10 steps to winning home infusion referrals

By Maryann Mahoney, RN , CCRN, CRNI

Executive Director

Clinical IV Network

Pawtucket, RI

Planning and coordinating the pre-admission phase of infusion home care is critical to maintaining a smooth operational flow and cultivating positive relationships with referral sources. If your organization is simply taking referrals, you may find yourself on the bottom of the provider list for case managers and continuing care coordinators. The provider who is easily accessible, knowledgeable in areas of reimbursement, and can provide care with just one phone call will be the provider who gets the referral.

Coordination is essential

Accessibility to coordinating staff, their knowledge of services available, and access to reimbursement coverage guidelines are frequently cited as key service areas in referral coordination for discharge planners and case managers who work with home care organizations. Many agencies use clerical staff who are not qualified to identify potential clinical problems and are unable to complete the intake referral form until "the insurance clears." Viewing the intake process as the pre-admission phase of care and the first step to care planning is the key to cultivating long-lasting referral relationships. The following are keys to successfully coordinating staff.

Keys to successful coordination

1. Complete an in-hospital assessment and teaching evaluation before discharge.

The current trend is moving away from doing inpatient evaluations due to diminished reimbursement and moving toward prioritizing schedules for busy clinicians. But in our experience, patients receiving a teaching session/evaluation by a clinician are better prepared for home infusion. Patients are often not told they will be taught self-administration of medication, they may not have adequate venous access to complete the therapy, or they do not have an adequate caregiver or home environment. Although these questions can be asked during the intake process, nothing fully replaces a person-to-person contact with the patient and caregivers. Caregiver participation in an in-hospital teaching session gives the clinician valuable information regarding the caregivers’ willingness to participate in a home infusion plan. It also allows for hands-on skills demonstration with equipment and supplies that will be used in the home.

2. Prepare for a phone assessment and teaching session.

If the referral came to your agency at the last minute and the patient doesn’t want to wait for a clinician, perform a "telephone teach" with the patient/caregiver, reviewing the basic concepts of what is involved in home infusion. This will give you a sense of the patient’s awareness of the complexity of the therapy and their willingness to actively participate in their care. It is also important to get a full history and report from the primary nurse before accepting the patient. Be sure to get an honest assessment of venous access by asking specific questions, not just, "How are his veins?" Questions to ask include:

• How often has the IV been restarted? By whom?

• In what condition are prior venipuncture sites?

• Have there been any access-related complications?

• What infiltrations and types of lines have been used?

• Which medications were administered during the course of admission and were there any adverse drug reactions, along with concurrent oral medications?

• Was the drug planned for discharge given at least once in the hospital without adverse outcomes (if your agency has a policy against giving first dose)?

3. Recognize that every referral is a sales call.

Keep sales and marketing strategies foremost in your mind for every call. Know how to take charge of the call without dominating the caller. If at all possible, "claim" the patient for your agency during the first inquiry call. Be prepared to offer immediate solutions. If the referral call is a "what if?" or "can you do this?" scenario, get as much information as possible. If nothing else, get a patient and caller name and number.

Develop sincere telephone relationships with referring customers. Avoid being overly friendly or chatty. Allow relationships to develop based on trust, efficiency, and accuracy of your information, as well as your ability to coordinate complex cases.

Most importantly, recognize all callers as customers, and always give them more than they expect.

4. Exceptional communication is a necessity.

Avoid generalizations. Anticipate questions, and provide specific, accurate information. If unsure of an answer, promise to follow up with accurate information. It helps to develop standard speeches to explain therapies, equipment, reimbursement, and other issues to answer common questions consistently.

5. Take control of the referral as early in the process as possible, particularly in scheduling the in-hospital teaching.

At the start of the day, have times in mind so you can schedule a clinician for a teaching session today, tomorrow, etc. When possible, see the patient on the same day as the referral is received, even if you just review the chart and leave written information for the patient or caregiver. Offer to schedule teaching sessions yourself. If you offer a specific time, most people will accommodate you. Avoid allowing them to choose the place and time: You may put yourself in a position to have to say no.

It also helps to have a good sense of humor and a tolerance for change. Also, be sure you know where your field clinicians are so you can change or rearrange schedules in response to new referrals.

Do as much work for the discharge planners as feasible, without being too pushy. Take charge of the case from the infusion perspective and allow them to do the rest. Never ask them to get non-critical information. Things such as physician phone numbers and Social Security numbers (unless needed for verification) can wait until the in-hospital review chart.

6. Follow up on all referrals.

Even if the call posed a theoretical question, if you didn’t get the case, find out why.

7. Provide preliminary information regarding insurance coverage to the discharge planner in the first call, particularly if the patient may have a co-pay.

Offer to discuss payment with the patient or family directly. If unsure of coverage, quote tentative information based on your experience with the payer. Be sure they know this is tentative information if you have not confirmed the coverage level.

8. If another agency is involved, be sure to call them to coordinate the plan for the patient.

Even if the agency’s responsibilities are not directly related to your services, reflecting coordination of care planning will help you meet the Joint Commission on the Accreditation of Healthcare Organization standards regarding cooperative care planning and non-duplication of services. Be sure to document the coordination in your records either narratively or by using a form developed by your agency, and fax or send a copy to the other agency. Adding an area on the back of the referral form for pre-admission notes is helpful, particularly if more than one person covers the referral lines. (See Coordination of Care Plan charts, pp 97-98). Let the discharge planner know that you will coordinate the case directly with the agency.

9. Be sure to confirm the discharge plan as soon as possible, and be sure the pharmacy has its orders confirmed before you set a time with the patient.

Always ask the patient to call your agency when he or she arrives home. This can be conveyed through a discharge planner or primary nurse and is a good way to "close the loop" of communication with the hospital. Remember to close all communication loops you open.

10. Give reasonable windows of time for the arrival of the nurse and/or delivery to the patient.

Try not to be held to a specific time unless the treatment plan requires it. A two-hour window is a reasonable and customer-friendly time frame. If the patient is coming home close to dose time, be sure to allow enough time for the nurse to complete the assessment and consents, start the line, and complete any other tasks that must be completed prior to dose administration.