Infusion Therapy across the Continuum of Care

Sharon M. Weinstein

THE EVOLVING HEALTH CARE ENVIRONMENT

In today’s complex health care industry, hospitals have strong financial incentives to discharge patients as soon as possible. Hospitals and other health care providers face an increasingly complex dilemma: how to provide the highest quality care at the lowest price. Because of continuing advances in medical science and technology and the influence of managed care insurance contracts, patients discharged from hospitals now can receive complex, high-level services, once available only in hospitals, in alternate care settings. The patient population receiving treatment outside the hospital ranges from critically ill newborns to chronically ill older adults. The nurse needs an array of clinical and critical thinking skills to care for these patients, often while working within an autonomous practice setting.

Cost-cutting measures have enhanced the growth of new ways to provide infusion therapy services. The growth of infusion therapy in the home and alternate clinical settings has created countless opportunities for infusion nurses nationwide. Infusion nurse specialists must assess the level of skills and services currently being provided and determine
venues where they can best use their skills, including, but not limited to settings such as the following:

Hospitals
The physician/licensed independent practitioner (LIP)’s offices
Home care
Long-term care facilities
Infusion pharmacies
Subacute settings
Teaching for other professionals
Ambulatory infusion centers (AICs)
Insertion of peripherally inserted central catheters (PICCs) and midline catheters
Hospice settings

This chapter examines alternate settings for the delivery of infusion therapy. It discusses the influence of managed care and cost-containment efforts. It thoroughly explores home infusion therapy, along with the parameters mandated by The Centers for Medicare & Medicaid Services (CMS), patient selection, the role of various health care team members, and typical infusion therapies provided in the home. It also explores additional sites for infusion therapy delivery, including hospice, subacute care, AICs, and long-term care.

INFLUENCE OF MANAGED CARE

Managed care is a system of controls to manage access, costs, and quality of health care services. The controls may include any or all of the following:

Preferred provider contracts
Prior approval/authorization
Patient education/incentives
Use review/quality assurance

Two other controls used in managed care include case management and capitation. Case management is a program to manage high-cost health care cases by exploring alternative care options to achieve the same patient outcomes while better controlling costs. Case management requires the insurance company and the provider of services (i.e., home care agency and infusion pharmacy) to discuss the necessary infusion therapy orders for the patient before the initiation of services. Usually, the parties determine and agree on a number of nurse visits necessary for the infusion therapy ordered. Periodic updates and communication continue throughout the duration of the therapy. Patients and caregivers are taught to administer the ordered therapy with limited nursing monitoring, which results in decreased nursing visits and costs.

Capitation is a system of prepayment for health care in which a provider receives a flat monthly fee for agreeing to provide specified services to members of Health Maintenance Organizations (HMOs) assigned to the provider for a contracted time (usually a year). Unlike traditional fee-for-service (FFS) systems, capitated systems pay providers, either
individually or collectively, the same amount per member each month, in advance, regardless of how many times the members use their services. Usually, risk sharing is involved, meaning that the HMO and contracted provider share the financial risks and rewards to provide cost-effective care.

Under the auspices of the managed care umbrella

Payers are changing
New delivery systems are designed around risk sharing
Payers/providers are competing for managed care savings (profits)
Competition is increasing
Risk is shifting (in both directions)
Attitudes of providers, payers, and employers are changing

Under the prior system, providers were paid on an FFS basis; they are now paid on a discounted FFS basis or by capitation. The patient base was the local community; now it is covered members/patients. The philosophy of care was to treat the disease and restore health; however, the paradigm has shifted and reflects the chronic disease focus worldwide. Providers globally are also focused on wellness. When providers are reimbursed under bundling or capitated contracts, the incentive is to keep members healthy, provide care in the least costly setting, and decrease total costs. The members are scheduled to have infusion therapy care and procedures performed in alternative clinical settings such as in the home, outpatient clinics, or AICs, rather than in the hospital to avoid the higher costs.

HOME HEALTH CARE

Home health care originally was conceived as a stage in the continuum of care after hospitalization, during which recovery and rehabilitation could continue effectively in the patient’s home at a lower cost than if furnished in a hospital. Today, home care services are viewed as low-cost alternatives for inpatient hospital care. Provision of services in the home decreases health care costs across the board and improves access to health care to all age groups in the community. The National Voluntary Consensus Standards for Home Health Care provided by the National Quality Forum (NQF, 2010) defines home health care as:

any health care services provided to clients in their homes, including but not limited to skilled nursing services, home health aide services, palliative and end-of-life care (e.g., in-home hospice services), therapies (i.e., physical, speech-language, and occupational), homemaker services/personal care, social services, infusion and pharmacy services, medical supplies, and equipment and in-home physician services (NQF, 2013).

