of those questions. But that is, again, just there’s so many resources. I was just talking to someone who just went into home infusion just yesterday and they said, well, we need education on billing. Well, we have a whole framework for billing education for members. So there are just a lot of resources there for anybody getting into it.
Reece Norris: That’s great.
Dylan McCabe: So good. We all stand on the shoulders of others. You’re not going to be successful alone.
Jenn Charron: Absolutely.
Dylan McCabe: Well, let’s share maybe another story, with everything that you’ve experienced. What’s a light bulb moment that you’ve had that’s kind of changed the way you look at home infusion and what people go through in this industry?
Jenn Charron: Yeah, I think probably it just really comes for caring for patients in the home, as a nurse from the hospital, I didn’t really understand what home infusion providers did and as soon as I was in the home taking care of that patient I think my biggest light bulb moment was caring for a patient and parental nutrition, we’d go in and we open up the box and there’s so many supplies and you just see the patient, their eyes are big and you just say that you’re going to be able to do this when you get done and then two weeks later, they’re drawing up their multivitamin, they’re entering into their bag, they’re using fantastic technique and it’s just an amazing way for patients to be in their home with their families and that’s when we’re ill, I don’t know about you, but that’s where I want to be is I want to be home close to my family, watching my own TV, sitting in my own chair and that’s, I think for me, what made me so passionate about home infusion and the fact that we have to keep spreading this and patients deserve a choice. If they want to go into an infusion suite, I think that’s okay. They should be allowed to do that. If they want to be home, they should be allowed to do that too. It’s all about patient choice.
Dylan McCabe: That’s so good and that’s something that comes out in every podcast we do, whoever we have on the show with us. I love it because your heartbeat is like so many others in that it’s really all about making the patient’s life better, giving people freedom, giving people a lifestyle that they want, that they can enjoy and that’s just great. I mean, we wholeheartedly agree and think that’s a great, great thing to really pursue.
Jenn Charron: I don’t think many people are going to say, hey, would you like to spend six weeks in a hospital? Most people are not going to say yes, that sounds wonderful to me.
Dylan McCabe: Yeah, no kidding. Well, I think I might know what part of your answer is to this next question, but tell us about what you’re most excited about right now in home infusion?
Jenn Charron: I think the trajectory is going home and that is huge for our industry and I think we’re starting to really get their respect throughout the medical community about what we can do at home. Having inotropes at home is a big deal, doing eye Remicade and the biologics at home. So I think there is a lot coming that way. I think for NHIA, our biggest excitement right now is data. So we started a bench-marking program for patient satisfaction. We’ve developed standard definitions for outcomes. We’ve done this over the last couple of years. But for the patient satisfaction, we’re in a pilot program right now with multiple home infusion providers across the US who have adopted our standardized questions. So we’re hoping to have some great data associated with that. The program will go live for anybody interested in collecting that data and submitting it. We’re taking applications for that part right now that’ll start in January. So we should have some information about that. That’ll be a quarterly report coming out probably later in 2019 and the other thing that we don’t have a lot of data about is just our business of home infusion. How many home infusion providers are in the US, what are their most done diagnoses? So we’re starting at business data definition or business data initiative as well. So just helping to kind of frame how big our industry is.
Dylan McCabe: That’s great. That is great and so with all that, I know a lot of this goes back to the conference you guys hold annually also to your website and then the app I saw you were sharing earlier that, I mean, you guys have clearly put a lot of resources and time and effort into equipping people. I’m really impressed with it. How can people get in touch with you guys?
Jenn Charron: Yeah. So if you just go to the nhia.org, www.nhia.org, our website there, and you can click in, you can actually email any of the staff there but we’re very accessible. So any type of information that you need just reach out and we’re happy to share and discuss what the benefits of NHIA are specific to your organization. We’re not going to recommend a membership if it’s not going to work for you. Our real focus is just making sure that people have the tools that they need to be successful in home infusion.
Dylan McCabe: Great. So with all that said, what would be one final parting piece of advice for our listeners?
Jenn Charron: Come to the conference. If you are or anybody in home infusion, you’re thinking about getting into home infusion, or honestly, if you have an office that prescribes home infusion, I think it’s really important to really understand what we do in this industry and how to promote it and really be comfortable with your patients to it too. If you’re in an infusion suite and a patient says I’d really like to think about getting my medication at home. We need to be talking in a consolidated voice about what’s appropriate for at home. What’s not appropriate for at home. But I think just understanding well-rounded what is actually happening in the home is huge for people and patients.
Dylan McCabe: So good. It’s a patient focused approach. We love it. Well, Jen Sharon, with the National Home Infusion Association, this has been great. We really appreciate you being on the show.
Jenn Charron: Thanks. I really appreciate it too. Thank you so much. We’re looking forward to having you out with us, Reece. That’s going to be a very well attended program.
Reece Norris: Excited.
Dylan McCabe: All right, well guys, thanks for joining the show and we will catch you on the next episode.
Guest Speaker:
Jennifer Charron, RN, MSN, MBA is COO at National Home Infusion Association (NHIA). She has 15 years of experience in healthcare, serving positions such as Home Care Manager, Vice President of Clinical Services, and COO at multiple companies.
