Putting the ‘ Home’ into Home Enteral Nutrition

1. Putting the ‘Home’ into Home Enteral Nutrition Helen Jackson and David Rhodes Tornado December 2006

2. What is Home Enteral Nutrition? • Commercially formulated nutrition products delivered by tube feeding or oral supplementation for people living at home • Used for any patient unable to meet nutrition requirements via usual oral intake (e.g. cancer, cystic fibrosis, pre & post surgery, malnutrition stroke, brain injury) • A feeding regime may cost $105 per week for a tube fed adult CVA (includes feed and consumables) • Clients demographics: 50% paediatric, 50% oral supps

3. Aim • To implement a standardised HEN service that is: • clinical best practice - supplies the ‘product of prescriber choice’ to meet the client’s clinical needs (not restricted by manufacturer / supplier) • convenient - delivery to the client’s home, anywhere in the Hunter • timely - delivery within 48 hours of ordering. • supportive – access to support by clients in their home environment • fair and equitable in pricing clients, wherever they live in the area • cost effective for health system • safe and efficient – reduced clinician time on handling products

4. Background • Different client experiences with different systems for different home locations • Inequitable client payment systems – from fully subsidised to full cost recovery (range $0-$100 per week) • Products collected from hospitals (inconvenient, parking frustrations, OH&S issues, loss of clinical care time), or home delivery at high cost • No monitoring system or database • Expanding cost impact on health system • Projected increasing demand for HEN service as LOS decreases (60% increase in client numbers 2003 to 2005)

5. Methodology • Literature search, review of models in other Areas / interstate and client consultation (survey). Recommended model developed • Working Party formed to oversee project (dietitians, supply, nursing, biomedical engineering, finance and managers) • Client demographics collected on known population. Client survey indicated substantial issues with product collection • Model refined through data analysis and consultation with clients/stakeholders • Process mapping – from initial prescribing, ordering, product delivery, re-ordering systems, client supports and clinical review • Focus groups and brainstorming to define product range, to design a new subsidy/ payment model and to conduct a mid-project review

6. Implementation • Appointment of a Project Dietitian who facilitated the following: • finalisation of product range • final model for service initiation, prescription, supply and review • subsidy and safety net model (based on ABS and Family Studies estimates). Incorporates provisions for disadvantage, hardship and exceptional nutritional requirements. • intranet/internet based information dissemination for clinicians and clients • calculation and negotiation of each client’s payment schedule with a phasing in of existing clients to new rates over 3 years • partnerships with PADP and Supplier to provide consumables

7. Planning and implementation • Most importantly – an effective communication strategy • call centre • information booklet • letters to existing clients • training prescribing dietitians • feedback loops for clients and dietitians • regular liaison with Medi-Rent

8. Planning & Implementation • Area Supply Dept co-ordinated negotiations with potential suppliers. Single supplier to provide full product range, pumps and consumables and home-based support (telephone and on-site) – Medi-Rent selected. • Transfer of budget from all services to a central cost centre for ease of management and tracking • New service commenced October 2004 – ‘Morisset to Merriwa’. Limited expansion into LMNC. • Key to successful implementation:- HEN Project Dietitian - a central contact point for clients, dietitians and supplier.Problem solver extraordinaire!

9. Outcomes & Evaluation • Customer survey - high satisfaction with new model • Home delivery (within 48 hours of order) anywhere in Area • Payment options available (supplier administered) • Improved discharge planning and home supports (24 hour contact no.) • Improved clinical monitoring and review • Consistent access to a single HEN service by users • Standardised, equitable client costs across the Area with effective safety net provisions; supplier administers invoicing • Savings re-invested to cover increased service demand • Version 2 now implemented based on KPIs and evaluation • More clinical review time for dietitians

10. Client Feedback “My delivery was on time and in excellent condition! No complaints. I believe this service will reduce stress levels : just the fact that no more hospital visits for food. Yeah!” (written feedback received November 2004) “..all your staff have been very helpful and I do appreciate all they have done for me….how grateful I am that we can use this system as it takes a lot of stress away from me”(Carer , 15th June 2005) Dietitian Feedback “I feel it has been the biggest advance in Nutrition Support for CF since we switched from low fat to unrestricted fat diets back in 1982!” “We LOVE the bigger range of products & the consideration shown in pricing for health care card holders.” “I have been able to offer improved oral nutrition support options to some of my young patients who otherwise would progress to gastrostomy feeding sooner”(HNE Dietitian, March 2005) Outcomes & Evaluation

11. Future Scope • Extension to all of Area Health Service • Provides a working model for consideration by the NSW Greater Metropolitan Clinical Taskforce state-wide HEN Project and other AHS • Database development: links with other AHS and GMCT project • Projected $75K pa saving in 3 years (re-invested to cover increased clients on program) • Model has informed the State tender process for HEN products