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 pharmacy 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 nutrients to the body, bypassing the digestive system and dripping nutrient 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 fistula, 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 stomach 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
Diarrhea 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 eating
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 glucose, lipids, amino acids, electrolytes, vitamins, and insulin
PARENTAL NUTRITION 11 Alternative Nutrition Delivery Mechanical complications with the tube/catheter
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, saline 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 blood test monitoring
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