Lou Anne Epperson, Director of Clinical Services – Nursing, at Amerita Specialty Infusion joined us to discuss her experience with scaling home infusion and AIC sites. She discusses the biggest challenges they’ve faced and how they’ve overcome them. Listen for her advice on how you can do the same thing.

How to Scale Home Infusion and AIC sites

Transcript: How to Scale Home Infusion and AIC Sites

Dylan McCabe: We Infuse podcast, episode number 39. Welcome to the We Infuse podcast. My name is Dylan McCabe. And in every episode, we give you a seat at the table as we talk with owners and operators of infusion practices. And in this episode, I’m going to be talking with Luann Epperson. She’s the director of clinical services for nursing for Emerita Specialty Infusion. And the neat thing about Emerita is that. They are successfully growing and scaling both the home infusion side of their business and practice and the ambulatory infusion center. They’re scaling to multiple locations. They are keeping things simple and repeatable doing very well. And I think you’re going to get a lot out of this because we’re going to talk about some of the biggest challenges they faced, how they’ve overcome those challenges. And she’s going to give her best advice for those wanting to do the same thing. All right, guys, let’s jump into this conversation with Luann Epperson, who is a nurse. All right. As I mentioned, we have a special guest on the show today, Luann Epperson with Amerita Specialty and Fusion. She’s actually the director of services and nursing for Amerita. She’s got a lot of great industry experience, and we’re going to be sharing some key insights today. So Luann, thanks for joining the show.

Lou Anne Epperson: Glad to be here, Dylan. Thanks.

Dylan McCabe: Okay. So for people who may not be familiar with Emerita, just share a little bit about your background in the industry and then let’s talk about who Emerita is.

Lou Anne Epperson: Sure. I started my career, we won’t talk about how many years ago, but I was in inpatient facilities, like many nurses start out their 10 years, I was introduced to this beautiful area called home care. And at that time I was, with a Medicare certified agency. We did a lot of private duty nursing. It was a wonderful venture and it was obvious that this was a place for, not only patients to, be comfortable and thrive and, be successful in their health journey, but also for, nurses to be able to. practice a different type of nursing. So I did that for several years and then in the year 2000, I was introduced to home infusion. And that, yeah, that was a while ago. That was 21 years ago, but It, it was very different, in 2000 than it is today. we didn’t have nearly the number of medications and drugs that were available to treat, especially chronic patients. and also we didn’t have an industry focus with physicians to refer patients into the home environment. to give some of the listeners an idea back when I started in home infusion, many of the patients that came out of the hospital that referred to us who received TPN, had to stay in the hospital to receive their TPN because no physician, trusted the fact that patients could receive this at home. Not only that, they also treated them in the intensive care units because they didn’t, think that the patient should receive TPN outside of intensive care. We have come a very long way since then. So the industry has absolutely changed because of the types of medications that are now afforded to patients, the types of in depth knowledge and expertise that’s needed in order to administer these medications. But also because physicians are now aligning with their patients to understand that it’s a better quality of life And a safe way of delivery of home infusion. So emerita has Over 35 facilities throughout the country. We’ve been growing like the rest of the industry because of all these changes that are happening in the push for side of care and a couple of years ago our President, Richard Irie, had met with some individuals from Lee and Pews and had talked about trying to look at a different class of trade than specialty home infusion, which of course is growing and thriving, but there’s also a need for the, AIC model, that, we’re talking about today for a variety of reasons. It allows for, a better acquisition of, drugs that come down the pipeline that may not be afforded to home, specialty home infusion companies. It allows, for Medicare patients. to be serviced, which, in our case, we are not a Medicare certified nursing agency. So, we’ve not been able to provide nursing care for those patients. And, it is a very efficient way of caring for patients with chronic illnesses. Stay safe. 30 to 70 percent of the hospital costs. I think that’s nothing new to your listeners. their quality of life is better, but also their ability to, be independent and, direct their care and make it easy has just now. created the reason for this, niche that we’re starting to get into that we’re very excited about.

Dylan McCabe: So I think it’s so interesting that you mentioned over the last, 20 years or so you’ve seen these significant changes in the way physicians work and where patients can receive care and the changes or the really the improvement in the drug availability and the options for patients. I can’t. I can’t imagine being forced to sit in a hospital, especially in an ICU area. you would want to be in your home, especially if you’re receiving, see if you have a chronic disease and you need to receive, treatment once a month or whatever it might be. It’s, just awesome that the industry has made these leaps forward. what would you say based on your experience? what would you say was one of the pivotal things that enabled this shift, in communication? For people to go these patients to go from having to stay in the hospital to receiving care in the home

