Current Status of Home Infusion Therapy KATHLEEN S. CROCKER, MSN, RN, CNA, CNSN Nursing Services, Critical Care America, Westborough, Massachusetts

ABSTRACT: The growth of home infusion therapy has been influenced by external forces that have changed the access to and use of health care. As home infusion therapy expands into other alternate care settings, clinicians, regardless of discipline, must be cognizant of how daily clinical practice is affected by regulations, changes in legislation, and consumerism.

settings outside of the hospital environment. What began as a simple desire to provide a better quality of life outside of the hospital setting for patients who require long-term parenteral nutrition has developed into a recognized and appropriate environment for professional practice and the provision of quality patient care. Nutrition support pioneers may not have envisioned that their work would establish standards of care and lead to access device and infusion control prototypes that are the basis of today’s infusion-related technology and patient care activities. Likewise, these early pioneers could not have imagined that external factors such as complex reimbursement methods, licensing and accreditation organizations, consumerism and customer satisfaction, and would determine the direction that the provision of care would take. The current infusion therapies that are administered at home are listed in Table 1. These therapies may be prescribed for patients who are already receiving home parenteral or enteral nutrition (HPEN). It is thought that at least 35% of those who receive HPEN require another infusion therapy. Conversely, many patients who are discharged on other infusion therapies may benefit from the use of HPEN as adjunctive therapy for the treatment of their primary disease. Home infusion therapy (HIT) accounts for a large portion of alternate-site infusion therapy; however, other nonhospital care settings have quickly emerged. The development of surgicenters, free-standing and community-based infusion suites, and expanded physicians’ office practices have broadened the &dquo;hospital without walls&dquo; concept of alternate-site care. Such settings enable infusion therapy to be given to patients

LU CREDIT

LEARNING OBJECTIVES-After reading &dquo;Current Status of Home Infusion Therapy&dquo; by Kathleen S. Crocker, the reader will be able to: 1. Define the duration of a &dquo;permanently inoperative internal body organ or function&dquo; as required for Medicare benefits for parenteral nutrition. 2. Designate the types of management strategies that characterize service-oriented organizations today. 3. Identify legislation and standards that have had a major effect on home infusion therapy.

Health care providers who were involved in the development of parenteral nutrition support could not have imagined the significance of their early work to the current use of infusion therapies in health care

Address for reprints: Kathleen S. Crocker, MSN, RN, CNA, CNSN, National Director of Nursing, Critical Care America, 50 Washington Street, Westborough, MA 015811

256

257

who require a higher level of medically monitored care, but who do not require hospitalization for their care. As these newer alternate sites of care become more common, more patients will receive care in different health care environments. Patients will receive care in a continuum of health care environments, moving in and out of settings, as their ability for self-care and their need for supervised care change. This article outlines the current status of HIT service and highlights specific external forces that have supported the evolution of clinical practice in HIT. Clinical training and experiences within the hospital did not expose clinicians to information such as changes in health care benefits, the influence of regulatory bodies, or market strategies that focused on customer satisfaction. Clinicians who practice in the HIT segment of health care are well aware of how such forces influence their clinical practice.

Table 1. Home infusion therapy

THE HIT PROVIDER MODEL

Organizational Structure. There are many organizational models for HIT providers. The first patients who were discharged on HPEN received all of their training before being discharged, picked up their pharmaceutical and medical supplies at the hospital pharmacy, compounded their own drugs at home, and received medical follow-up at the physician’s office or in the outpatient clinic. This model evolved into one in which a hospital discharge planner referred patients to an outside service organization. The independent provider compounded the pharmaceuticals, provided the medical supplies and infusion pump, and employed nurses who visited the patient at home to reinforce what had been taught by the hospital staff. There are

many combinations of organizational structures and relationships. Providers may be for-profit or not-for-

profit, private or public companies, hospital-based programs, independent companies, or divisions of large medical suppliers. Providers may be small, &dquo;mom and pop&dquo; operations, multimillion dollar organizations with a national network of of~ces, or organizations that are linked to other related organizations through shared services, joint ventures, or preferred provider agreements. Successful HIT providers, regardless of the type

