Home Health

New Trends in Healthcare

Overview

  • Avera Home Infusion Services: Spearheaded by Cindy Kannenberg, RN, Nurse Manager of Hospital at Home, and Kathy Schoenfelder, RN.

  • Mission Statement: Aims to positively impact the lives and health of individuals and communities through quality services guided by Christian values.

Objectives

  • Goal: To summarize the steps required to initiate home infusion therapy.

The Continuum of Care

Historical Context

  • Florence Nightingale: Advocated for nursing sick individuals in their homes; expressed a vision for the abolition of hospitals in her 1867 statement.

  • Quote: "My view you know is that the ultimate destination is the nursing of the sick in their own homes… I look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2000."

Services Offered

Avera Home Infusion Pharmacy

  • Types of Therapies Available:

    • IV Antibiotic Therapy

    • IV Antifungal Therapy

    • IV Antiviral Therapy

    • Total Parenteral Nutrition Therapy

    • Pain Management Therapy

    • Immune Globulin Therapy (e.g., Hizentra, Gamunex, Gammagard)

    • IV Hydration Therapy

    • Continuous Glucose Monitors (Dexcom & Libre)

Additional Services

  • IV Catheter Care

  • Respiratory Syncytial Virus (RSV) Prophylaxis (e.g., Synagis)

  • Specialty Injections (e.g., Xolair, Invega, Lupron)

  • Specialty Infusions: Remicade, Fabrazyme, Ocrevus, IVIG.

Current Census by Therapy Type

  • Demonstrated percentages for therapy types in Avera Home Infusion:

    • INF-Spec: 6.8%

    • ABX: 7.3%

    • Hydration & Catheter Care: 3.4%

    • TPN: 1.0%

    • Synagis: 0.5%

    • Pain Management: 81.0%

Home Infusion Therapy

Cost-effectiveness and Patient Convenience

  • Description: Home infusion therapy provides a cost-effective alternative to hospital care with better comfort and convenience.

  • Patient Care Continuity: Avera McKennan Home Infusion ensures continued care through simple referrals.

Referral Process

  1. Sources of Referral: Receives calls from hospitals, clinics, home health agencies, insurance companies, or family members. Available through Voalte, Email, Expanse, and phone.

  2. Insurance Verification: Check the patient’s insurance for benefits, preferred provider status, and required authorizations.

  3. Collaboration with Home Health Agencies: Contact home health agencies as needed; in Sioux Falls, Avera Home Infusion receives specialty infusion referrals.

  4. Team Effort: Inclusion of pharmacists, pharmacy techs, insurance specialists, pharmacy patient specialists, and nursing staff.

Home Infusion Nurse Responsibilities

Responsibilities Before Visit

  • Initial Contact: Arrange the initial visit with the patient.

  • Review Pre-requisites: Assess if the patient had recent infections, surgery, or live vaccinations.

Home Infusion Visit Procedures

  • Introduction to Home Infusion: Verify patient’s name, birth date, current medications, allergies, and orders.

  • Medication Review: Discuss the medication purpose, potential side effects, and address patient concerns.

  • Pre-Infusion Questions: Record vital signs and ensure IV access is established.

  • Administration: Administer pre-medications as ordered, start infusion, monitor infusion according to protocol, and obtain ordered lab tests.

  • Post-Visit Procedures: Document last vital signs; assess the patient, thank them, and schedule the next infusion. Charting informs Avera Home Infusion staff for patient care continuity.

Specialty Medications Administered at Home

  • Medications Include:

    • Remicade

    • Renflexis

    • Inflectra

    • Stelara

    • Entivio

    • Gammunex- IVIG

    • Fabrazyme

    • Venofer

Innovations in Home Infusion

Advances in Administration

  • Gamunex and Gammagard: Approved for IV administration; currently being administered subcutaneously, improving convenience and reducing time.

  • Ocrevus: For Multiple Sclerosis, also available subcutaneously but administered by a nurse, with significant infusion duration reduction to 10 minutes with 15 minutes of observation.

