Guideline for Home enteral nutrition service (HENS) for outpatients

Guideline number: QH-GDL-015

Effective Date: 4 February 2024

Review Date: 4 February 2027

Supersedes: Version 4

1.  Introduction

This guideline provides recommendations to support application of consistent practices across Hospital and Health Services (HHS’s) in relation to the prescription and supply of clinical products and consumables for HENS.

1.1 Scope

This Guideline applies to all HHSs and to all HHS employees. This Guideline also applies to all organisations and individuals acting as an agent for HHSs (including Visiting Medical Officers and other partners, contractors, consultants and volunteers) involved in the care, finance and supply of enteral nutrition (EN) products. Compliance with this guideline is not mandatory, but sound reasoning must exist for departing from the recommended principles within a guideline.

1.2 Definition

Enteral nutrition (EN) is the delivery of specialised nutritional products into the gastrointestinal tract and is a standard measure for restoring or preserving nutritional health in chronically or critically ill patients including adults, children and infants. In Queensland, this includes nutrition support delivered both orally and by feeding tube.

In Queensland, patients and families can access Queensland Health funded enteral nutrition support for home use through the Home Enteral Nutrition Service (HENS). Currently, the supply of enteral nutrition products and consumables is provided through a Standing Offer Arrangement (SOA) with external suppliers to enable access to a range of nutritional products via a home delivery model.

1.3 Objectives

The primary objectives for Queensland’s Home Enteral Nutrition Service are that:

1. HEN is equitable, accessible, and affordable for patients, consumers and families

2. HEN promotes patient and consumer autonomy and decision making and meets individual needs

3. HEN is safe, high quality, and aligns with best evidence

4. HEN is consistent and coordinated across Queensland Health

8. HEN is high-value, sustainable and represents an efficient use of health system resources

2. Eligibility

Eligibility is determined by both administrative and clinical criteria.

2.1 Administrative Eligibility

Queensland residents who are treated as a public outpatient in a Queensland public health facility receiving EN products on the List of Approved Medicines (LAM) OR have individual patient approvals (IPA) for access to EN products for indications which are not included on the Queensland Health LAM. Non-Queensland residents are only eligible for the duration they are receiving active treatment by a specialised service for a clinical condition within a Queensland public health service.

2.2 Clinical Eligibility

Clinical eligibility will be determined by the dietitian based a nutrition assessment.

Eligible outpatients must meet ALL of the following clinical inclusion criteria:

• EN products are required to meet their nutritional requirements
• All reasonable and clinically indicated attempts have been made to meet nutritional requirements with increased food frequency and/or fortification of foods and fluids (food first approach)
• There is a definable treatment goal for which EN is an essential part of the clinical process and ongoing Queensland Health dietitian input is required
• The prescribing health professional clearly documents the treatment goal, clinical justification, and the expected benefit in the medical record
• The patient can administer EN independently and safely in the home environment or there is access to the required supports for home administration

If there is uncertainty that nutrition support will be effective for meeting a definable treatment goal, then a trial of HEN should be offered as below:

• Initial trial period for a maximum of three months
• Initial review to be offered within one month of commencement
• The patient is assessed against relevant, measurable clinical outcomes and adherence to the prescribed HEN
• If the patient fails to adhere to HEN provision despite adequate supports or if no progress is seen towards the defined treatment goal, Queensland Health funded HEN to be discontinued.

2.3 Persons not eligible for HEN

Queensland public health system outpatients who satisfy ANY of the following exclusion criteria are not eligible for Queensland Health funded HENS:

• Department of Veteran Affairs (DVA) Gold Card holders and in some cases White Card Holders
• Non-Queensland residents
• Patients who are not eligible for Medicare
• Residents of non-Queensland Health residential and aged care facilities
• Patients accessing level 3 or 4 home care packages
• Patients eligible for NDIS where nutrition support requirements are directly related to a person’s disability support needs (Additional information can be found in “Dietetics and the National Disability Insurance Scheme – A guide for dietitians”)

The prescriber has a responsibility to strictly adhere to all inclusion and exclusion criteria. If all reasonable attempts to uphold these criteria have been made, yet a patient has no other access to the nutritional products they require, the prescriber may seek extraordinary approval from the appropriate delegate for provision of a short-term supply of Queensland Health funded HEN.

2.4 Ongoing eligibility

At all times, HEN should be provided when:

• There is an ongoing clinical indication for EN to meet the patient’s nutritional requirements.
• There is evidence the patient is meeting or progressing towards the defined treatment goal/s.
• The patient is self-administering HEN safely and as prescribed.