organizational structure, maintain a local presence within well-defined medical communities and provide a full range of infusion services within an environment of decentralized decision-making to meet customer needs in a timely manner. As many as 4500 of senior

separate providers of HIT currently exist, but as few as 10 of these have 40% of the market share. Of these 10, two national

provider organizations have 30% of the market share.1 Most providers started small, with several employees, and opened offices based only on promises of patient referrals. The first employees typically are a nurse and a pharmacist, who each have administrative responsibilities related to reimbursement, supply inventory, and marketing in addition to their patient care duties. As patient referrals increase, a support staffand additional clinicians are hired. Offices that serve an expanding metropolitan region can have more than 100 employees and provide services to more than 500 patients. Because many patients return to the hospital only when they have serious illnesses or acute-care needs, HIT providers have expanded the depth of their clinical services. In addition to the nurse and pharmacist, the services of registered dietitians, medical social workers, physician assistants, and/or nurse practitioners are often offered. Opportunities for specialty practice increase as certain patient populations such as patients with human immunodeficiency virus infections, bone marrow transplantation patients, and neonates receive focused (niche market) services. The Service Process. Despite variations in the size and number of services, the service process is similar for HIT providers (Fig 1). Verification of health benefits and price negotiations occur at the time of referral; assessment of the patient and the receipt of treatment orders are completed by the nurse and pharmacist, and pharmaceuticals are compounded, packaged with the ancillary supplies, and delivered to the patient’s home. The nurse meets the patient in the hospital for the first encounter, or as is now more often the case, meets the patient in the physician’s office or at the patient’s home. A delivery schedule for supplies and a schedule for visits are determined, on the basis of an assessment of the patient’s need for supervision and support. Routine clinical feedback is given to the physician and utilization reports may be prepared for the payor. Billing and collection procedures can take place locally or at an-

258

other location, depending tional structure.

on

the

provider’s organiza-

Service Intensity. The basic service process works amazingly well. The challenges that face the provider staff relate to requests from referral sources to accept sicker patients of all ages, to provide complex therapies with narrow therapeutic ranges, and to initiate therapy at a moment’s notice, 7 days a week, 24 hours a day. A provider must be proactive and innovative to develop systems that allow services to be provided in a consistently safe manner with positive therapeutic outcomes. With increasing competition, the choice of whether to accept a specific referral is limited. The provider must constantly ask, &dquo;What must I do to assure that I can meet the needs of the referral source without putting the patient or my staff at risk?&dquo; Today, the patient often does not start therapy in the hospital, may not be clinically stable, is not capable of self-care, or has a caregiver burdened with other responsibilities. The

patient may not have sufficient benefits to cover the prescribed care. Guidelines for the acceptance of patients are now more flexible, as clinically labile patients can be cared for by an increased use of costly services. The philosophy of home care has always been to return the patient to independent functioning and selfcare as quickly as possible. Chronic diseases, complex therapies, and the increased potential for adverse reactions necessitate intense clinical involvement over a longer time. In 1984, a home visit for intravenous antibiotics administered via a short, peripheral catheter averaged 20 minutes. Today, a visit to a patient who receives multiple intravenous antibiotics, who requires the placement of a peripherally inserted, central catheter and peak and trough blood samples drawn, often requires 2 or more hours of nursing time. Additional pharmacy time is required to assess potential drug/drug interactions, to assess serum drug concentrations and to consult with the physician about changes in dosage. The administration of two units of packed red blood cells can require up to three home visits and as many as 10 hours of professional time.22 Within the course of a day’s work a clinician may be in a metropolitan neighborhood to teach a patient how to use patient-controlled analgesia and then travel many miles to the countryside to reinsert a midline catheter for a farmer who inadvertently pulled out the catheter while working in the fields. In some neighborhoods, the clinician may need to be accompanied by a

security guard or need the services of a translator. The clinician may arrive to perform an initial assessment only to find that the patient is without a caregiver and is too weak to climb the stairs to open the front door.

