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Lawrence Carey, PharmD PSHP 2015
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Home Infusion Therapy: A PrimerPSHP 47th Annual Assembly
Lawrence Carey, PharmDAssociate Chair, Department of Pharmacy Practice
Temple University School of Pharmacy, Philadelphia
Clinical ConsultantJefferson Home Infusion Service, Philadelphia
Lawrence Carey, PharmD PSHP 2015
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Conflicts of Interest Disclosure
I have no conflicts of interest to disclose.
Lawrence Carey, PharmD PSHP 2015
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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.
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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.
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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 antibioticsb) 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 medicationsd) 66 year old ulcerative colitis patient requiring long-term nutritional support
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Assessment Question 2
Which of the following catheters would likely be considered acceptable to complete 2 more weeks of antibiotics for an endocarditis?
a) PICCb) Chest wall portc) Hickman tunneled catheterd) Triple lumen catheter inserted in jugular without suturing
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Setting The Table
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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.
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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
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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)
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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
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The “Core Four” Major Therapies
• Anti-infectives• Nutrition
– Parenteral– Enteral
• Chemotherapy• Pain management
– Intravenous– Subcutaneous
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Other Therapies Provided
• Hydration, antiemetics, CSFs– Post chemotherapy
• Inotropics – Heart failure
• Immunotherapy – IVIG
• Corticosteroids– Multiple sclerosis
• Chelation– Iron overload
• Inhalation therapy – Anti-infectives for
infections secondary to cystic fibrosis
• Specialty therapies• Catheter care
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The Referral Process
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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
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Patient Selection and Eligibility
• Before patient is taken onto service, consider– Medical stability– Functional status– Motivation– Reliability– “Trainability”
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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
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Venous Access Devices
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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
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PICCwww.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdf
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Tunneled Catheter, Implanted Portwww.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdf
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Ambulatory Pumps and Innovative Devices
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Pumps: Moog Curlin, CADD-Solis www.moog.com, www.smiths-medical.com
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Elastomerics: Eclipse, Infusor
www.specials.fresenius-kabi.com/eclipse, www.baxter.com
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Care Planning
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Carey’s Definition of Care Planning
A collaborative, interdisciplinary effort to identify goals of therapy
and a framework to meet those goals.
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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.
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Miscellaneous Issues
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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)
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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
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Back to Assessment Questions
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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 antibioticsb) 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 medicationsd) 66 year old ulcerative colitis patient requiring long-term nutritional support
Lawrence Carey, PharmD PSHP 2015
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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 antibioticsb) 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 medicationsd) 66 year old ulcerative colitis patient requiring long-term nutritional support
Lawrence Carey, PharmD PSHP 2015
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Assessment Question 2
Which of the following catheters would likely be considered acceptable to complete 2 more weeks of antibiotics for an endocarditis?
a) PICCb) Chest wall portc) Hickman tunneled catheterd) Triple lumen catheter inserted in jugular without suturing
Assessment Question 2
Which of the following catheters would likely be considered acceptable to complete 2 more weeks of antibiotics for an endocarditis?
a) PICCb) Chest wall portc) Hickman tunneled catheterd) Triple lumen catheter inserted in jugular without suturing
Lawrence Carey, PharmD PSHP 2015 35
Lawrence Carey, PharmD PSHP 2015
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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?
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Questions?
