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Home Nutrition Support

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Presentation on theme: "Home Nutrition Support"— Presentation transcript:

1 Home Nutrition Support
Mae Reilly, MS, RD, LDN, CNSC Jennifer Bryant, MS, RD, CSO, LD, CNSC 12/7/15

2 Overview Types of home nutrition support
Enteral nutrition Parenteral nutrition Indications/ Contraindications Management Differences between inpatient and outpatient roles Home care company role

3 Home Enteral Nutrition
Nutritional assessment Completed inpatient and/or outpatient Medical and nutritional history Estimating needs Indications Inability to consume enough calories orally Inability to swallow Contraindications Non functional GI tract

4 Home Enteral Nutrition
Access Short term vs. long term Nasogastric tube Percutaneous endoscopic gastrostomy Jejunostomy Home starts Safety Teaching – helpful for caregiver to be present Plan for patient Referral process Multidisciplinary team and home care company

5 Home Enteral Nutrition
Recommendations Individualized plan with Homecare and RD contact info Administration method Bolus feeding Gravity feeding Pump feeding – insurance justification Formula choice Caloric density/water content Standard/elemental Fiber content Disease specific Water needs Schedule Volume and timing for bolus feeds Hours fed and rate for pump feeds

6 Home Enteral Nutrition
Management Advancement Bolus vs pump Clinic visits Labs Physical assessment Fluid status Food records Adjusting needs Weaning

7 Home Enteral Nutrition
Risks/complications Constipation/Diarrhea/Nausea/Reflux Hyperglycemia Aspiration Tube clogging/falling out Actions Slow feeds down Change feeding method Review medication list Check labs Assess hydration status Clinic visit

8 Home Parenteral Nutrition
Nutritional assessment Completed inpatient and outpatient Medical and nutritional history Estimating needs Indications Non functioning GI tract Nutrient malabsorption Contraindications

9 Home Parenteral Nutrition
Access PICC PAC Home starts Can be high risk Started inpatient at BWH 3-5 day hospital admission for advancement and cycling High risk: DM, refeeding syndrome, cardiomyopathy, renal insufficiency, electrolyte abnormalities Referral process Documentation of medical necessity/insurance review

10 Home Parenteral Nutrition
Recommendations Volume Macronutrient distribution Cycle Additives Oral diet

11 Home Parenteral Nutrition
Transition to home Teaching Communication First clinic visit Lab draw Delivery

12 Home Parenteral Nutrition
Management Clinic visits/Reassessment Labs Physical assessment Fluid status Food records Weaning Phone calls

13 Home Parenteral Nutrition
Risks/Complications Infection Glucose control Fluid management Electrolyte abnormalities Actions Check labs Change cycle Adjust electrolytes Adjust additives Assess volume status Clinic visit

14 Differences between Inpatient and Outpatient Management
Patient stability Teaching Less regular communication and monitoring Lab draws Calorie counts Relying on patient/family Food record Weight Physical assessment

15 Withdrawing Support Patient decision Multidisciplinary team discussion
Treatment goals Quality of life Hospice (may or may not take TPN) Communication/education

16 What do we do when it’s time to leave the hospital?
Referral Process Considerations for the home Considerations for the patient Management of the long term nutrition support patient

17 The Referral Process Inpatient team member (RD, Care Mgr, SW) will communicate the need for home nutrition support to a NELC team member. Demographic, insurance, and clinical information gathered and reviewed. Verification of benefits is completed, and coverage (or non-coverage) is communicated to the patient.

18 Medicare Qualification
Permanent non-function or disease of the structures that normally permit food to reach the small bowel Disease of the small bowel which impairs digestion or absorption of an oral diet, requiring enteral feedings to provide sufficient nutrients to maintain weight and strength

19 Medicare Qualification
Can be anatomic (obstruction due to head/neck cancer or major reconstructive surgery), or due to a motility disorder (dysphagia after stroke or gastroparesis) Must be considered to be a permanent impairment. If the condition is documented in the medical record to be of long and indefinite duration, the test of permanence is considered met (ordinarily at least three months).

20 Medicare Qualification
Additional documentation required for Total Parenteral Nutrition in the home setting: Evidence of a qualifying diagnosis such as Short Bowel Syndrome, Crohn’s Disease requiring bowel rest, Pancreatitis requiring bowel rest, Enterocutaneous fistula, complete mechanical small bowel obstruction where surgery is not an option 10% weight loss over three month period Albumin less than 3.4 If indicated, trial and failure of enteral feedings

21 Other Referral Information
Insurance Provider-specific documentation includes, but is not limited to: Kcals/day written on order Scoops/day Packets/day Grams/day Cans/month Cartons/day

22 Considerations for the Home
Electricity, Heat, and Access to clean water Acceptable means of communication (for Safety and Regulatory Compliance) Acceptable means of Refrigeration (for Safety and Stability) Ability to lift and carry packages (can we utilize a third party provider like UPS or FedEx, or do we need to deliver by van?)

23 Considerations for the Patient
Reading Level/Learning Style – how do we determine if the patient knows what we need them to know? Dexterity – can the patient squeeze small syringes, open cans and cartons, or manipulate valves and connectors? Technology – can the patient change pump settings to reflect an alteration in rate or dose?

24 Considerations for the Patient
Visual Acuity – can the patient read the fine print on the back of cans and cartons, read the unit line on a small syringe to dose insulin, or read the mL line on a small syringe to administer multivitamins or trace element products? Medication schedules – does the patient take any medications that must be administered on an empty stomach? Or with milk? Do they need to hold feedings around Cipro dosing?

25 Considerations for the Patient
Work Schedules of the Patient – can the patient infuse adequate calories in the hours they are not at work? Can they bolus feedings at breaks and lunch? Is the school nurse willing and able to do this? Caregiver Involvement/VNA – can we match the infusion schedule with the time that the patient has a caregiver in the home to help?

26 Management of the Long Term Enteral Patient
Pump to bolus; continuous to nocturnal Increase caloric density to ease schedule burden Adding modulars or changing formula as indicated by medical condition Change to age appropriate formula at life stages (infant to child; child to adult)

27 Management of the Long Term TPN Patient
Standing lab monitoring What and when? Specialty lab monitoring Frequency of lab monitoring VNA involvement/”homebound status” Insurance changes and requirements

28 Questions?


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