Clinical Management Challenges. Providers must expert clinicians who can provide high-quality patient care, make independent decisions based on limited information, and respond to unanticipated changes in the patient’s clinical condition. In a small business, each clinician is a well-trained generalist who is able to provide a wide range of therapies to different patient populations. In a larger operation, there are more opportunities for specialization; clinicians can be assigned to specific patient populations. Even clinicians in specialty practice, however, must be knowledgeable about all of the therapies and services that are provided because many patients receive multiple therapies. As new therapies and drugs become acceptable for HIT, the staff must have easy access to inservice programs, medical publications, and other experienced clinicians who can act as mentors. attract and retain

The retention of expert staff is vital. HIT providers compete with hospitals for experienced clinical staff. 1. The service process flow typical of current home infusion therapy providers. This process provides direct services to patients and supportive services to physicians and payors. Data collection for quality improvement analysis is a natural part of day-to-day operations. CQI, Continu-

Figure

ous

quality improvement.

Clinicians who have critical care or specialty backgrounds, years of experience, and advanced degrees are in particular demand. The salaries and benefit packages that attract and retain staff represent a large percentage of operational expenses. Staff retention can also relate to the procedures that deal with safety

259

during travel or to the exposure to blood-borne pathogens.

Clinical managers must control expenses by analyz-

ing staff productivity data

to justify staffing needs. Most managers collect data about each visit to bill for skilled services. Other activities, described as indirect care, must also be quantified. The time for activities such as travel, pharmacy production, documentation, patient care coordination (or case management), and orientation must be included to determine actual staffing requirements. As many as 4 hours of indirect time are spent for every hour of direct patient care.

Expansion of Service,. The service process adapts well to other alternate settings and to the hospital without walls concept. The term &dquo;seamless&dquo; has been used to describe a patient’s transition from one site of care to another. HIT providers have broadened their scope of services to support the seamless concept of care and have used their facilities and staff to support the new opportunities. Clinicians who were hired to provide infusion therapy in the home may work within several care settings to monitor a patient through his or her course of therapy. For example, a nurse who is experienced in chemotherapy may visit a patient at home to initiate hydration therapy, in the physician’s office to administer a vesicant and initiate a continuous infusion, and then return to the patient’s home to monitor the patient’s response and provide clinical feedback to the physician. The ultimate differentiation between one provider and another is the depth of the services each provides, the responsiveness to customer needs, the expertise of the clinical staff, and of course, the outcomes of the patients-all factors that affect the cost of services. As HIT providers become more operationally complex and expand their services to meet customer demand, the overhead costs to maintain a physical plant and retain expert staff will increase and narrow the cost differences between hospital care and alternate-site care. INFLUENCE OF REGULATORY AND ACCREDITATION ORGANIZATIONS

In the early 1980s, the American Bar Association issued a report entitled, &dquo;The Black Box of Healthcare.&dquo; Although this report did not discuss HIT, it raised the &dquo;

consciousness of many consumer and governmental groups about inconsistent care being provided and the potential for fraud and abuse in this segment of health care. Indeed, in the early days, some HIT providers consisted of a few supplies, tables and chairs, a laminar flow hood placed in the back of a warehouse, and a few

dedicated clinicians who worked around the clock. The philosophy of &dquo;make up the rules as you go along&dquo; was required because focused standards of practice and guidelines lagged behind the expansion of HIT. Clinicians adapted hospital policies and procedures to the home setting. Providers differentiated themselves from one another by the establishment of internal guidelines

that were more strict than those of external bodies or of competitors. Table 2 provides a partial list of groups or organizations that issue regulations or standards of practice for HIT.

Regulatory Bodies. Regulations have been a part of HIT since its beginnings. Clinicians must abide by State Practice Acts; all or part of the office must be licensed as a retail pharmacy; and in some states, a license or Certificate of Need must be obtained to offer skilled nursing services. To receive Medicare reimbursement, a provider must be certified in accordance with Medicare’s Conditions of Participation and must obtain specific governmental provider numbers to bill for skilled nursing services, drugs, supplies, and durable medical equipment. Standards that relate to the pharmacy compound-

ing facility (sterile product complex) are not new, nor are the standards for the use of biologic safety cabinets.