Lou Anne Epperson: That’s a great question. It was a lot of hard work from professionals in the home infusion and ambulatory infusion world. as physicians opened their own infusion suites, they began to recognize, how I don’t want to say simple because this is not simple, but how much easier it was to be able to treat their patients on site, get to see what’s going on with them, not lose them in the hospital system. That’s one thing. patients, who are, have chronic illnesses, generally are parts of, communities within their own disease state. And they talk and they communicate with each other and say, Hey, I get my infusion. at this, Ambulatory Infusion Center, or in some cases, I get mine at home, and so then those patients will go to their physicians and ask for that as well. Something that was interesting, during COVID, we, as All members of our industry were, pivoting to try to make sure that all the patients that needed the care continued to get it, knowing that patients may not be seeing their physicians or may not be admitted into the hospital and may forego some treatment. which can have disastrous effects, of course. there were some hospital systems, I’m in the Denver area, in the Denver area that closed down their infusion centers during COVID, for obvious reasons and requested us to assist them with caring for their patients, which, of course, we did, and we, had an agreement with them that as long as they needed that care with us, we would provide it. Well, as you might imagine, as the infusion centers with the hospital started to open up, many of those patients said, well, hey, I liked getting my infusion. In a small facility where the parking was right up front and I didn’t have to navigate through the halls of the hospital or in some cases, which is the beauty of being a home infusion company, we were able to see the patient at home. And so they have requested with their physician. And also with, the payers, because that’s very important, the site of care with the payers, to, switch sites of care. so, and that’s gonna, I think, continue, as more and more, Payers recognize the cost savings, but also the quality of life that patients are communicating to them. They’re going to authorize, more, ambulatory infusion center care side of care and home infusion. So it’s going to continue to benefit patients, and the industry overall.

Dylan McCabe: Yeah. One of the things I like about the world of infusion, I’ve worked in the several different industries. And the thing I like about the infusion space is that people are collaborating. People are connecting to improve things like side of care optimization, all these different industry buzzwords that we hear over and over again. People are really working together, like the NICA and stuff like that. It’s just, great. So now with the Maritop, do you guys have, for, people listening to this, do you guys have ambulatory infusion centers and home infusion?

Lou Anne Epperson: Yes, we do. And sometimes we have to have, clarity sessions where we remind ourselves which part of the business are we working in here. So, we actually worked with WeInfused to help develop a Our, ambulatory infusion center portion of the business, which, we call mosaic and it is, separate and distinct from our home infusion business. The payer contracts are different. The credentialing is different. The, nurse practitioner model is brand new, to us. That’s not a, usual, type of nurse that you use in a home infusion setting. And so we had to, so in some cases, we actually, maybe share some space, but have separate and distinct inventory, billing, documentation, staff, supplies, everything’s, totally separate, in order for us to remain, as we call ourselves an infusion center, so depending on what works best for the patient, they could come into our home infusion space, receive their therapies at home, or, they can also get it, in the center. so our nurse practitioners then as they do with all many other anti inflammatory infusions centers work very closely with the prescribing physician to, obtain the orders and provide the care as needed.

Dylan McCabe: Well, so let me ask you this for those listening to this, we have a lot of our listeners are in the healthcare space and maybe want to start an infusion center. And a lot of our listeners are providers who have an infusion practice, but maybe want to start a home infusion, add home infusion to that. So you guys started with home infusion and then. And then grew to AICs as well. So what would you say is the biggest thing you learned that you would want to share with our listeners about expanding from home infusion to the AIC model?

Lou Anne Epperson: that is a great question, Dylan. In home infusion, it’s pharmacy driven. And, the nurse, the nursing department is an adjunct therapy. I call it a core therapy. we’re extremely important in the care of our patients. And we provide of course, teaching and education, and then. observing and, preventing any catheter, infections or other outcomes that are, that we don’t want to see. but it’s pretty, much driven from physician pharmacy communication. pharmacists double check all the orders. They review drug interactions, drug food interactions. They manage all of that as they’re required to do as a pharmacist within their own board of pharmacy. All of the compounding is done based on USP 797 or CDC. USP 800, which is, the Bible of standards for those who don’t know for pharmacies. So, when you move to, when we move to an infusion center, we’re now a nursing nurse practitioner focused model, not a pharmacy model. So, we don’t interact with our pharmacists. We then needed to look at what is it that pharmacy does for our home infusion patients that we need to make sure we put into place in our ambulatory infusion center. So it includes, drug review interactions, that are done now by the nurse practitioner. We mix the medications outside of a clean room environment. So we need to have extra competencies, very specific competencies for that in order to assure a sterile product for patients. And our inventory, as I mentioned, is separate. Our communication patterns with physicians is a bit different. It’s Not to say that our home infusion business is not collegial between pharmacy and physicians, but with the ambulatory infusion center model is very closely directed between the nurse practitioner and the physician. So helping the, the nurse practitioners develop competencies for communication with physicians or, giving them tools for drug, interactions. assuring that they understand the requirements for being able to initiate therapy. All the things that in our other business is done by pharmacists are now done by nurses.