The Federal government uses quality measures to assess how well home health agencies care for patients with certain conditions. By law, any measures reported on the Home Health Compare Web site must reflect accepted standards of health care quality.

The NQF is an independent organization created to develop and implement a strategy for health care quality measurement and public reporting. The NQF brings together stakeholders from throughout the health care industry to jointly decide which quality measures
meet certain industry standards. While NQF endorses some of the quality measures reported on Home Health Compare, it does not monitor or review the data that are collected from and about home health agencies.

NQF considers several factors when deciding whether a quality measure should be reported:

Whether it addresses care or treatment that improves people’s health or well-being
Whether it can be measured accurately and reliably in different home health agencies
Whether the information can be used to improve the quality of care or to inform patients’ decisions about where to go for care (NQF, 2013).

IV therapy in the home care setting has become well-accepted practice with the many advantages including cost saving, decreased length of hospital stays, care of patients surrounded by family and caregivers, and a lower risk of infection (O’Hanlon, 2008). Therapies that are frequently provided in the home setting include antibiotic therapy, chemotherapy, total parenteral nutrition (TPN), rehydration, and pain management. Commonly used diagnoses requiring infusion therapy in the home setting include cellulitis, sepsis, osteomyelitis, urinary tract infections, pneumonia, multiple sclerosis, cancer, gastrointestinal diseases, dehydration, and immune deficiencies (National Home Infusion Association [NHIA], 2013). Home IV therapy allows patients and families to enjoy an increased quality of life, a sense of participation in the therapy, and a feeling of control over illness. Clinicians in the home care setting need to be competent to carry out the skills as well as educate patients and/or caregivers to manage, monitor, and sometimes self-administer therapy. The expanded role of IV therapy in the home setting will only continue to grow, and how agencies and clinicians are prepared to adapt will make the difference in quality outcomes (Martel, 2012).

Quality and Safety

During the past decade, spurred by national initiatives and research, health care has increased its emphasis on safety and competence in practice. The Institute of Medicine (IOM) recommends that all health care agencies offer continuing education programs that impact quality clinical outcomes (Institute of Medicine, 2010).

Although home IV therapy has tremendous benefits, it also carries a high risk to both the patient and clinician if not performed within standards of practice. To protect both the patient and the clinician, IV therapy must only be performed by clinicians who have the specialized educational and technical skills required. Practice that is evidence based is required to meet quality standards and is effective and efficient (INS, 2011a,b). Practice that is based on “how we have always done it” or based on skills picked up “on the job” can lead to misinformation and substandard care. Quality education programs are essential to correct misinformation and teach evidence-based practice.

CLINICAL COMPETENCIES

Competencies are the knowledge and skills required to safely practice. Competency assessment is an evaluation measuring a set of skills and knowledge required to provide care. Key components are technical skills and critical thinking—with the ability to apply
these competencies appropriately. Across the continuum of care, Standards of Practice, professional guidelines, and facility policies and procedures are the framework from which competencies are developed.

Competence is defined as the individual’s capacity or potential to perform his or her own job (Billings & Halstead, 2009). Accrediting bodies such as The Joint Commission (TJC) look at competence as part of the process of maintaining a high-quality work force (TJC, 2012). Areas that are generally targeted for competency testing include the areas that are considered high risk or low volume. IV therapy is considered a high-risk procedure, and some of the therapy used in the home care setting can also be considered low volume. Risks include infection, thrombosis, hypersensitivity, infiltration/extravasations, and vein inflammation. Clinicians’ practice is guided by standards of practice such as those published by the INS as well as infection control practice guidelines such as the Centers for Disease Control and Prevention (CDC) (O’Grady et al., 2011). It is the responsibility of the organization and the practicing clinician to maintain these standards when providing infusion therapy.

Reimbursement for Home Care Services

Third-party payers for home care therapies are diverse. Most home infusion therapy services are paid on a per diem basis, a convention initiated in the 1980s, when these services were first utilized as a cost-effective substitute for inpatient care. Per diem billing allows payers to aggregate all the individual costs within a single line item for each day the patient is on service. This method streamlines claims submission processing and enhances utilization and financial management of infusion therapy services, while facilitating cost comparisons to other IV therapy treatment settings, such as acute and chronic hospitals and skilled nursing facilities (SNFs) (Table 23-1).

