Chapter 18 Nutrition Support

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TABLE 18.3 Laboratory Monitoring for the Adult Client on Long-Term Parenteral Nutrition Frequency Weekly

Laboratory Data

Serum glucose, serum electrolytes, BUN, creatinine, serum magnesium, and serum phosphorus until stable Other laboratory data as clinically indicated

Monthly for three months, then every other month

Quarterly

Complete blood count, serum proteins, serum triglyceride, serum glucose, serum electrolytes, BUN, creatinine, serum magnesium, serum phosphorus, serum calcium Other laboratory data as clinically indicated

Serum albumin, [aspartate aminotransferase] AST, alkaline phosphatase, total bilirubin, prothrombin time, [international normalized ratio] INR every three to six months

Micronutrients as clinically necessary or if deficiency suspected

Oley Foundation has a patient-focused chart for home parenteral nutrition (HPN) patients to use at home as a component of self-monitoring and complication avoidance (www.oley.org/charts/newHPN.pdf).

REIMBURSEMENT OF ENTERAL

AND PARENTERAL NUTRITION Older adults requiring enteral or parenteral nutrition typically use Medicare to provide reimbursement for health care services, including nutrition support therapy (32). Medicare has strict criteria for coverage of home (or nursing home) EN and PN support. The client must be enrolled in Medicare Part B and meet criteria to qualify for EN or PN. For EN coverage under Medicare Part B, all of the following criteria must be met to qualify for standard tube-feeding reim- bursement: 1) a diagnosis reflecting a functional impairment and 2) permanent impairment (ie, a need for enteral nutrition for 90 days or a lifetime). Formula selection is important, and standard enteral formulas are more likely to be covered than a spe- cialty formula. If a specialized formula is required, such as one that is carbohydrate reduced, it is impera- tive to document intolerance to a standard formula- tion. Additional documentation and justification are required for a pump when feeding into the stomach, as intolerance to other feeding methods must be demonstrated and documented.

For PN coverage under Medicare Part B, all of the following criteria must be met to qualify for standard reimbursement: 1) a diagnosis reflecting malabsorption

of nutrients and 2) permanent impairment (ie, a need for PN for 90 days or a lifetime). Malabsorption of nutrients must be documented with diagnostic workup/ evidence to categorize the individual into the appropri- ate criteria. This is a very complex process, and assis- tance may be found online at (www.Medicare.gov) or by working with an experienced home infusion provider.

Medicaid coverage for EN or PN varies by state.

A commercial payer may cover EN, but it must be a contracted benefit and may cover supplies only. PN is usually a covered benefit by a commercial payer; however, if the client is a Medicare recipient, then the commercial payer benefit is usually in the form of a supplemental or a secondary commercial policy. This may be used for PN or EN, but this also requires careful assessment to determine coverage.

RESOURCES FOR PATIENTS Many people have lived well on home EN and PN with a good quality of life. The Oley Foundation is an edu- cation and support foundation/group that is free to clients and caregivers. It can provide the support of “peers” that clients and family need when they are receiving this specialized therapy. The information on the website is both clinical and supportive—useful to patients, caregivers, and clinicians. Anyone who is receiving home EN or PN should be provided informa- tion about the Oley Foundation (www.oley.org).