Former CPR+ CEO & Co-Founder Jeff Johnston shares his knowledge regarding the HIT space, and how companies can use this information to better operate and care for their patients. Jeff is also an Infusion Technology Advisory Council (ITAC) member and serves alongside other home infusion & specialty pharmacy professionals.
What is Home Infusion Therapy?
Home infusion therapy (HIT) is the administration of medications or fluids directly into the patient’s bloodstream through intravenous (IV) or other delivery methods that occur in the patient’s home. In addition, home infusion therapy also includes the administration of enteral formulas to patients in their homes via a catheter placed in a patient’s gastro-intestinal (GI) tract.
What is a Home Infusion Pharmacy?
A home infusion pharmacy (HIP) compounds and dispenses intravenously infused medications to patients in their homes. Similar to traditional retail pharmacies, home infusion pharmacies are licensed by the State Board of Pharmacy in each state and often are accredited by various bodies, such as the Accreditation Commission for Health Care (ACHC). Unlike retail (i.e. walk-in) pharmacies, infusion pharmacies are typically “closed-door” pharmacies with little to no face-to-face patient interaction. They prepare and dispense medications in accordance with a physician’s prescription.
Why Home Infusion?
Home infusion therapy is administered to patients with a disease, illness, or other medical condition that requires treatment with a drug that is not available in pill, tablet, or capsule form. If an equally effective oral medication exists that will treat the patient’s condition, the physician will usually prescribe such oral medication. Because intravenous infusions carry additional risk and cost, they are most often used when other safer and cheaper options are not available. Many medications, however, are simply not available in oral form. These drugs make up the majority of commonly administered home infusion therapies. In addition, patients sometimes present with conditions that limit or prevent them from swallowing or absorbing oral medications. These patients will also require IV fluids or nutritional supplementation.
When the treatment of a patient’s condition requires medication in an intravenous form, then the next question becomes, WHERE will the therapy be delivered? This depends on many factors, including: the patient’s present severity of illness, age, competence, availability of other family members/support people, their home environment, and the required frequency of administration (i.e., how often the medication will need to be delivered and health insurance coverage).
“Typical” Home Infusion Patient
Home infusion therapy is administered to patients of every age who may be experiencing a very wide range of conditions. For simplicity and clarity, let’s describe a “typical” example patient.
Mr. Jones is a 60-year-old male, married, with two grown kids. He is in good health and works out regularly. On a recent trail run, he lost his balance going down a hill, fell, and broke his hip. Clearly in pain, his running partner called 9-1-1 and Mr. Jones was transported to a local hospital where an ER physician diagnosed a fractured hip. He was admitted to the hospital and the next morning, an Orthopedic Surgeon performed a total hip replacement.
Following surgery, Mr. Jones did well, started his rehab, and seemed to be on the road to recovery. However, on the fifthh post-op day, he developed a fever along with swelling, pain, and redness around the surgical incision.
An Infectious Disease physician was consulted and she ordered an aspiration (insertion of a needle into the tissue in order to aspirate – suck out – fluid around the new joint) of the surgical site. She sent the aspirated fluid to the lab for a “Culture and Sensitivity” test.
All bodily fluids should be sterile – free from bacteria or other contaminants – however, Mr. Jones’ culture grew a bacteria . . . MRSA – Methicillin-resistant Staphylococcus aureus. This is a malignant germ which can cause serious, even life-threatening infections. Standard medical protocol is to treat MRSA infections with up to six weeks of intravenous antibiotic therapy.
As a result of this infection, Mr. Jones will need up to six weeks of IV antibiotics. The question is, WHAT drug should be prescribed and HOW/WHERE will it be administered?
As noted, his Infectious Disease physician obtained a C&S of the fluid from around the new hip joint. The “culture” determined what bacteria was present and causing the infection – MRSA. The “sensitivity” determines what drug(s) the bacteria are sensitive to, in other words, what medications will kill the bacteria and resolve the infection. The lab reports that the bacteria is sensitive to Vancomycin, a powerful antibiotic that will be administered intravenously. Based on Mr. Jones’s weight, the doctor prescribes 1.5 grams of Vancomycin to be infused intravenously every twelve hours for eight weeks.