In the 1990s, the Health Insurance Portability and Accountability Act (HIPAA) required nationalized coding standards for all health care payers as a means of reducing the administrative costs inherent in allowing each payer to use its own coding system. As part of this process, in 2002, the federal government published a complete set of Health Care Common Procedure Coding System (HCPCS) per diem “S” codes for home infusion
therapy per diem billing. This code set is the only HIPAA-approved, comprehensive code set available to submit home infusion claims that supports the typical per diem contracts present in the commercial marketplace. Consequently, most commercial and some government insurers use the HCPCS per diem “S” codes for home infusion service billing. The codes were modified in 2013 by the Centers for Medicare & Medicaid Services (CMS). The HCPCS per diem “S” codes specifically include administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment. All drugs, enteral formulae, and nursing visits are coded and billed separately on the claim for reimbursement (Table 23-2).

TABLE 23-1 MEDICARE PAYMENT RATES FOR INTRAVENOUS DRUG INFUSIONS ACROSS SETTINGS, 2012

	Inpatient	SNF	Home Care
Drug	Packaged within Diagnostic Related Group (DRG) payment	Packaged within SNF PPS payment	Paid separately to pharmacy
Supplies and equipment	Within DRG	Within PPS	Limited supply coverage for gravity infusion under home health benefit
Drug administration	Within DRG	Within PPS	Within home health PPS payment
Cost sharing	Inpatient hospital deductible of $1,156	None for days 1-20 and $144.50 per day for days 21-100	None for home health

Combined with a working knowledge of precisely what types of therapy that various payer sources cover, it is essential that the written record of care, including the diagnosis, be consistent with the type of therapy provided. As in the tertiary care setting, a series of codes has been developed to reflect procedures (current procedural terminology [CPT]) and diagnoses (International Statistical Classification of Diseases and Related Health Problems
[ICD10]). ICD is a medical classification list by the World Health Organization (WHO); it codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease.

TABLE 23-2 SELECT EXAMPLES OF HOME INFUSION CODES

Description		Interval	HCPCS Code
1.	Home infusion therapy, antibiotic, antiviral, or antifungal, once every 3 h; administrative services, pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Q 3 h	S9497
2.	Home infusion therapy, antibiotic, antiviral, or antifungal, once every 4 h; administrative services, pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Q 4 h	S9504
3.	Home infusion therapy, antibiotic, antiviral, or antifungal, once every 6 h; administrative services, pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Q 6 h	S9503
4.	Home infusion therapy, antibiotic, antiviral, or antifungal, once every 8 h; administrative services, pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Q 8 h	S9502
5.	Home infusion therapy, antibiotic, antiviral, or antifungal, once every 12 h; administrative services, pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Q 12 h	S9501
6.	Home infusion therapy, antibiotic, antiviral, or antifungal, once every 24 h; administrative services, pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Q 24 h	S9500
7.	Home infusion therapy, continuous (24 h or more) chemotherapy infusion, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Continuous—24 h or more	S9330

The CPT code set is maintained by the American Medical Association through the CPT Editorial Panel (AMA, 2013). The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians/LIPs, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October. The current version is the CPT 2013. It is available in both a standard edition and a professional edition.

CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim ICD-10 (effective October 2013).

CPT is currently identified by the Centers for Medicare & Medicaid Services as level 1 of the Health Care Procedure Coding System.

Pay for Performance (P4P)

Long before the passage of the Patient Protection and Affordable Care Act of 2010, a movement has been in place to alter the practice of medicine. For years, performance in medicine was determined by a patient’s outcome; today’s focus is on pay for performance (P4P) programs. P4P programs are performance-based payment arrangements that align financial rewards with improved outcomes and changed behavior. The impetus behind P4P originated in response to rising medical costs, growth in chronic care conditions, and consumer demands for efficiency and improvements in the quality of care (Baker, 2003).

P4P programs typically include three kinds of performance measures: structural measures, which engage key systems to improve quality of care; process measures, which assess performance against evidence-based guidelines and protocols; and outcome measures, which focus on a patient’s progress and condition.

