Building a Headache Infusion Program

Transcription

1 Building a Headache Infusion Program Lauren Doyle Strauss, DO UCNS Board Certified Headache Specialist Headache Clinic Director Assistant Professor in Pediatric Neurology Associate Residency Director, Child

2 None Financial Disclosures

3 Objectives Identify goals of starting an infusion program. Define staffing and space needs for starting an infusion practice for a headache practice. Strategize on optimal billing and coding for infusions in the clinic. Learn from other established headache infusion programs from recent survey results.

4 Infusion Therapy Refers to the intravenous (IV) administration of medicines. Reserved for status migrainosus or severe persistent headaches and/or for chronic headache requires more aggressive treatment.

5 Headache in the ED 2.1 million visits annually (2.2%) Often report multiple ED visits annually > $13 billion/yr due to lost productivity Agency for Healthcare Research and Quality Review, 2012 Friedman et al, current management of migraine in Us emergency department: An analysis of National Hospital Ambulatory Medical Care Survey. Cephalalgia 2015

6 Why Start an Infusion Program? What are your program s current goals? Improving Patient Experience: Improvement compared to the ED? Would you target acute or chronic headache? Directing Patient Care: Do you want control of medications choices? Expanding Headache Program: Offering new treatments as expected of a Headache Program/Center? Improve marketability/patient recruitment? Financial Incentive: Looking at ways to change or improve compensation? Offering services to increase billing?

7 Our Survey Surveyed members of inpatient and program director sections Varying practices included (private practice, academic, etc.) # ed, # responded

8 Program Locations WakeForestBaptist UniversityofCinnicinati DukeUniversity WakeForestBaptist GrahamHeadacheCenter GrahamHeadacheCenter Mayo NYULangone ThomasJefferson ThomasJefferson StanfordHeadacheandFacialPain HofstraNorthwellHealth UniversityofColorado-Denver UniversityofUtah HartfordClinicsHealthcareHeadacheCenter DeanMedicalGroup ClevelandClinic CincinattiChildren's CincinattiChildren's MedstarGeogetownHeadacheCenter YaleUniversity CHOP UofTSouthwesternMedicalCenter MichiganHeadPain+NeurologicalInstitute NorthshoreUniveristyHealthSystem

9 Survey: How often is infusion therapy used to avoid ED visit/hospitalization?

10 Infusion Availability Consistency is KEY Repeat customers Consistent, predictable staffing and provider support Strategic Timing Morning versus Afternoon Only certain days/week Weekends Manage Expectations Same day Within a few days

11 Survey: What time of the day do you offer them?

12 Survey: What do you estimate is the average time to treatment?

13 Survey: How many days during the 5 day work week do you offer infusions? Survey: Do you offer infusions outside of clinic hours (weekdays 9am to 5pm)?

14 The Patient Experience Goal: rapid and sustained headache relief, without side effect to allow patients to return to work, school, or usual activities Operations Ease with scheduling appointment Reduced door to needle time Reduced overall treatment time

15 Patient Education How do you market available times/services? How do you advise patient on what to expect?

16 Possible Infusion Locations Within a standard clinic room Infusion suite or chairs within the clinic space Hospital Run Day Hospital Hospital observation service/inpatient service Local Urgent Care center Patient s home

17 Home Infusions Offered standardly for antibiotics, IVIG Convenience of home use preferred by patients Unable to add medications if continued pain or side effect Unable to have provider to assess for S/E (ex: Chest pain) Our patients do not have central access, so would need to have a service that also places IVs.

18 Survey: Where are infusions performed?

19 Infusion Space Needs Private or semi-private room Infusion Chair/hospital bed Dimmable or dark lighting Perfume-free Additional seating for family

20 Infusion Space Needs Familiarity if held in same space as clinic Proximity to parking, reduced parking cost Patients may prefer being with other HA patients rather than other conditions (oncologic, etc.) Access to ordering or supervising provider, nursing, and medication storage

21 Medication Storage Room Air Storage IV Fluid bags Dexamethasone Dihydroergotamine Diphenhydramine Methylprednisolone Metoclopramide Prochlorperazine Pharmacy Support Valproate Sodium (mixed, 24 hours) Magnesium Sulfate

22 Survey: Do you have pharmacy support on site where you offer infusions?

23 Anticipated Staffing Needs Support staff to triage incoming calls to identify patients Appointment coordination (Admin, MA, Nurse, NP/PA) Prior authorization (MA, Nurse) IV placement (Nurse, NP/PA, Fellow) Medication administration (Nurse, NP/PA) Vitals (MA, Nurse, NP/PA)

24 Survey: Who places majority of the IVs?

25 Survey: Do you obtain prior authorization prior to scheduling?

26 Provider Experience Orders Who is going to place orders? Are they placed in advance or on the same day? Who places additional orders that may be needed? Supervising Is there one covering provider of the day? Do providers only care for their own patients? Is there a provider schedule? What other conflicting schedule demands does that provider have? If NP/PA or fellow, who is supervising them?