Patient Experiences

Patient Story

  • Patient A's Experience: Initially apprehensive about home Ocrevus infusion, but received thorough explanations and positive reinforcement from the nurse.

  • Feedback from Patient: Positive reinforcement noted in the patient's thank-you note to the Home Infusion RN, highlighting their positive interaction and comfort during the procedure.

Conclusion

  • Team Efforts: Acknowledges the critical role of a dedicated team in executing home infusion therapies and the growing trend towards home-based healthcare.

Future of Healthcare

  • Increasing Focus on Home-Based Care: Emphasis on the continued shift towards patient care in home settings.

Hospital at Home Services

Understanding Hospital at Home

  • Introduction: Hospital-Level care delivered at home; initially launched at John Hopkins in 1995.

  • Growth Barriers: Challenges primarily centered around payment reimbursement strategies. Previously only 5-10% of patients qualified for such services.

Historical Context and Growth

  • Pre-COVID Trends: Shift toward value-based care, minimizing risks associated with traditional hospitalization methods for vulnerable populations (elderly, immunocompromised).

  • Impact of COVID-19: Surge in demand for home-based alternatives due to hospital bed shortages, according to the American Hospital Association.

Value Additions of Hospital at Home

  • Benefits:

    • Lower mortality rates

    • Decreased delirium instances

    • Reduced use of sedative medications

    • Lower occurrences of pressure ulcers, DVTs, and hospital-acquired infections

    • Improved functional outcomes and high patient satisfaction rates.

Regulatory Progress

Pathway to Approval

  1. November 2020: CMS approved waivers for hospital-at-home service reimbursements.

  2. July 2021: Collaboration request for Avera McKennan to deliver home care for hospitalized patients.

  3. September 2021: Launch of Avera McKennan Hospital@Home program.

Required and Optional Services

Compliance with CMS Requirements

  • Mandatory Services:

    • Physician daily virtual visits

    • In-person advanced practice provider daily visits (optional)

    • RN visits twice daily

    • 24/7 remote monitoring and video connection

    • Medications, meals, labs, X-Rays, medical equipment, transportation, physical and occupational therapy, social work, case management, spiritual care, and education on discharge and transitional care (optional provided by Avera).

Patient Enrollment Criteria

  • Enrollment Requirements:

    • Resident within 30 miles of Avera Hospital

    • Completion of an appropriate care plan in two nursing visits

    • Capacity for self-care or adequate support at home

    • Consent from patient and family

    • Safe home environment

    • Clinical criteria met as per agreement.

  • Exclusion Criteria:

    • Non-domiciled patients

    • Unsuitable living conditions (e.g., lacking essential utilities)

    • Residents of skilled nursing or government-funded facilities

    • Ineffective establishment of peripheral IV

    • Routine IV narcotics for pain control

    • Certain diagnostic and surgical procedures must be completed prior to admittance to Hospital at Home.

Avera Hospital@Home Outcomes

Performance Metrics

  • Patient Satisfaction: High in all assessment categories.

  • Average Length of Stay (LOS):

    • Average LOS: 2.1 days

    • Average Full LOS: 4.1 days

  • Clinical Outcomes:

    • Nosocomial infections: zero cases reported

    • Medication errors: 9 out of 369 events with no harm to patients

    • Falls reported: 6 out of 369 incidents.

Admission Statistics

  • Over 521 patients admitted to Avera Hospital@Home as of April 29, 2025, resulting in 1065 fewer hospital nights required.

Future Directions for Avera Hospital@Home

Growth Plans

  1. Increasing Awareness: Enhance provider and patient understanding of program capabilities.

  2. Capacity Expansion: Create more clinical admission criteria to facilitate broader access.

  3. Technology Utilization: Continue to leverage technology to improve service availability for patients.

Patient Stories

  • Experiences of Hospital-Level Care at Home: Testimonials reflecting the effectiveness of home-based care.

Questions

  • Feedback & Inquiry: Open floor for discussing questions regarding home infusion and hospital-at-home services.