A person must meet all of these eligibility requirements to receive an ongoing HEN prescription and may become ineligible for funded HEN if their circumstances change.

3. Funding for HEN Service

The Queensland HEN Service, including the clinical services to prescribe and monitor HEN, and the provision of all clinically required products to eligible patients and consumers is covered by activity based funding (ABF). There is no out of pocket expense for eligible patients. Tier 2 Non-Admitted Services Classification (Tier 2) is the ABF classification for non-admitted care described by the Independent Health and Aged Care Pricing Authority (IHACPA).  The Tier 2 clinic classifications that are relevant to HEN include:

• 10.18 “Enteral Nutrition - home delivered” covers enteral nutrition self-administered by the patient in their home without a health care provider present. All Tier 2 class 10.18 sessions performed per month are to be bundled and counted as one non-admitted patient service event per patient, per calendar month, regardless of the number of sessions. Costs associated with the delivery, management and all other overheads of HEN, including consumables, formula, clinical administration are accounted for by Tier 2 class 10.18.  In some circumstances supplementary funding may be available through alternative external funding sources.
• 40.23 “Nutrition and Dietetics” covers provision of nutrition advice and guidance to manage nutritional problems and individual dietary requirements. Service events captured under Tier 2 class 40.23 must be an interaction between one or more healthcare provider(s) with one non-admitted patient, which must contain therapeutic/clinical content and result in a dated entry in the patient’s medical record. The interaction may be for assessment, examination, consultation, treatment and/or education.

Further information on ABF counting rules and funding definitions can be found in the IHACPA Tier 2 Non-Admitted Services Definitions Manual and the Tier 2 Non-Admitted Services Compendium.

4. Prescriber Role

HEN operates under a prescriber model.  Only HHS dietitians can approve eligible patients for home delivery of EN products. Patients should be referred to their local HHS dietetic service for follow-up on discharge.

Some HHSs may also grant approval for NGO Dietitians and/or Allied Health Assistants to prescribe HEN for eligible patients, NGO dietitians may undergo an approval process for prescribing rights, while Allied Health Assistants are required to work under a delegation model.

4.1 General information

Prescribers:

• Are responsible for the accuracy of the prescription.
• Must familiarise themselves with the following documents: “Guideline for Home enteral nutrition service (HENS) for outpatients” and the “Clinician User Guide for HENS”.
• Must ensure the consumer is informed and involved in the prescription process and provides consent for HEN.

HEN prescriber training resources are available on the DNSC SharePoint site if required.

4.2 Assessment

Prescribers:

• Conduct a nutrition assessment and consider any HEN products prescribed in the context of the intended clinical outcomes, cost and practicality.

4.3 Provision of Information

Prescribers should ensure the following is provided to patients in both written and verbal modalities:

• Information regarding eligibility criteria including that ongoing HEN eligibility is not guaranteed and that all criteria must continue to be met.
• Education and training to ensure patients, carers and/or support networks have the required knowledge and skills to safely deliver EN in their home environment.
• Information regarding the process to place HEN orders (via either hospital pick-up or home delivery as appropriate) including the “HEN Consumer Factsheet”.
• Information and education regarding enteral nutrition product and consumable selection and use
• Any other required information to empower active involvement in their HEN care and support informed decision making.

4.4 Selection of Home Enteral Nutrition Products

• Enteral Nutrition formulas are selected from the Queensland Health List of Approved Medicines (LAM). An Individual Patient Approval (IPA) is completed and submitted to the HHS medicines committee for non-LAM/SOA EN products [refer to Queensland Health Guideline: Management and Governance of Individual Patient Approval for further details].
• Patients should be prescribed all clinically required HEN products selected from SOA QH212 “Enteral Feeding and Nutrition” for enteral nutrition products, infant formula, related equipment, consumables, accessories. The consumables, related equipment and accessories may vary depending on the individual patient’s circumstances. Selection of products should be guided by information within the “Clinician User Guide for HENS”.
• Patients and consumers should be given visibility over product options that are appropriate for their needs. They should be encouraged to contribute to product choice decisions acknowledging their preferences for non-clinical product preferences (e.g. brand, flavour or packaging choices).
• Patients are initially provided with a supply of EN products and consumables for a reasonable period (up to 30 days). This allows the patient the time to make appropriate arrangements to obtain a further supply from local services/home delivery.
• Patients, when required, are provided with a feeding pump by the HEN external provider (as per SOA 212). If patients are provided with a loan pump from either the HHS or external provider, they should be advised of the terms and conditions of the loan including the requirement to return the pump when it is no longer required.

4.5 Registration Process

Prescribers need to complete and collate all administrative documentation associated with registering a patient for HEN.

