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 .