While this hypothetical represents a “typical” home infusion patient, many other types of therapies are administered to patients of all ages treating an extremely wide variety of illnesses. Some HIT providers specialize in treating certain types of patients, some are exclusively pediatric, and others focus on providing certain types of therapies such as immunoglobulin (IG). However, most HIT companies are generalists and will provide the full range of home infusion services.
Other Common Home Infusion Therapies:
- Patients with cancer need chemo, fluids, and pain management
- Women who are pregnant with severe hyperemesis (“morning sickness” x 100) need IV fluids. If they have intermittent preterm labor, they are given IV or SQ magnesium sulfate
- Patients who cannot swallow or absorb nutrients from their food need intravenous infusions of nutrition – protein, fats, carbs, vitamins and minerals, and fluid to sustain life (this is TPN)
- Patients with congestive heart failure need IV infusions of Dobutamine, a drug that increases cardiac output
- Patients with hemophilia, Crohn’s, Multiple Sclerosis, cancer, serious infections, and more all receive infusion therapy
The bottom line is this: If a patient has a serious illness or is recovering from an injury or surgery and needs medication that can only be given intravenously, those patients often receive their medication from a home infusion therapy company.
Why Home?
So why treat these patients at home? Mostly, convenience. As noted in our example above, the typical home infusion therapy patient might require IV medication once, twice, or more per day for weeks, sometimes months, and occasionally for the rest of their life. Infusion times vary by drug but could take 30 minutes to 4 hours per infusion. Some medications are ordered on a continuous infusion around the clock. As long as these patients are medically stable enough to be home, they are likely not going to stay in the hospital or go to a skilled nursing facility to receive their medications given the costs of care in these facilities. Likewise, it would be impractical to ask the patient to come to an ambulatory infusion center (AIC) twice a day for an hour long infusion, seven days a week, for 6 weeks. The patient’s home is a comfortable, convenient, and cost-effective place to receive therapy.
What’s an IV?
As you’ve gathered, IV stands for intravenous. This literally means “into a vein”. The circulatory system contains the heart, lungs, arteries, and veins. Arteries carry oxygenated blood under pressure (AKA – blood pressure) away from the heart. Veins carry deoxygenated blood from the body back to the heart/lungs.
Most home infusion therapy patients receive medications intravenously via some sort of venous catheter. “Catheter” is just another word for “tube”. An IV catheter is a tube with a needle that goes through the hole. Once the IV catheter is inserted into a vein, the catheter is held down and the needle is withdrawn.
See www.BD.com to view their line of IV catheters. Catheters are described by their length and circumference, known as gauge. Just like shotguns, the smaller the gauge, the larger the circumference (thus a 20 ga. catheter is smaller in size than a 16 ga. catheter).
Peripheral IV Catheters
Catheters can be “peripheral” or “central”. Peripheral veins are smaller in diameter and closer to the surface. For example, look at the back of your hand, your forearm, or inner elbow area – these are peripheral veins. When a nurse puts a tight band around your arm, he closes off your veins to restrict your venous blood return. This causes blood to back up and expand the vein, making it easier to see and feel and to stick an IV catheter into. Once an IV catheter has been inserted into a peripheral vein, the nurse applies a sterile dressing to the area to protect and secure the IV and to prevent contamination of the site.
Peripheral IVs are commonly used in the hospital and are suitable for administering many types of medications. Their one drawback, however, is that they are prone to occlusion, meaning they get plugged up and stop working. Blood around the catheter tip clots, making it unusable.
In a hospital, there are lots of nurses and doctors around to place a new catheter if the one the patient has in becomes occluded. However, for a homecare patient, this is not the case. The nearest nurse may be miles away or may not be available for an emergency home care visit. Even if they are, successfully placing an IV is not guaranteed.