Dylan McCabe: it’s great that you make that distinction. We used to, tell people when we did, when I was with, we infused doing consulting, working with Reese, Consulting with different clients. We tell people that if they were used to the home infusion space, like you mentioned, the pharmacy driven model, we would tell our clients, you really have to take your pharmacy hat off, so to speak, and know that if you’re going to branch into the ambulatory infusion model, it’s a different business model. It’s a different, workflow and it involves different staff. So it’s, it definitely takes a lot of adjustment to do that. And you guys are obviously doing it very well. So I think it’s great that you can speak to that because I think there’s listeners in this audience that are doing one or the other. Most are not doing both really well. And you guys are doing both really well because you’ve scaled it To, multiple locations. So let’s, let me ask you about that. What would you say has been one of the biggest challenges as you guys have scaled to multiple sites? I think you mentioned somewhere around 30 or 35 sites.

Lou Anne Epperson: Yeah, we have 30 to 35 home infusion suites. Home infusion sites. Right now, we have, four mosaic sites and we’re expanding to ten by the end of this year, so not quite as many, but each one of those feels like three, so I suppose that scales up. We, have learned, we got a lot of help from WeInfuse. We had regular meetings with our consultant, who happened to be in Greece. He was very helpful, to help us, Walk through step by step how to not only establish a business, but what kinds of credentialing information is needed for nurse practitioners and that’s been a big hurdle because That as we expand into different states as you well aware and others are well aware that There’s different regulations in each state and so and there’s different payers. And so while we might send in credentialing documents for a nurse practitioner for ABC payer in Colorado, now we have DEF payer in Texas. and they require a whole new set of credentialing information, which can create a delay in our ability to staff up, if you will, to be able to provide the care that we need to these patients. Some states require physician oversight, medical director, based on state regulations. Some states don’t require that. Some states, are very specific about, the rules and regulations for an ambulatory infusion center. And again, I think your audience, Knows well that this is true, for anyone who’s working in more than one state. So, trying to develop a checklist of all the items that we need to make sure are in place, including the specific address and phone number and suite number of an organization before we send in all of our documents is very important. So that has created a delay in some cases. with, our ability to open and start accepting patients. Because if our, nurse practitioners aren’t credentialed by that particular payer, doesn’t mean they’re not qualified, doesn’t mean that they don’t have the credentials, but the payer hasn’t given their approval, then we can’t accept any patients.

Dylan McCabe: Well, I, so that’s great that you can speak to that challenge. You guys have gone through that, you’re expanding, successfully. So what’s a key piece of advice you would like our audience, our listeners to know about how you guys dealt with that challenge? What’s one key piece of advice you’d like them to take away from that if they’re trying to do the same thing?

Lou Anne Epperson: I would say get a consultant, who, has been there, understands the business, they’ve got the tools they’ve got the, Oh, I’ve been there, done that, mentality. and I, again, in our own situation, I recall there were, two or three times where Reese would say on a phone call now, remember, You have to be sure to do A before B because otherwise it’s going to create a delay in what you do. And sometimes it took me more than one phone call to hear that. But, once I was on board with, those items, it was very helpful. we are, in my opinion, we are experts in specialty infusion in the home. And, we were not experts in ambulatory infusion centers. So utilizing individuals who have the experience, and the knowledge is probably the key item that I would take

Dylan McCabe: away from that. We all stand on the shoulders of others and there’s just, I like to say you’re going to pay for your education. You’re either going to pay for it by using a consultant like we infuse, or you’re going to pay for it the hard way by making very costly mistakes. And so I think the smart, the smart provider, the smart business owner, the smart executive, Knows to pay in advance the right way by relying on the knowledge of experts. I think that’s so good Well, let’s let me ask you another question because I think you’re Your model is so interesting with the home infusion and the ai season both are growing There is a high level of complexity there. Every time you hire somebody new you’re dealing with A new personality new experience new level of training needed you’re constantly increasing the complexity Of your business and all the while you’re trying to Serve patients well and all this stuff. So What would you say is your biggest advice to those listening this that are also wanting to grow and expand like you guys have? What’s your best advice on keeping things simple keeping things repeatable?