Table 2. for HIT

Organizations that issue regulations or standards

260

These standards, originally written for hospital pharmacy practice, have been applied to HIT. Guidelines that will soon be released by the United States Pharmacopeia (USP) will provide new standards for the structure of the environment for compounding sterile products for HIT (eg, Class 10,000 cleanroom, Class 100 compounding environment, presence of an anteroom, and restricted access to the area). The USP guidelines are standards that may be adopted by State Boards of Pharmacy. Many HIT providers will need to make structural changes within their current compounding facilities to adhere to these guidelines. Nurses have functioned under the guidance of individual State Nurse Practice Acts that, in general, allow the nurse to perform functions for which he or she has been trained or for which prescriptive orders from a licensed physician exist. Some states restrict specific functions, such as the insertion of peripherally inserted catheters or the involvement of the registered nurse in the use of anesthetic agents for pain management. Providers must comply with recently released Occupational Safety and Health Administration (OSHA) guidelines for the handling and follow-up of exposure to blood and body fluids, Environmental ProtectionAgency regulations related to infectious and hazardous waste management, and the new American Disabilities Act. Substantial fines can result from noncompliance. Standards o f Practice. Standards of practice vary in form and structure but originate from several professional organizations such as the Intravenous Nurses Society, Oncology Nurses Society, American Society for Parenteral and Enteral Nutrition, American Society of Hospital Pharmacy, and the National Alliance of Infusion Therapy. Each provider also develops its own clinical policies and procedures. The most influential standards are those that were implemented by the Joint Commission on the Accreditation of Health-Care Organizations (JCAHO) in 1988. The home care standards of the JCAHO became the benchmark by which quality in HIT was initially measured. Community Health Accreditation Program (CHAP, a National League of Nursing program) was until recently the accrediting body for traditional home health agencies and now also accredits HIT providers. CHAP recently received deemed status with Medicare (JCAHO awaits its deemed status approval at the time of this writing). With deemed status, a provider who wishes to obtain Medicare certification can receive it via survey by another accreditation organization that the Health Care Financing Administration (HCFA) has appointed. For example, a provider can become Medicare certified and CHAP accredited by going through the CHAP program. Although accreditation is voluntary, a provider who does not seek accreditation is at risk of losing referrals and reimbursement opportunities. Today, the need to monitor and assure compliance with all related regulations and accreditation stan-

dards receives a great deal of attention within provider organizations. Staff and financial resources must be dedicated to monitoring and enforcement. HEALTH CARE BENEFITS AND REIMBURSEMENT PRACTICES

Advances in biotechnology and increased clinical acceptance are the usual forces that fuel the growth of a new segment of health care. Indeed, home parenteral nutrition succeeded because of improved access devices, pharmaceutical advances in intravenous nutrition formulations, and a better understanding of energy and protein metabolism. Economic events that have changed health care reimbursement practices continue to have the greatest influence on the growth and patterns of professional practice in HIT. Health care expenses currently exceed 12% of this country’s gross national product (GNP). Despite continued restrictions on health care expenditures, factors such as an aging population and the continued development of expensive medical technology are expected to result in an increase in this figure to as much as 20% by the year 2001.3 HIT currently represents approximately $3 billion of the current governmental expenditures devoted to hospital care in the United States. Although this seems a large expenditure, it represents only 1% of targeted expenditure. As cost containment continues to focus on decreasing hospital lengths of

stay, and, in

some

cases,

preventing hospitalization,

there are many opportunities to use HIT. The legislation described below affects patients who receive care that is reimbursed by Medicare. The Medicare guidelines have been incorporated into the reimbursement practices of many private payors. Nongovernmental payors have broadened policy benefits related to out-of-hospital care. These expanded benefits, however, are accompanied by tighter utilization review requirements that often include the assignment of a case manager. Case managers oversee the utilization of services and often negotiate the price of services to decrease cost shifting. Cost shifting is a practice used by some providers to offset underpayment from government programs by charging higher fees to the private indemnity insurers. Medicare and HPEN Therapy. Legislation that directly affects many patients who receive HPEN is the &dquo;prosthetic device&dquo; benefit of Medicare, Part B. This is the source of payment for the majority of long-term HPEN patients. To qualify for this benefit, patients must meet the &dquo;test of permanency&dquo;; that is, the prosthetic device must replace a permanently inoperative internal body organ or its function. Permanency has been interpreted to be a duration of at least 90 days. People under the age of 65 may qualify for this benefit if they are classified as permanently disabled, a process that occurs in most cases after 2 years of documented medical disability. Reimbursement for this benefit is a

