Ambulatory Infusion Therapy

Ambulatory infusion therapy is a flourishing nationwide trend. Due to a confluence of health care trends, such as an upsurge in specialty medications that require expert-level administration, a population increasing in age, and steep health care costs, a challenging, but lucrative opportunity for pharmacies and pharmacists alike has begun to emerge.

The ambulatory infusion therapy market is currently estimated to represent between $9 billion and $11 billion in annual US health care expenditures.¹ According to CVS/caremark’s Insights 2013 Specialty Drug Trend Report, infused drugs make up roughly $35 billion of the specialty drug market. In addition, specialty medications are expected to increase from $92 billion in 2012 to $235 billion by 2018.² Many retail pharmacies are taking advantage of these opportunities by offering both home infusion services and alternate-site infusion.

This heightened emphasis on cost effectiveness and cost containment has prompted a necessary change from long, expensive hospital stays for the duration of infusion therapy. Technological advances have enabled safe and effective alternative methods for obtaining these infusions. Ambulatory infusion therapy enables patients to decrease or totally avoid hospital or nursing home stays and resume normal routines and work behaviors while still treating their illnesses.¹

Home infusion therapies may be provided by a variety of organizations, such as hospitals, community pharmacies, hospices, and home health agencies. They may provide all of the following and more: infusion therapies, specialty pharmacy services, respiratory equipment and clinical respiratory services (including oxygen), home medical equipment and supplies, and enteral products and supplies.³

Ambulatory infusion allows management of chronic and complex conditions such as cancer and cancer-related pain, congestive heart failure, Crohn’s disease, hemophilia, immune deficiencies, rheumatoid arthritis, hepatitis C virus infection, multiple sclerosis, chronic inflammatory disease, dehydration, and malnutrition. By far, however, the chief infusion therapies are intravenous (IV) antibiotics prescribed for cellulitis, sepsis, osteomyelitis, urinary tract infections, pneumonia, sinusitis, and more.

Pharmacist Duties

In most cases of alternate-site or home infusion, patients are being discharged from an inpatient facility, such as a hospital or nursing home, and require extensive coordination of care. Pharmacists are an important part of the patient care team focused on providing effective transitional and continual care. Once the referral for alternate-site or home infusion therapy has been approved by the third-party payer and a doctor’s order has been secured, pharmacists can begin the alternate-site or home infusion process.

Managing infusion therapies requires specialized facilities and expertise. The infusion pharmacy must ensure that infusion drugs are compounded in a sterile environment by maintaining an atmosphere conducive to keeping drugs sterile and stable and ensuring the suitability of vascular access sites based on the pH, osmolarity, and osmolality of medications, as well as the duration of therapy. Drugs must be administered with the appropriate drug-delivery device and flushed with the proper solutions between doses. Infusion pharmacists are also responsible for identifying potential drug—drug, drug–dose, or drug–catheter incompatibilities.¹

Pharmacists must perform comprehensive patient assessments, including patient history; current prescription and OTC medications; physical, emotional, and mental status; lab results; and support networks. They must also educate patients on treatment plan expectations and patient-specific goals.⁴

Although all patients must be educated to maintain complete compliance and to recognize and report all adverse drug reactions, home infusion patients must also be educated on issues that include proper infusion technique and flushing requirements, medical and disposable equipment use and troubleshooting (such as IV pumps and poles, syringes and infusion bags), storing and handling of medication, sterile technique, emergency procedures, and vascularaccess device management (sterility, cleaning, flushing).

It is essential that pharmacists continually monitor and reassess patients, and provide clinical support as therapy continues. Continuous monitoring for response to treatment, drug complications or adverse reactions, and patient compliance is required. Clinical support including pharmacokinetic dosing; monitoring peak and trough levels of appropriate medications, therapeutic selection, and serum creatinine levels; and managing adverse effects are all important parts of clinical practice. Pharmacists can also monitor nutritional status and electrolyte levels, and suggest dosing adjustments in patients receiving parenteral nutrition. As a part of the health care team, pharmacists must also coordinate with employed or subcontracted nurses, physicians, and home health agencies to provide comprehensive care for infusion therapy.

Accreditation is voluntary; however, it assures patients, referral sources, and payers that the pharmacy meets a basic level of patient care quality.³ Most third-party payers require infusion-therapy pharmacies to become accredited to validate the organization’s compliance with state and federal regulations, as well as professional standards of practice.¹ The Table provides a list of some of the accrediting organizations.

Third-Party Payers

Most commercial health plans consider home infusion therapy a medical service that is reimbursed under a patient’s medical plan rather than a prescription drug benefit. These expenses are paid for using a per diem for clinical services, supplies, and equipment; the drugs and nursing visits are paid for separately.¹ Governmentsubsidized health plans, including Medicaid, Tricare, and the Federal Employees Health Benefits Program, also cover home infusion therapy. Under Medicaid, however, several states have gaps in the coverage provided. Unfortunately, Medicare does not cover many of the home infusion expenses.¹

As for ambulatory infusion sites, most commercial insurers now recognize this type of infusion setting as an appropriate and cost-effective alternative to other infusion locations. Medicaid coverage for ambulatory infusion sites varies by state, and Medicare Part D may cover the infusion drugs, but the costs of services, supplies, and equipment are not covered. Therefore, the infusion therapy provider must determine coverage and advise the patient on third-party coverage and the expenses the patient will be personally responsible for prior to the start of service.¹

Dr. Kenny earned her doctoral degree from the University of Colorado Health Sciences Center. She has 20-plus years’ experience as a community pharmacist and is a clinical medical writer based out of Colorado Springs, Colorado. Dr. Kenny is also the Colorado Education Director for the Rocky Mountain Chapter of the American Medical Writers Association.

References

• Infusion FAQs. National Home Infusion Association website. www.nhia.org/faqs.cfm. Accessed May 18, 2015.
• 2014 Insights report: specialty drives trend. www.cvshealth.com/2014-insights-report-specialty-drives-trend. Published 2014. Accessed July 15, 2015.
• ASHP guidelines on home infusion pharmacy services. American Society of Health-System Pharmacist website. www.ashp.org/DocLibrary/BestPractices/SettingsGdlHC.aspx. Published 2014. Accessed July 16, 2015.
• Accreditation for infusion pharmacy. Joint Commission website. www.jointcommission.org/assets/1/18/OME_Pharmacy_value_flyer_4-19.pdf. Accessed July 16, 2015.
• Infusion pharmacist. Health-Care-Careers website. www.health-care-careers.com/pharmacy/infusion-pharmacist. Published February 24, 2014. Accessed June 30, 2015.