Starting IV’s is a skill that requires training and lots of practice and generally, after a nurse sticks a patient three times without success, they let the next nurse try. That means a trip back to the hospital ER or to the doctor’s office. For these reasons, peripheral IVs are generally not used for home infusion cases except those expected to last just a few days or less.
Central Venous Catheters
A patient receiving home infusion therapy for nearly any duration requires secure, reliable IV access. This generally means that the patient’s physician will write an order to have a Central Venous Catheter placed. CVCs are a more permanent, longer lasting catheter, improving the likelihood that the patient will be able to complete their prescribed course of infusion therapy without interruption.
The primary advantage of CVCs is that the catheter tip (where the medication comes out) lies in the patient’s superior vena cava (SVC) or right atrium. These large diameter vessels offer significant blood flow and quickly dilute the medication being infused. This reduces the risk of vessel wall irritation, clotting, and other complications. There are many types of central venous catheters used for home infusion therapy patients, including PICCs, Ports, Hickman, and Groshong catheters. The one feature shared by them all is that the catheter tip is advanced all the way to the patient’s heart, specifically to the SVC, which empties into the right atrium.
- PICC – PICC stands for peripherally inserted central catheter. By definition, a PICC line is inserted into a peripheral vein, commonly the median basilic on the inside of the elbow, and advanced carefully up the arm until the tip reaches the SVC. PICC line placement can be performed by a specially trained RN and can be done in the home, clinic, or hospital setting.
- Port – A port is a surgically implanted device used to achieve long term access to a patient’s venous circulation for IV infusion and/or blood draws. Ports are unique in that they are implanted and lie completely below the surface of the skin, typically on the upper chest wall. This results in a palpable raised area, about the size of a quarter. Just below the “bump”, the port can be accessed with a special needle inserted through the skin and into the chamber of the port. A silicone catheter is connected to the chamber which then enters the subclavian vein and advances into the SVC.
- Hickman & Groshong Catheters – Like ports, Hickman and Groshong catheters are also surgically placed by a physician in an operating room. The tip is inserted into the subclavian vein (beneath the collar bone) and advanced to the SVC. The other end of the catheter exits the body in the upper chest wall area and is sutured in place.
Other Types of Catheters Used in Home Infusion
- SQ – SQ stands for subcutaneous, which means “below the skin”. The skin contains a vast blood supply. A small needle inserted just under the skin is a commonly used method for infusing medication into a patient. This “access” type works well for medications infused at a slow rate (1 -30 mL/hour), allowing the medication to be quickly absorbed by the skin’s blood supply.
- PEG / NG / J-tube – These abbreviations refer to different types of catheters that access the gastro-intestinal tract (GI tract), rather than the venous circulation. Some patients suffer from conditions that interfere with their ability to swallow, digest, or absorb food normally. This could be due to tumors, neurological issues, and more. These catheters access the GI tract beyond the point of deficit and allows for the “infusion” of nutritional formulas like Boost, Compleat, and others.
What do Home Infusion Pharmacy Companies do?
Home infusion pharmacies play a crucial role in delivering safe and effective therapies outside of traditional healthcare settings such as hospitals or clinics. They work in collaboration with healthcare providers and other stakeholders to ensure patients receive necessary medications in the comfort of their own homes.
As previously noted, home infusion pharmacies are licensed by their State Board of Pharmacy and often accredited by ACHC. They typically employ pharmacists, pharmacy technicians, registered nurses, intake and customer service personnel, warehouse staff, drivers and delivery technicians, sales staff and persons who manage healthcare insurance billing, and collection services.
One of the characteristics of home infusion pharmacies is that they typically serve patients within a defined service area. They typically interact with the patient in a “face-to-face” manner. For example, infusion nurses frequently visit the patient’s home to assess, teach, administer the medication, manage the patient’s IV access, and monitor the patient’s progress. Delivery personnel deliver the ordered medications and supplies to the patient’s home, usually on a weekly basis. For these reasons, a HIT provider usually limits their service area to a 60-90 mile radius from their office.