261

and complex process that requires specific documentation of the need and the use of services. Reimbursement allowables and denials vary, depending on the interpretation of intermediary carriers assigned to administer this benefit for HCFA.

lengthy

Health Maintenance Organization Assistance Act. A second piece of legislation that affected health care costs and services is the Health Maintenance Organization (HMO) Assistance Act of 1973. Because of the increased cost of health care since the passage of Medicare legislation during the 1960s, the HMO Assistance Act was passed to create payment systems that provide financial incentives for cost containment. HMOs agreed to provide a broad range of health care services for a predetermined fee, regardless of how frequently services are used. This fee is paid by the patient or his or her employer. This payment system removed any financial incentives to provide more than the actual level of needed services. HMOs profit by &dquo;managing&dquo; the use and the cost of care. Patients or employers benefit because they know in advance what their annual health care costs will be. The HMO Assistance Act also created competition among providers. In the 1970s, physicians and hospitals did not compete for patients on the basis of prices. Consumers did not shop for services on the basis of prices because they were confident that their insurance would pay for most of the health care they required. These new financial incentives were predicted to cause the health care industry to act like other industries that had implemented cost containment strategies. The full effect of the HMO Assistance Act has been felt since the 1980s. The number of patients who are enrolled in managed care plans continues to rise and providers compete with one another for preferred provider contracts. Flat per diem (daily) fees that disregard the intensity of the services provided have replaced the traditional fee-for-service payment systems. Fee-forservice payments are still common among some indemnity plans and payment is based on the itemized charges submitted. Per diem rates are often negotiated at the time of referral. &dquo;Capitated rates&dquo; are the newest payment method in managed care. Historically, capitation referred to the payment received by an HMO from a payor; for a fixed monthly fee, enrollees received relatively unlimited services. Capitation has now been extended in

concept to mean a negotiated per-enrollee payment to

providers in exchange for an exclusive service contract. For example, under capitation, an HIT provider receives a predetermined monthly payment that depends on the number of enrollees in the managed care organization. Out of this payment, HIT goods and services are provided to an enrollee when requested. Thus, instead of therapy-specific, predetermined per diem fees (one fee for total parenteral nutrition, another fee for pain management), the provider receives the same payment for each patient regardless of the therapy

requested. Capitated rates are renegotiated during a contract period only when the level of service intensity exceeds certain predefined &dquo;risk corridors&dquo; or outliers. Diagnosis-Related Groups Prospective Payment System. By far, the most influential piece of health care legislation has been the diagnosis-related groups (DRG) prospective payment system for hospitalized Medicare recipients, enacted in 1983. No longer are hospital services rendered, billed, and reimbursed on a fee-forservice basis. Payment is based on specific groups of diagnoses that are associated with well-defined lengths of stay (LOS). Simply stated, a hospital receives the same payment regardless of the patient’s LOS, although exceptions are made for specific diagnostic outliers. There are financial incentives for hospitals to discharge patients earlier. The rapid growth in HIT services is directly related to this legislation. Home care providers expanded their services to care for more referrals, especially for high-tech therapies. The DRG payment system was not accompanied by a broadening of Medicare benefits related to high-tech home care, or a reimbursement strategy for the physician. If a patient remains in the hospital for the defined LOS or less, Medicare reimbursement to the hospital equals or exceeds costs. For similar services in the home setting, reimbursement is often for 80% of approved charges, the services must be covered under a home care benefit, and certain restrictions must be met. For example, the patient must be homebound to qualify for skilled services. This creates a dilemma for many patients on Medicare who do not have supplemental insurance. The failure to enact the Medicare Catastrophic Act of 1988, which would have provided Medicare reimbursement for infusion therapies such as intravenous antibiotics, has forced many patients who could be treated at home to remain hospitalized until their therapy is complete. HIT providers do set aside specific funds to care for a percentage of patients who do not have insurance coverage. For the physician, payments for daily hospital visits decreased along with the patient’s LOS, but the time required to manage the patient’s home care treatment increased. The majority of the physician’s clinical management time was spent in the following activities: reviewing laboratory results and nurses’ notes, giving prescriptive orders to the provider, being on-call for changes in clinical status, and completing and signing an increasing amount of required paperwork so that the provider would receive third-party reimbursement. Some physicians, pressured by the hospital to discharge patients early and besieged by HIT providers for referrals, entered into agreements with providers who were willing to pay the physician a &dquo;management fee&dquo; for each referral. This type of financial arrangement, among others, has been viewed by some as a kickback to physicians in exchange for referrals. Such practices are under increased scrutiny. Nevertheless, the physician’s responsibilities for managing the HIT pa-

