Home Nutrition Support: Ethics and Reimbursement

Addressing the unique needs and quality of life issues for adults receiving long-term home enteral nutrition

Individuals who require home enteral nutrition (EN)-and, subsequently, their families-undergo major changes in family dynamics. They would benefit from an approach that provides ongoing nutrition, hydration, enteral access, and quality of life assessments from knowledgeable clinicians. Most individuals and families will be new to the enteral access device, handling and administration of the nutrition formula, medication delivery through feeding tubes, and troubleshooting associated complications. Educational sessions are typically given but may not be comprehensive enough to meet all needs, especially in the first weeks to months of home EN therapy. Quality of life assessments obtained in the early stages of EN support would help clinicians identify and focus on areas that need special attention for that individual and family. Ongoing clinical care is essential because over time, the nutrition prescription, delivery methods and schedules typically require alterations and feeding tubes need to be assessed and replaced. In addition to these important physical dimensions of care, attention should be placed on the psychological, cognitive, social, and ethical aspects of life for these individuals and their families.

Reducing outpatient gastrostomy tube complications

OBJECTIVE

To monitor the effectiveness of a multidisciplinary education protocol for gastrostomy tube (GT) use and care for patients to reduce complications postplacement.

METHODS

Baseline assessment included a preintervention/intervention design through quantitative measures to determine reduction in the number of GT complications postprocedure following implementation of a patient education protocol for 16 patients in the study.

INTERVENTION

A multidisciplinary approach was used in protocol development for standardizing patient education. Verbal, written, and hands-on demonstration methods for GT care were used to provide multiple education pathways to increase patient knowledge. Over the progression of 8 months (July 2019 to March 2020), patients with a new GT were followed postprocedure (1-2 weeks prior to starting radiation treatments) and throughout their course of radiation treatments (typically 6-7 weeks).

RESULTS

All 16 patients (100%) in the intervention group were included in the final analysis. GT complications were reduced from 91% in the preintervention group (n = 11) to 37% in the intervention group (n = 16). The most significant reduction occurred in technique issues, which decreased from 36% (n = 4) to 0%.

CONCLUSIONS

Implementation of a multidisciplinary approach with multiple educational sessions prior to GT placement and use led to increased patient knowledge and reduced GT complications.

A narrative review of healthcare financing and reimbursement of nutritional support for patients in Singapore

AIMS

Nutritional support is used frequently in Singapore's healthcare settings, but limited research has been published on how it is financed. This paper aims to provide a narrative review on the financing of nutritional support in Singapore for acute care, step-down care, intermediate and long-term care (ILTC), community and home settings.

METHODS

A structured search strategy was applied to available electronic databases using selected search terms, with additional reports and grey literature identified using iterative searches.

RESULTS

A limited number of publications were found via electronic databases. The majority of publications were from governmental reports/ press releases, and healthcare organizations' websites. While funds are available via MediSave, MediShield Life, MediFund, and various other schemes, they may not be sufficient for individuals on long-term nutritional support.

CONCLUSIONS

More funding sources for nutritional support are urgently required for patients in ILTC. Means-testing mechanism and targeting may need to improve to ensure access to financial assistance for nutritional support and prevent poorer outcomes and higher medical costs. Medical providers, dietitians, pharmacists and social workers play a role in determining need, prescribing and accessing nutritional support for optimal care of individuals in hospitals and ILTC. Future policies will need to address the issues of access to nutritional support in the elderly and low-income populations.

A Survey of Home Enteral Nutrition Practices and Reimbursement in the Asia Pacific Region

Literature regarding the use of home enteral nutrition (HEN) and how it is reimbursed in the Asia Pacific region is limited. This research survey aims to determine the availability of HEN, the type of feeds and enteral access used, national reimbursement policies, the presence of nutrition support teams (NSTs), and clinical nutrition education in this region. An electronic questionnaire was sent to 20 clinical nutrition societies and leaders in the Asia Pacific region in August 2017, where thirteen countries responded. Comparison of HEN reimbursement and practice between countries of different income groups based on the World Bank’s data was investigated. Financial support for HEN is only available in 40% of the countries. An association was found between availability of financial support for HEN and health expenditure (r = 0.63, p = 0.021). High and middle-upper income countries use mainly commercial supplements for HEN, while lower-middle income countries use mainly blenderized diet. The presence of NSTs is limited, and only present mainly in acute settings. Sixty percent of the countries indicated an urgent need for funding and reimbursement of HEN. This survey demonstrates the varied clinical and economic situation in the Asia Pacific region. There is a lack of reimbursement, clinical support, and inadequate educational opportunities, especially for the lower-middle income countries.