Don’t rush into dobutamine without referral sources
Marketing, physician education critical
When it comes to administering dobutamine to congestive heart failure (CHF) patients in the home, chances are everybody’s doing it in your area, or no one’s doing it at all. If you’re in the latter group, the fact is there’s little that should inhibit you from offering this service to your referral sources and patients.
This month, Home Infusion Therapy Management speaks with a pair of North Carolina home infusion providers that provide congestive heart failure patients with dobutamine in the home. They provide you with a nuts-and-bolts look at the ease and difficulty of home dobutamine.
Regardless of how ready your company may be, if there’s no market for home dobutamine you’d be foolish to take the time to create the procedures. The problem is, your market isn’t necessarily just finding patients with the proper clinical diagnosis.
"What drives what we do are referral sources," says Jean Eddy, RN, CRNI, CPN, director of patient care for Chartwell Southeast in Mooresville, NC. "If you do not have cardiologists in your area who are aware and believe me, there are physicians who do not know the extent of home care and home infusion then you will not see that [geographic] pocket doing the therapy. The fact is, though, that this is very, very wonderful for these patients to get home on these ambulatory pumps and receive this drug."
Doc encourages company to start therapy
For Advanced Home Care in Greensboro, NC, it was a referral source who started the ball rolling for its company. "We happened to have an aggressive local physician who was ready to do this, and that’s what kind of prompted us," says Pam Chandler, RN, CRNI, infusion program coordinator for Advanced.
Finding a local physician willing to refer qualified patients to your company should be your first step in creating such a program.
"Target a physician and look at his patient population," recommends Chandler. "See why they were readmitted to the hospital and if they would be candidates for home dobutamine therapy based upon Medicare reimbursement and clinical findings."
Once you’ve got that first potential referral source, others likely will fall into place.
"For some, it was not difficult, and some groups still haven’t bought in, but a lot depends on your credibility," says Chandler. "They may be buying into you already for other therapies."
The ease with which you are able to set up your program will depend in large part on the qualifications of your staff. Chances are, you’ll need some outside help. Chandler notes that the support and knowledge of a local cardiologist was critical in the early stages of her company’s program development. But even with such available expertise, Advanced had to do its fair share of research to obtain the most current information.
"The first thing we did was a literature search and found tons of articles," notes Chandler. "We were then able to pull out the information we needed."
Because of the need to conduct research, she recommends giving yourself six months or more to get everything up and running before you take on your first patient.
Both Chandler and Eddy agree that because of the nature of home dobutamine, your policies and procedures should not get too specific. Physicians’ orders frequently vary from one patient to another, and broad policies allow plenty of flexibility for physicians.
"If the doctor is writing specific orders, he may give you parameters," says Eddy. If you create specific policies, any changes from your procedures require a signed doctor’s order.
"A lot of patients are more stable than others, and they don’t need the same type of procedure as a patient who is more stable," she says.
There are certain red flags patients must be taught to watch for. Eddy says the following are examples:
• shortness of breath;
• weight gain of two or more pounds in 24 hours or four or more pounds in a week;
• headache;
• increased heart rate;
• hypertension;
• hypotension;
• increased urinary output;
• coughing;
• edema;
• increased dryness of the skin or mucous membranes;
• faintness.
To help with patient education, Advanced provides patients with a fact sheet that explains not only the intended effects of the drug but also potential adverse effects. (See patient education sheet, above.) Such patient education for self-monitoring is critical because patients usually require 24-hour infusion, and a nurse typically won’t be with the patient around the clock.
When it comes to staff training, Chandler says Advanced uses a host of tools and has several requirements of its nurses. These include:
• three months of experience with Advanced prior to administering dobutamine and certain other therapies;
• review of a one-hour advanced home care cardiac assessment video;
• review of a pharmacology video that addresses pharmacology management of a patient with cardiac disease specific to dobutamine therapy in the home care setting;
• pass a written test (scoring 85% or higher) that includes nursing, pharmacology, side effects of the drugs, and situational testing.
In addition to the above, Chandler notes that many infusion nurses gain experience with home dobutamine through their six-week orientation program with Advanced. And certain employees may already have applicable experience.
"If you’ve got someone who has worked for an IV team in a hospital, ICU, or an ER setting, they will be familiar with the monitoring and the terminology, and they’ve likely already worked with a lot of the drugs and managed these types of patients."
Reimbursement can be a hassle
Getting reimbursed through Medicare for home dobutamine patients can be confusing and require plenty of upfront work.
"Medicare has strict guidelines regarding what they will pay for," says Eddy. "There are certain things that have to be filled out by the doctor, and these patients have to have failed the traditional regime which has to be documented before they can go on dobutamine."
Because of the requirements, Chandler is currently developing a form that will assist the company in collecting the proper information prior to submitting a claim.
"The form letter will go out to the physicians who can just fill in the blanks with the necessary information," she says.
But payment is difficult even if you know what’s required and provide the information to Medicare. "We’re going before an Administrative Law Judge for three of these patients because four have identical information, and we can’t figure out why one got paid and three did not," says Chandler.
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