262

tient are substantial and how or if physicians should be reimbursed for their time spent on home care has not been settled. Some third-party payors do reimburse physicians for home care management. The National Alliance of Infusion Therapy advocates to both governmental and private third-party payors direct reimbursement to physicians for their home health care medical management services.

Resource-Based Relative Value Scale. Medicare

implemented a new physician payment method in January 1992 that replaced the &dquo;reasonable charge&dquo; system that was introduced 25 years ago. The new payment system is based on a Resource-Based Relative Value Scale (RBRVS). RBRVS payments are based on the resources (as measured by Relative Value Units)

actually used to render service and are adjusted by regional differences in costs. The effect of this payment reform will not be a reduction in total spending, but a redistribution of the funds allocated to reimbursement of physicians. Of particular interest is the effect that this reform has had on oncology physician practices. Oncologists are reimbursed at a higher rate when antineoplastic

Table 3. HIT indicators*

drugs are administered within their office rather than a hospital outpatient setting. It is anticipated that office chemotherapy programs will increase but that the oncologist will contract with other providers, such as HIT providers, to provide supportive services.

in

As health care enters the 21st century, the burden of proof will be on providers, who will have to demonstrate their ability to achieve positive therapeutic outcomes to justify the cost of the intensity of services they provide. Clinicians will be asked not only to provide quality patient care but also to document that care

extensively. CUSTOMER SATISFACTION

Customer Service. Customer service and

quality

improvement are important to HIT providers. Successful business strategies center on a &dquo;market needs&dquo; philosophy. Customers are asked what they need and the provider is flexible, innovative, and uses a variety of resources to ensure that the customers’ needs are met. Tom Peters,4 and more recently Stephen Covey5 and Neil Rackham,6 have described how to be successful in a service-oriented business. The successes of service organizations such as Disney, Federal Express, and Wal-Mart are often used as examples. These organizations listened to their customers and ensured that the services they provided were of a consistently high quality. Service organizations now embrace a management strategy that supports decentralization, innovation, and decision-making by all levels of employees. The employees closest to the customer have the authority to take immediate action if a customer complains. Customer input is asked for and acted upon. Customer satisfaction has been shown to do more for an

organization’s profitability than just containing operational costs. Reichheld and Sasser have said customers who change to another provider can tell you exactly what parts of the business you must improve.’

* Developed by the Home Infusion Therapy Indicator Task Force, JCAHO, 1991.

Quality Improvement. Service organizations now heed the advice of their manufacturing counterparts; quality does not improve unless it is measured. Clinicians are familiar with quality control and with quality assurance programs that focus on improving systems by investigating errors after the fact. Today, quality improvement efforts must be continuous and involve as many levels of the organization as possible. These programs seek to improve the processes of care, and any factor that might limit the quality of the services is revised or removed. To be effective, quality improvement efforts should be part of day-to-day operations. HIT providers collect data for analysis over the course of a patient’s treatment. Quality improvement efforts are cost effective but, more importantly, are investments in customer retention. The JCAHO implemented their Agenda for Change in the late 1980s. Emphasis is no longer placed on the organization’s &dquo;potential&dquo; ability to meet standards but