All relevant forms and documents required for HEN prescription are maintained on the Statewide Nutrition and Dietetics SharePoint site - https://healthqld.sharepoint.com/sites/OCHO-ND

4.6 Ongoing review and monitoring

It is recommended that prescribers arrange a review within 1-3 months following the initial prescription of HEN to:

• Ensure the patient has received home delivery of the required products.
• Assess whether the nutritional products are appropriately meeting the patient’s nutritional requirements and document whether the defined treatment goal is being met.
• Amend the patient’s prescription if modifications are required.

A review should occur within 1 month in circumstances where a trial of HEN is indicated due to uncertainty that nutrition support will be effective in meeting a definable treatment goal.

All HEN patients should be reviewed at a minimum of once every 6 months. Interim review frequency should be determined by the responsible clinician, depending on the clinical status of the patient.

• Reviews may be delivered via face to face, phone, telehealth or electronic communication methods.
• Review modality should be selected in consideration of the patient’s individual treatment requirements and individual preferences and needs (e.g. accessibility limitations).
• Virtual care should be offered as an option for HEN reviews when clinically appropriate so patients can make the right choice about their care for their circumstances.

5. Transfer of Care

• In cases where a patient’s care is transferred from one HHS to another, the relevant dietitian in the receiving facility/HHS will review and update the HENS order form within 30 days and then review the patient within the timeframe negotiated between the treating dietitians.
• The referring dietitian will provide clinical handover, including a nutrition and dietetics discharge report and copy of HENS paperwork to the residing HHS/facility dietitian and relevant key contacts (e.g. GP, NGO, community health nurse) via email/fax/mail to facilitate follow up prior to the patient being discharged.
• When a patient’s care is transferred from one HHS to another, dietetic services, supply and cost of EN products become the responsibility of the receiving HHS.
• If ongoing dietetic care is provided at more than one facility for an individual patient, the treating dietitians should communicate clearly any changes to the patient’s nutrition care plan.
• The treating dietitian should continue to provide ongoing dietetic follow up Including EN care until such time that an appropriate referral to another facility/hospital’s dietetic services is negotiated and alternate dietetic service is arranged or until it is determined that HEN is no longer required.

6. Standing Offer Arrangement (SOA)

The supply of HEN is managed via a Standing Offer Arrangement (SOA) - QH212 Enteral Feeding and Nutrition.  The SOA is formal arrangement with external commercial providers that manages the supply and delivery of home enteral nutrition formulas, consumables and associated equipment, for an agreed price and for an agreed period of time.

7.  HEN Services Governance and Issue Escalation Mechanisms

The governance of the Queensland Home Enteral Nutrition Service is the collaborative responsibility of the Department of Health and Queensland HHS’. The Queensland HENS Governance Framework describes the governance structure for the Home Enteral Nutrition Service within Queensland Health including roles and responsibilities and risk escalation pathways for all stakeholders.

8.  Service Performance Indicators

Quality improvement and outcome measurement activities should be conducted by all hospital and health services involved in HEN service delivery. The performance of the service should be measured and reported on against the primary objectives described in 1.3 Objectives.

9. Related Documents

Key Queensland HENS Documents

• Home Enteral Nutrition Patient Registration and Order Form https://qheps.health.qld.gov.au/__data/assets/pdf_file/0015/2114421/hen_order.pdf
• Standing Offer Arrangement (SOA) QH212 for Enteral Feeding and Nutrition https://qgad.govnet.qld.gov.au/arrangement/ca3cdfb1-06d7-4ddc-aecd-4123b94022a3
• Queensland Health List of Approved Medicines (LAM) enteral nutrition products and food supplements https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/medicines/approved-list/nutrition-and-food
• Queensland HENS Governance Framework   https://qheps.health.qld.gov.au/alliedhealth/html/professions/nutrition-and-dietetics-enteral

10. Other Relevant documents

• Statewide Nutrition and Dietetics SharePoint – HENS Resources https://healthqld.sharepoint.com/:f:/r/sites/OCHO-ND/Shared%20Documents/HENS%20Resources?csf=1&web=1&e=AF9Fxl
• Statewide Nutrition and Dietetics SharePoint – NDIS Resources https://healthqld.sharepoint.com/:f:/r/sites/OCHO-ND/Shared%20Documents/EN%20COP/NDIS?csf=1&web=1&e=cgJ2Hj
• IHACPA Tier 2 Non-Admitted Services Definitions Manual and Compendium https://www.ihacpa.gov.au/resources/tier-2-non-admitted-services-2023-24

11.    Document History