ALTERNATIVE NUTRITION DELIVERY: ENTERAL VS PARENTERAL NUTRITION IN THE HOME SETTING

Fran Brown MSN MBA Director of Nursing

1 Alternative Nutrition Delivery „ I am the Director of Nursing and Patient Care Services for Bright Star Care. We supply private skilled and non-skilled clinical services to clients in their home.

„ I am not affiliated with a or DME supplier

DISCLOSURES 2 Alternative Nutrition Delivery „ 1. Describe alternative feeding options

„ 2. Identify ‘why’ individuals require alternative feeding options

„ 3. Describe complications of alternative feeding options

„ 4. Describe home support options

„ 5. Describe qualifiers for insurance coverage

„ 5. Resources

OBJECTIVES 3 Alternative Nutrition Delivery „ Enteral Feeding

„ Tube feeding – liquid nourishment. Similar to what you would get from food and digested the same way

„ Parenteral Feeding

„ TPN – Supplying to the body, bypassing the digestive system and dripping solution directly into the vein

ALTERNATIVE FEEDING OPTIONS 4 Alternative Nutrition Delivery Gastrostomy Tube Nasogastric Tube Central line

5 Alternative Nutrition Delivery „ TPN – When and individual should not eat. When the bowl needs rest, presence of an , Crohns disease, pancreatitis, severe burns, weak individuals in need of surgery, chemo etc.

„ Tube Feeding – individuals cannot obtain nutrition by mouth, swallowing complications, cannot consume enough calories

WHY PRESCRIBE ALTERNATIVE NUTRITION 6 Alternative Nutrition Delivery „ Tube Feeding „ Delivered via nasogastric tube, gastrostomy tube (G Tube) „ Delivers nutrients directly to the „ Post-pyloric feeding tube delivers to the duodenum/small intestine (J Tube) „ Delivery Types „ Continuous infusion (pump) „ Intermittent/cyclic feeding (pump) „ Bolus/Gavage (syringe) „ Gravity drip

ENTERAL NUTRITION 7 Alternative Nutrition Delivery „ Feeding tube may become clogged

„ Feeding tube may come out

„ Infection around the GT site

„ Psychological

„ and/or constipation

„ Large amounts of gastric residual

COMPLICATIONS 8 Alternative Nutrition Delivery „ Blended at home

„ Made with whole foods, baby food, real food

„ Can replace all feeding or be used to supplement feedings

„ Cost efficient if tube feeding formula is not covered by insurance

„ Allows caregivers and patients to be involved in meal preparation

„ Patients like to eat what the family is

„ Can be organic or non-GMO

BLENDERIZED TUBE FEEDING (BTF) 9 Alternative Nutrition Delivery „ In-adequate nutrients

„ Un-safe food handling

„ Not for patient on continuous tube feeding

„ Not for immunocompromised individuals

„ Tube clogging

„ Large amounts of gastric residuals

COMPLICATIONS 10 Alternative Nutrition Delivery „ Solution is specific to height, weight, age and the medical condition

„ Contains , , amino acids, electrolytes, , and insulin

PARENTAL NUTRITION 11 Alternative Nutrition Delivery „ Mechanical complications with the tube/

„ Infection

„ Metabolic

„ Fluid and electrolyte imbalance

COMPLICATIONS 12 Alternative Nutrition Delivery „ Skilled nursing support

„ Completes the initial assessment

„ Teach and train how to care and use the GT/Central line

„ Establishes a goal for and evaluates therapy

„ Caregiver or CNA support

„ Can be daily for a duration of 4, 8, 12 or 24 hours

„ Under current California law a Caregiver or CNA cannot administer feeding via gastric tube.

HOME SUPPORT OPTIONS 13 Alternative Nutrition Delivery „ Medicare Part B (Medical Insurance) covers enteral nutrition supplies & equipment under the prosthetic device benefit. „ Medicare Part A (Hospital Insurance) helps cover cost post- hospital care furnished by a home health agency in the patients home. „ Managed Care, HMO, or VA patients „ Third Party insurance „ Direct Patient payment „ Medicaid

„ Enteral nutrition supplies & equipment www.medicare.gov

ARE MY SUPPLIES & EQUIPMENT COVERED BY INSURANCE? 14 Alternative Nutrition Delivery „ Requires a written order from the physician

„ Supplied by the specialty pharmacy

„ Supplies (IV pump, sterile dressing kits, flush etc.) covered under insurance benefit

„ Number of skilled nursing visits is determined by the client condition – often teach and train is the goal

PARENTERAL NUTRITION (TPN) 15 Alternative Nutrition Delivery „ Alzheimer’s disease Amyotrophic lateral sclerosis „ Aneurysm Anoxic encephalopathy „ Bowel infarction Cancer of any part of the upper GI tract „ Cancer of the brain Cerebral palsy „ Cerebrovascular accident (CVA) Hx of CVA with residual effects „ Cerebrovascular insufficiency Closed Head injury „ Comatose Degenerative Brain disease „ Duodenal obstruction Encephalopathy „ Esophageal obstruction Esophageal paralysis „ Esophageal perforation Gastrectomy „ Gastric outlet obstruction Gastrointestinal fistula „ Gastrointestinal hemorrhage Guillian-Barre syndrome „ Hepatic encephalopathy Multi-farct dementia

„ COVERED CONDITIONS 16 Alternative Nutrition Delivery „ A diagnosed functional impairment of the gastro intestinal (GI) tract necessitating enteral feeding

„ Permanence of that condition necessitating enteral feeding

„ Feeding is administered via enteral feeding (non-oral)

ALTERNATIVE NUTRITION QUALIFIERS 17 Alternative Nutrition Delivery „ Enteral Feeding – Supports nutrition delivery by bypassing the mouth. Delivered via NGT/GT. Commercial formulas available. Formula and supplies may be covered by Insurance. Blenderized feeding is an option to reduce cost and provide client preferred foods. Education and clinical support increase nutrition delivery success.

„ Parenteral Feeding – Formula is specific to the individual. Delivered directly into the vein. Nursing support for education central line care and test

„ All forms of alternative delivery have associated risk.

SUMMARY 18 Alternative Nutrition Delivery „ CMS.gov „ Gastoroparesis Partner Association www.g-pact.org „ MitoAction www.mitoaction.org

„ AGMD www.agmd-gimotility.org „ America Society for Parenteral nutrition www.nutritioncare.org „ Soleo Health www.soleohealth.com „ Nestle Health Science www.nestlehealthscience.us „ Shields Healthcare www.shieldhealthcare.com „ ASPEN www.nutritioncare.com

RESOURCES 19 Alternative Nutrition Delivery QUESTIONS 20 Alternative Nutrition Delivery