263 on the actual measurement of whether the standards indeed have been met. HIT providers who have gone through the JCAHO accreditation process have experienced this change in focus firsthand. The JCAHO concept of continuous indicators was extended to the home infusion arena in 1991. Six indicators have been identified (Table 3).8 Data from these six indicators are subcategorized, and these indicators will eventually provide an organization with many datum points for

evaluation. ConsumerActiUism. Another societal change that is on customers in health care results from consumerism. Consumers demand health care information, demand to participate in health care decisions that directly affect them, and expect that the health care they receive will be of the highest possible quality. Consumers want to receive their health care close to their homes, with minimal interruption to their family life and work schedules. They also wish to maximize the use of their health care dollars, especially when chronic illness quickly depletes their lifetime maximum insurance benefits. Patients with human immunodeficiency virus infections and AIDS activists have demanded community-based services and quicker

the patient who was cut off by the answering service and is angry and annoyed. Clinicians also provide information to others within the organization so that they can complete their responsibilities. Some third-party payors require that copies of signed physician prescriptions and nurses’ notes be attached to the billing invoice. If the documents are not received in a timely manner, billing cannot proceed, accounts receivables rise, and the cash flow of the organization is adversely affected. A positive focus on internal and external customers leads to employee and patient satisfaction and retention.

responsible for the focus

promising new treatments. Third-party payors pressured to provide reimbursement for investigational drugs or the off-labeled use of a Food and Drug Administration (FDA)-approved drug. access to are

Who Are the Customers? HIT

providers

have

a

variety of customers. Traditionally, the patient and the physician were identified as customers. Today, customers are third-party payors (which include case managers and managed care organizations), community organizations, and pharmaceutical companies that want to conduct clinical trials in alternate-care settings. These customers have a variety of needs that require an individualized approach. There is also increased recognition that an organization has both internal and external customers. Positive working relations among intradepartmental and

interdepartmental employees are important. For example, when a nurse visits a patient at home to initiate therapy, the drugs and supplies must have been packed and shipped properly so that the therapy can begin without delay. Clinicians must incorporate the strategies of customer satisfaction into their daily practice. Clinicians providing HIT, in particular, interact with all customer groups. Interaction is not just at the direct patient care level but also when a clinician meets with physicians to discuss how to provide services to their patients, or when a clinician describes to a case manager the level of services rendered. HIT staff must develop positive approaches to the physician or discharge planner who has received too many HIT provider phone calls or to

SUMMARY

HIT is more

now

in its second decade. The

industry is

mature, more complex, more regulated, and more

costly than in previous years. Consolidation among providers is expected to continue as a measure to control overhead and to hold the market share. Providers will be requested to accept patients who require more specialized care. Clinicians will need to handle complex patient care needs while being cost effective, timely in response, and cognizant of their role in ensuring positive patient outcomes. Clinicians will be asked to record more data that measure positive

therapeutic or supportive outcomes or improved quality of life. Aggregate data on the clinical effectiveness of alternate-site care

are

needed.

Computer technology and clinical databases will make the acquisition of information in the home as easy as it now is in hospitals by the use of point-of care computer technology. Clinicians will have the ability to transmit pertinent information to physicians, thirdparty payors, regulatory agencies, and other providers of care. Such

technologic advances will give providers the ability to better quantify the patient’s HIT experience and to expand services to other alternate-care settings. a &dquo;can do&dquo; attitude, and a focus on quality improvement will continue to be the supporting

Clinical innovation,

structure of a successful

provider.

REFERENCES 1. Webb LC. Home infusion therapy services. Robert W. Baird & Co., Inc.’s Health Care Research, May 1992. 2. Crocker KS, Coker MH. Initiation of a home hemotherapy program using a primary nursing model. INS J 1990;13:13-9. 3. Curtin LL. Signs of things to come (editorial). Nursing Management 1992;23:7-8. 4. Peters T, Austin N. A passion for excellence. New York: Random

House, 1985. Covey SR. The seven habits of highly effective people. New York: Fireside Publishing, 1989. 6. Rackham N: SPIN selling. New York: McGraw-Hill, 1988. 7. Reichheld FF, Sasser WE. Zero defections: quality comes to services. Harvard Business Review 1990;68:105-11. 8. Home infusion therapy indicators readied for alpha testing. Joint Commission Perspectives 1991;11:4. 5.

Current status of home infusion therapy.

The growth of home infusion therapy has been influenced by external forces that have changed the access to and use of health care. As home infusion th...
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