27 Provider Experience Patient Visit Do you want to have a provider see all infusion patients? Consider ways to triage: Serious side effect Unpleasant adverse effect Nausea, Dizziness Change in medications (order error, patient reports having previous S/E) Patient questions

28 Creating Protocols Phone Triage Protocol What types of patients/calls should be flagged Nursing Protocol Timing of Vitals Screening Questions- prior medications, pregnancy Do you want/need screening labs? Creation of Ordersets

29 Headache Still? Send to another location? Home Urgent Care ED Direct Admission

30 Treatment Paradigm Step-wise sequence until headache resolves Sequence of medications chosen in advance, without goal headache resolution Multi-day outpatient infusion protocol

31 Overview of Treatment Options More than 20 different parenteral medications are used to treat headache Migraine specific (DHE) Antidopaminergics (metoclopramide) Neuroleptics (prochlorperazine) Steroids (dexamethasone, methylprednisolone) Anti-histamines (diphenhydramine, promethazine) Medications and intravenous fluids require different storage capacities and pharmacy support. Vinson DR, Treatment patterns of isolated benign headache in US emergency departments, Emerg. Med 2002

32 Survey: If offered in clinic, which medications are you giving? (Click all that apply)

33 Survey: How many medications are infused in one treatment session?

34 Survey: How many days/consecutive days per headache episode?

35 Type of Visit Procedure only visit (no E/M): Should be majority of visits Establishment and Management visit (E/M): Every procedure (whether major or minor) already includes an inherent E/M component Can add on to infusion, but only if: Another diagnosis other than Headache that you are managing (Anxiety, HTN, Weakness, Concussion, etc not related to infusion) Clearly documented evidence of medical decision making Physical exam required/documented supports need for E/M Document timing of when visit is done (best if before or after infusion timing) Although it s not required, best practice is to separate the E/M note from the procedure note. Add modifier 25 Significant to appropriate E/M service code. Can be a source of audit! - CMS policy documents: Centers for Medicare and Medicaid Services - Medicare Claims Processing Manual, Chapter 12, Section 40.1.C -

36 Nursing Documentation Author: Ashleigh K Payne, RN Service: (none) Author Type: Registered Nurse Filed: 5/11/2016 4:42 PM Note Time: 5/4/2016 2:07 PM Status: Signed Editor: Ashleigh K Payne, RN (Registered Nurse) Patient arrived for a migraine cocktail infusion and rated her pain at a 7 on the pain scale. A 22 gauge IV was placed in the left hand at 1:16 PM and was flushed with 3 cc NS with no redness, pain, or swelling noted. IV was secured and the infusion of 1000 ml of NS to run over 1 hour was started at 1:20 PM with no complaints of pain. At 1:23 PM Toradol 30 mg was added to the NS bag to infuse over 1 hour. At 1:26 PM Benadryl 25 mg was added to the NS bag to infuse over 1 hours. At 1:29 PM Reglan 10 mg was added to the NS bag to infuse over 1 hour. Patient was provided a blanket and the lights were dimmed for comfort. Both patient and mom were advised on the use of the call bell. At 1:46 PM patient rated her pain at a 7 on the pain scale with no improvement. At 2:16 PM the infusion was completed and patient said it was only a little better with pain at a 6 on the pain scale. IV left in until the provider advises. Laura Granetzke, NP ordered Depacon infusion. Depacon 500 mg in 100 mg of NS to go over 30 minutes started at 3:59 PM. Depacon infusion completed at 4:29 PM and patient rated her pain at a 4 on the pain scale. IV discontinued at 4:32 PM and pressure was held until the bleeding stopped. A bandage was placed and patient was allowed to check out.

37 Billing Codes CODE wrvu DESCRIPTION Initial Hydration Subsequent Hydration Drug in bag initial (31 mins to 1 hour) Each additional hour beyond initial 60 mins (billable at 91 mins) Concurrent infusion of additional drugs IM injection IV push, initial drug IV push, each additional drug

38 Infusions vs. Injections by RVUs Mixed in the Infusion Bag In the bag: wrvu Total 0.38 IV Push through line IV Push (2 Drugs) wrvu Total 0.37 IM Injections IM Injections wrvu Total

39 Financial Viability Infusions have low RVU/revenue per visit However, in the advancement of the World 2 model, compensation is tailored towards different metrics Outpatient infusion treatment may Greatly decrease the cost to insurance company/patient Improve patient experience (Press Gainey scores) Improve access and waiting times in the ED with lower headache patient volume

40 Expanding Your Headache Program Improve marketability May increase patient recruitment

41 Tracking Progress Patient Experience Survey infusion patients Change in Press Gainey Encourage reporting of positive experiences Operations Number of infusions performed Number of patients unable to be scheduled Coverage capability for providers Billing RVU generation Medication cost revenue Tracking denials

42 Anticipating Difficult Stituations Unreasonable patient expectations Scripting for staff on where to direct patient if unable to provide service Identifying patients that may be overusing service (risk of medication side effect, pain amplification syndrome)

43 Thank you! Any questions? Lauren Doyle Strauss, DO Wake Forest Baptist Medical Center Assistant Professor, Child Neurology Associate Residency Director, Child