Alternatives to P4P

Many providers and payers are exploring Integrated Provider Performance Incentive Plans (IPPIPs), Alternative Quality Contracts (AQCs), and Accountable Care Organizations (ACOs) as alternatives to traditional P4P programs. While they are similar to P4P, the focus is on the flexibility of their structure, payments, and risk assumption.

An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. In the Affordable Care Act (ACA), an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least 3 years.

SPECIFIC CONSIDERATIONS RELATED TO MEDICARE

Home care has been one of the fastest growing benefits in the Medicare program, which is the largest purchaser of home health services in the United States. The number of Medicare beneficiaries has been expanding by approximately 2% each year (Disbrow) and is expected to accelerate even more rapidly with the enrollment of the baby-boomer generation.
Eligibility for the home care benefit within the Medicare program requires that the following conditions be met:

The patient must be at least 65 years of age and have received acceptance for Medicare coverage.
The patient must be homebound. In other words, the patient must be confined to the home in such a way that leaving requires considerable effort and the assistance of another person or an adaptive device such as a cane, walker, or wheelchair. Absences from the home must be infrequent, of short duration, and for the purposes of receiving additional medical care.
Home care services must be provided under a Plan of Care established and reviewed by a licensed physician/LIP directly involved in the patient’s care. Written physician/LIP orders are required for home care.
The home care services the patient needs must be skilled intermittent nursing, physical therapy, occupational therapy, or speech therapy.
A certified Medicare program provider who agrees to adhere to the extensive Medicare Conditions of Participation regulations and requirements and accepts Medicare’s reimbursement for the provision of those services must provide home care (CMS, 2013).

Services eligible for Medicare reimbursement fall under Part A or B. Implementation of a prospective payment system (PPS) reduced the cost of hospitalization by shifting the end point of care to the home, thereby contributing to the growth of the alternative care delivery system. The home health PPS is composed of six main features, detailed in Box 23-1.

Patient Criteria for Home Care Infusion Therapy

In addition to meeting Medicare criteria for home care, patients must meet other criteria to qualify as candidates for home infusion therapy (Box 23-2). Patients are responsible for specific aspects of their infusion therapy, including administration of the ordered therapy, monitoring, catheter line management, operation of electronic infusion equipment (if necessary), and other duties. The patient, caregiver, or both are taught to identify signs and symptoms of complications that must be reported to the nurse and are also taught how to identify any other situations that require immediate attention. A 24-hour emergency phone number is provided to patients and families should they need help.

APPROPRIATE DIAGNOSIS

The type of drug therapy ordered may determine a patient’s appropriateness for home infusion therapy. Many drugs given in the inpatient setting are acceptable for home infusion programs.

The therapy ordered must be consistent with the patient’s diagnosis and ability to receive care in the home. Common diagnoses for antibiotic therapy include osteomyelitis, otitis media, sinusitis, cryptococcal meningitis, pneumonia, subacute bacterial endocarditis,
primary bacteremia, cellulitis, urinary tract infections, pyelonephritis, septic arthritis, histoplasmosis, peritonitis, toxic shock syndrome, Lyme disease, rickettsial infection, opportunistic infections related to acquired immunodeficiency syndrome, and many others. All types of patients with cancer are appropriate candidates for home infusion of antineoplastic agents, especially combination protocols. Fluorouracil (5-FU) is a common antineoplastic agent infused in the home setting. Additional infusion therapies for the oncology patient may include nutritional support, pain management, antiemetics, antibiotics, and leucovorin rescue regimens.

BOX 23-1 SIX FEATURES OF THE HOME CARE PPS

1. Payment for the 60-day episode

An agency is paid half of the estimated base payment for the full 60 days as soon as the fiscal intermediary receives the initial claim and the residual at the close of the 60-day episode.

2. Case-mix adjustment—Adjusting payment for a beneficiary’s condition and needs

The HHA assesses the patient’s condition and likely skilled nursing care, therapy, medical social services, and home health aide service needs, at the beginning of the episode of care. The assessment must be done for each subsequent episode of care a patient receives.

3. Outlier payments—Paying more for the care of the costliest beneficiaries

Additional payments are made to the 60-day case-mix adjusted episode payments for beneficiaries who incur unusually large costs.

4. Adjustments for beneficiaries who require only a few visits during the 60-day episode

The PPS has a low-utilization payment adjustment for those whose episodes consist of four or fewer visits. These episodes will be paid the standardized, service-specific per-visit amount multiplied by the number of visits actually provided during the episode.

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