Here are some key characteristics and services provided by home infusion pharmacies:
- Medication Preparation: Home infusion pharmacies prepare customized medications tailored to each patient’s specific therapy requirements in accordance with a physician’s order. These medications can include specialty biologics, antibiotics, pain management drugs, nutritional therapies, hydration support, chemotherapy, immunoglobulins, and other specialized therapies.
- Patient Education and Training: Home infusion pharmacies provide education and training to patients and their caregivers on the proper administration and management of infusion therapies. This includes instructions on medication storage, handling, and potential side effects. This ensures patients and caregivers are equipped with the knowledge and skills needed for safe and effective treatment at home.
- Delivery and Equipment: Home infusion pharmacies coordinate the delivery of medications and all necessary infusion supplies and equipment to patients’ homes. This can include IV pumps, infusion sets, catheters, and other supplies required for administering the therapy. They also provide ongoing support and troubleshooting assistance to patients and caregivers.
- Monitoring and Support: Home infusion pharmacies play a crucial role in monitoring patients’ progress and providing ongoing support throughout the course of therapy. They may conduct regular check-ins, remote monitoring, or in-person visits to ensure the therapy is progressing as intended and address any concerns or complications that arise. Generally speaking, once a patient is “on service” (receiving one or more infusion therapies), the HIP is available to the patient 24/7. Clinical staff are on call to respond to any issues the patient may experience related to their therapy.
- Billing and Collections: Reimbursement for home infusion therapy is very complicated. There is currently limited reimbursement available for most home infusion therapies under traditional Medicare. State Medicaid programs will typically cover most HIT drugs but may not cover the supplies, delivery, and other services. In some cases, payers require that HIT claims are billed through the patient’s pharmacy benefit (like traditional pharmacy claims) via NCPDP. Others process HIT claims under the medical benefit.
As a result of this complexity, home infusion providers train employees to work with each patient’s insurance company(ies), verifying benefits and, if necessary, obtaining prior authorization for each therapy. Payers frequently ask HIT providers to “jump through a lot of hoops”, including but not limited to providing Statements of Medical Necessity, copies of the signed Physician Order, Nurses Notes, and more. Other members of the reimbursement staff receive and post payments, manage A/R, and perform other financial and reporting functions.
In conclusion, the home infusion industry is very complex and labor intensive. It is also very personal and rewarding. Because the patients tend to stay on service for weeks, months or even longer, a close relationship develops between the patient, their entire family and the HIT staff. Every patient receiving infusion therapy has experienced a significant health issue. They’re thrilled to be out of the hospital and recovering at home but they’re also anxious about the IV’s, the drugs and the pumps. Their infusion nurse, the driver that delivers their medications and supplies and the entire home infusion therapy staff are a source of tremendous support for them – they become their lifeline to recovery. I can’t think of many other professions that can make that claim.
About WeInfuse
WeInfuse is the premier technology and consulting provider for infusion therapy and medication delivery in the U.S. The WeInfuse software platform powers over 700 infusion centers across the country. Backed by decades of experience, WeInfuse consulting services guide clients through the dynamic infusion landscape.
WeInfuse has expanded its software platform to include a complete home infusion and specialty pharmacy workflow. WeInfuse software helps organizations operate efficiently, maximize profitability, decrease burnout, and improve clinical outcomes. Its powerful, intuitive features for infusion workflows and robust reporting & analytics engine help take the confusion out of infusion. To learn more, email marketing@weinfuse.com or visit www.weinfuse.com.
Guest Author: With many years of home infusion software experience, Former CPR+ Co-Founder and CEO, Jeff Johnston, now serves as the WeInfuse Advisor on the Infusion Technology Advisory Council (ITAC) and guides our team to further advance our HIT platform solution.
