Home Infusion Therapy: A Primer PSHP 47th Annual Assembly

1. Home Infusion Therapy: A PrimerPSHP 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

2. Conflicts of Interest Disclosure I have no conflicts of interest to disclose. Lawrence Carey, PharmD PSHP 2015

3. 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

4. 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

5. 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 long-term nutritional support Lawrence Carey, PharmD PSHP 2015

6. 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

7. Setting The Table Lawrence Carey, PharmD PSHP 2015

8. 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

9. 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

10. 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

11. 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

12. The “Core Four” Major Therapies • Anti-infectives • Nutrition • Parenteral • Enteral • Chemotherapy • Pain management • Intravenous • Subcutaneous Lawrence Carey, PharmD PSHP 2015

13. 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 Lawrence Carey, PharmD PSHP 2015

14. The Referral Process Lawrence Carey, PharmD PSHP 2015

15. 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

16. Patient Selection and Eligibility • Before patient is taken onto service, consider • Medical stability • Functional status • Motivation • Reliability • “Trainability” Lawrence Carey, PharmD PSHP 2015

17. 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

18. Venous Access Devices Lawrence Carey, PharmD PSHP 2015

19. 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

20. PICCwww.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdfPICCwww.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdf Lawrence Carey, PharmD PSHP 2015

21. Tunneled Catheter, Implanted Portwww.jointcommission.org/.../CLABSI_Toolkit_Tool_1-3_Pictures_of_Central_Venous_Catheters_F-2.pdf Lawrence Carey, PharmD PSHP 2015

22. Ambulatory Pumps and Innovative Devices Lawrence Carey, PharmD PSHP 2015

23. Pumps: Moog Curlin, CADD-Solis www.moog.com, www.smiths-medical.com Lawrence Carey, PharmD PSHP 2015

24. Elastomerics: Eclipse, Infusor www.specials.fresenius-kabi.com/eclipse, www.baxter.com Lawrence Carey, PharmD PSHP 2015

25. Care Planning Lawrence Carey, PharmD PSHP 2015

26. 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

27. 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

28. Miscellaneous Issues Lawrence Carey, PharmD PSHP 2015

29. 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

30. 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

31. Back to Assessment Questions 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 long-term nutritional support Lawrence Carey, PharmD PSHP 2015

33. 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 long-term nutritional support 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. 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

36. 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

37. Questions? Lawrence Carey, PharmD PSHP 2015