Lou Anne Epperson: Well, that’s another great question one is You to base. Your policies and procedures and processes on accepted standards, and that provides a segue into the fact that NICA is in the process of updating, its standards of care as a excellent panel of individuals who are, working to do that. and, that’s, one thing that’s important. And I know that there are many people that I’ve spoken with that have said, are there standards? Can we just have a Bible to go on so that we’re sure that we repeat orientation and competency development every time we, take on a new business. competencies. and competent nurses are, right now, our biggest challenge. It doesn’t mean we don’t have competent nurses, but I can tell you our, number of nurses in the pool that is available to us has significantly dropped. And you can imagine, why. We just, as a matter of fact, lost a, nurse practitioner to a private practice where she’s going to be doing, evaluations telephonically. with, that physician’s practice, which so nicely fits in with her, home life and her ability to be flexible. So COVID has changed that not only in our nursing pool, but everywhere, as we all know, in terms of the workforce. so trying to. Finding someone who’s available who fits into our, time frame that we need is a big challenge. It’s important to be very clear, when you’re, working with recruiters or sending the word out for what you need, to be exact with what you need, and be enticing to, what the nurses might be interested in joining up for. once they’re on board, then the competency development and, competence and confidence that we can build upon, which we actually did a presentation on this for, NICA last month, is again, key. You need a toolbox of, orientation plans. Orientation competencies and one on one assistance with any new nurse or nurse practitioner who joins your facility to make sure number one that they’re very comfortable with what you’re expecting, but that they have confidence in the company. That is providing them with all of this information and the one on one support. And, that to me is the biggest challenge, that we’re facing right now is staffing. And the ability to staff up when we don’t have, many individuals, out there who are, Interested in either changing a position or, coming on board with a new company.

Dylan McCabe: that’s great. Great that you can share that. And I think that, you mentioned competency and training and path and stuff like that. And we like to say, you have to have the right people in the right seats. They need to be uniquely wired for that role and they need to get it. They need to get the company’s core values, the company’s mission. to take hold of it and make it their own. They need, they also need to want it. They would need to want that role and not be looking for something else or a change in lifestyle like the one you mentioned. And they need to have the capacity to do it. All three of those have to be checked off. They have to get it, want it, and have the capacity to do it. And that capacity can’t be realized without a solid training plan, without a solid path to show them that they can be successful. So it’s. Great that you guys have done that. I think there’s just a lot that can encourage people from our talk today, Luann, because you guys are scaling two business models well. You are simplifying communication and processes. You have a standard set of ways you do things, so you’re a process centered company and not just a person centered company. And you guys are overcoming the challenge as well because, let’s face it, some don’t, but you guys have figured out how to do it. And I think that there’s a lot of good things here that you’ve shared. So as we wrap this up, what’s a parting piece of advice to anybody listening to this, that you’d like them to get the one thing that you’d like to them to take away from our talk today.

Lou Anne Epperson: Chi, getting it down to one, I think, is, really maybe talking about the patient. The patient, thrives in this kind of an environment. patient outcomes are significantly improved over, being seen in the hospital. we know, what, what can happen. when there’s an extended stay in the hospital, with a nosocomial infection, or something else that the patient may be, exposed to. the independence, the ability for them to participate in their care, is greatly improved, in this industry. And I think, we have the secret sauce as an industry, and it’s only going to be stronger as we move forward. as we get new medications that come down and are FDA approved, there’s, Gosh, at least every month we’re looking at some new medication. It gets easier and easier to adapt to because we know the drill. We know what, REMS are in place for these drugs. and. have the capacity to pivot and learn, specifics about, how to care for these patients. So I think, we, we all have the right stuff. We’re going in the right direction. This is where it’s going to be and patients will benefit greatly, the more we can move them into ambulatory infusion centers.

Dylan McCabe: So good. I keep it patient focused. I love it. Well, Luanne, thank you for taking time out of your busy schedule to join us today. And, we just really appreciate you being on the show.

Lou Anne Epperson: Thank you, Don. I appreciate it.

Dylan McCabe: All right. That concludes our talk with Luanne Epperson. And I hope you got a lot out of that. And if you didn’t catch how many times she mentioned we infused, she talked about doing consulting with Reese. And I will tell you, I’ve met so many. Experts and leaders in the industry of infusion. And it’s very rare. If ever I found a situation where Reese didn’t know as much or not more than the people at the table and his attention to detail a second to none. We infused has a substantial consulting program that. is pivotal for many practices that we interview on this show and around the U.S. So I highly encourage you, if you’re thinking about growing your infusion practice or starting an infusion practice, or like Emeriti, going from one very successful practice to, adding another one, the AIC model, you need to do yourself a favor and reach out to WeInfuse and just see what the roadmap could look like for, WeInfuse Consulting. All right, guys, I hope you got a lot out of this. If you did, please take a minute and rate and review on iTunes. It’s a great way to say thank you and let other people know about our show. This is Dylan McCabe with the We Infuse podcast, and I will catch you in the next episode.

Guest Speaker: LouAnne Epperson, MSN, serves as the Director of Clinical Services – Nursing at Amerita Specialty Infusion. She is an Advisory Board Member of the Immunoglobulin National Society (IgNS) and has over 20 years of experience with specialty infusion services.