Hands-on Care in the Home Setting

Successful at-home administration of specialty medications requires extensive preparation and constant assessment of the patient's response by the specialty therapy nurse.

As a patient prepares to receive a specialty therapy in the home care setting, many aspects of his or her care need to be coordinated. Along with the physician and specialty pharmacy staff, specialty therapy nurses are key members of the patient’s therapy care team. The specialty therapy nurse has advanced education, training, and expertise in the administration of drugs and biologics.

For 13 of the past 14 years, Gallup polling has shown that nurses are ranked the most trusted professionals in America—and for good reason.¹ Nurses work face to face with the patient and family, taking the time to explain and teach, and also hold the hand of any patient who needs reassurance.

Multiple components are involved in conducting a specialty therapy visit in the home care setting. These consist of the pre-visit preparation, the visit, troubleshooting, and the post visit care. Each step encompasses a multitude of tasks and assessments required to complete the administration successfully.

Pre-Visit Preparation

Prior to the visit taking place, the nurse verifies that the patient has received the drug, supplies, and equipment. The nurse asks which support persons will attend the visit for medication administration training and if any language barriers exist that may interfere with the therapy administration or education.

Upon arrival at the patient’s home, an inventory of medication, supplies, and equipment is performed by the nurse. The nurse educates the patient on pro-per storage of supplies and medication. Most likely, the supplies are still in the box that the specialty pharmacy shipped them in. The nurse assists the patient in removing the supplies and equipment. The delivery ticket is used to educate the patient on how to identify the supplies and the quantity needed for the reorder prior to the next delivery.

The nurse reviews any documentation that requires the patient’s signature with the patient. Instruction is initiated on the patient’s disease, therapy, the potential risks and benefits of therapy in the home care setting, and the plan of care. Once the patient acknowledges that he or she understands the information, the nurse obtains the patient’s consent for care.

The Visit

To initiate a visit in the home, the nurse performs a patient assessment. The patient is evaluated for dehydration and symptoms of cold, flu, or infection. The patient’s emotional status is assessed for readiness to learn and receive the therapy. Any issues, concerns, or symptoms that need to be addressed prior to the start of therapy are evaluated and reported to the pharmacist and/or physician.

The home is assessed to determine whether the environment is conducive to learning and administration of the therapy. The nurse must identify potential barriers that could interfere with the therapy and assess how to remove those barriers prior to the start of therapy. Examples of barriers are small children, animals, inadequate lighting, and disruptive family members.

The nurse then proceeds to establishing intravenous (IV) access prior to the preparation of the drug. Once IV access is established, the nurse begins the reconstitution, preparation, and administration of the therapy. Depending on the therapy, reconstitution could be simple or very complex. Adequate time must be taken to properly reconstitute the drug in the home environment.

Once the drug is reconstituted and prepared, the nurse obtains baseline vital signs (VSs) and begins the administration per protocol. The patient is monitored throughout the entire administration and assessed for any side effects or adverse events, with dosage adjustments made per protocol.

Troubleshooting

One complication that could delay therapy initiation or extend the therapy visit is unsuccessful venous access via a peripheral or central venous access device. It may be necessary to reschedule the visit if the problem cannot be resolved immediately and requires further follow-up.

Adverse reactions to the therapy require that the nurse make quick decisions on the course of action. It may be necessary to slow down or briefly stop the infusion before restarting or to administer additional medications before continuing with the therapy.

If the patient experiences a serious adverse reaction, the nurse must then initiate the emergency plan by discontinuing therapy, dialing 911, and administering medications to treat anaphylaxis.

Post Visit Care

Documentation is completed during the home care visit to validate the patient’s status while receiving the therapy. Post therapy, the nurse assesses whether the patient is alert and oriented, has stable VSs, has provider and emergency contact information readily available, and understands the potential of delayed adverse events requiring immediate medical attention.

At the conclusion of the visit, the nurse submits the appropriate documentation to the specialty pharmacy and physician and notifies them of any issues or concerns that require further follow-up.

Many times, the length of the visit is estimated in relation to the type of therapy and dosage; however, no one can predict what the specialty therapy nurse will encounter in the home care setting. At every phase of the visit, the nurse may encounter an issue, concern, or barrier that will need to be addressed in order to move forward with the therapy. It is also important to realize that the nurse is solo in the home with only telecommunication for support. The specialty therapy nurse must use good judgment, have keen assessment skills, and be able to react under pressure. SPT

References

• Nurses remain most trusted professional in America, Gallup survey says. Advance Healthcare Network for Nurses website. http://nursing.advanceweb.com/news/National-News/Nurses-Remain-Most-Trusted-Professionals-in-America-Gallup-Survey-says.aspx. Published December 5, 2012. Accessed March 1, 2014.

About the Author

Cherylann Gregory, RN, BSN, is founder and president of the Specialty Pharmacy Nursing Network (SPNN) and has more than 30 years of experience as an oncology/infusion nurse. Cherylann serves on the Specialty Pharmacy Times editorial board.