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Section A - Policy

16. Specific Programs & Technical Details

Appendix 8-Home Enteral Nutrition

1. Definition

Enteral feeding involves the delivery of liquid high-concentration nutritional formula directly into the intestinal tract via a feeding tube. The tube may also be inserted through the nose or stomach. Home enteral nutrition (HEN) is the use of enteral nutrition therapy in a home setting.

2. Background

There is growing evidence that optimal nutrition can have a positive effect on health and treatment outcomes. Technological improvements in enteral feeding systems for use in home settings and advances in enteral formulae have made HEN safer and more effective. Home based care can significantly improve quality of life by increasing independence of patients. These factors combine to make HEN a practical and positive treatment option for some patients and have resulted in an increase in acceptance and usage by physicians, dietitians and consumers.

In November 1996, the Minister for Health established a Working Party to review the policy framework and funding arrangements for HEN in Victoria. The review recommended funding for HEN services through the public hospital system and the provision of services within a best practice framework. It also recommended the development of a minimum dataset and Victorian-based research and development projects for future enhancements to the Program.

The HEN Services Pilot Program commenced in October 1997 with a $2 million recurrent commitment. 1999-2000 is the third year of the Program and builds on the knowledge and experience gained in providing HEN services in the previous two years. Four research and development projects were funded in 1998-99 to formally evaluate the outcomes and cost effectiveness of HEN and the development of best practice protocols in the delivery of HEN services. The titles of the projects and their respective auspice agencies are as follows:

• Development of a Best Practice Model for HEN Support - Austin and Repatriation Medical Centre;
• Evaluation of the Effect of HEN on Quality of Life and Nutritional Status - Royal Melbourne Hospital;
• Evaluation of HEN and Development of Victorian Disease-Specific Guidelines - Royal Children's Hospital; and
• Study into the Outcome of Nutritional Support of Patients with Cystic Fibrosis and HIV - The Alfred.

All four projects are expected to be completed by 31 January, 2000.

3. Program Aims

The 1999-2000 HEN Program aims to:

• Provide high quality and cost effective HEN services for eligible consumers;
• Encourage improvements in service delivery; and
• Promote best practice.

4. Consumer Eligibility

For consumers to be eligible to receive HEN services through the Program, they must:

• Be managed by a health care provider participating in the program;
• Live in the community;
• Make a standard co-payment if they are not health care card or equivalent concession card holders; and
• Provide consent for the use of de-identified consumer level data for monitoring and evaluation purposes.

6. Provider Arrangements

Health care providers participating in the Program are required to:

• Undertake, three monthly and then six monthly clinical reviews of consumers;
• Provide written information to consumers about HEN services, hospital arrangements and consumer rights and responsibilities;
• Implement and adhere to the best practice guidelines as described by the AuSPEN Clinical Practice Guidelines for Home Enteral Nutrition; and
• Collect consumer co-payments at specified rates.

7. 1999-2000 Budget And Funding Arrangements

In preparation for mainstreaming the program, HEN funding in 1999-2000 will be provided as a specified grant under the Victorian Ambulatory Classification System for Group A hospitals, Ballarat Health Services and the Bendigo Health Care Group, and as a Non-Admitted Patient Grant to other hospitals. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998-99 due by 30 July 1999. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year and will assist in the determination of the following year's funding allocation.

Unexpended funds will be recalled by the Department as part of the financial year wrap-up for the Program.

As in 1998-99, Health Care Networks and Major Rural Regional Hospitals will be responsible for the management and accountability of funds allocated by the Department. However, all hospitals with eligible consumers will be able to participate in the Program and receive funds through their Health Care Network or Major Rural Regional Hospital.

Metropolitan

• North Western Health Care Network
• Southern Health Care Network
• Inner and Eastern Health Care Network
• Women's and Children's Health Care Network
• Peninsula Health Care Network
• Austin Repatriation Medical Centre
• Bethlehem Hospital Inc.
• St Vincent's Hospital (Melbourne) Ltd

Rural

• Geelong Hospital Barwon South Western Region
• Ballarat Health Services Grampians Region
• Bendigo Health Care Group Loddon Mallee Region
• Latrobe Regional Hospital Gippsland Region
• Goulburn Valley Base Hospital Hume Region

The purpose for allocating funds in this way is to:

• Encourage collaboration between health care providers;
• Encourage consistency in service provision standards and practices; and
• Streamline administration and reporting processes and minimise workload for hospitals with small throughput.

The 1999-2000 HEN budgets are based on submissions by hospitals regarding their expected level of activity. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998-99 due by 30 July 1999.

Health Care Networks and Major Rural Regional Hospitals may reallocate funds within their Networks or Regions as required.

The 1999-2000 budgets are capped and Health Care Networks and Major Rural Regional Hospitals are expected to bear the financial risk for over expenditure on budget. Providers are expected to use effective purchasing arrangements in order to keep the cost of nutrition and consumables within budgeted levels and maintain a high quality service. Funds will be paid as a specified grant in equal monthly amounts.

All participating health care providers are to collect consumer co-payments at the specified rates and report on this revenue. Shortfalls in revenue resulting from the non collection of co-payments will be borne by providers.

8. Reporting Requirements

All participating hospitals are required to provide a year-end certified income and expenditure statement to the Department by 31 July 2000 as set out in Attachment 1.

9. Monitoring, Evaluation And Review

Providers funded under the Program are required to participate in the evaluation of the program and other research and development projects. Projects currently funded by the Program are listed in Section 2 above.

Hospitals are encouraged to continue to make full use of the Hospital HEN Register for local patient and program management.

10. Future Directions

The "Best Practice Model for HEN Support" service development project, auspiced by the Austin and Repatriation Medical Centre and funded by the Department, will provide a useful guide for providers in establishing and maintaining best practice in the provision of HEN services. This project is due to be completed in July 1999.

11. Contact Persons

Vivien Adler, Manager Continuity, Acute Health
Tel: (03) 9616 7100 Fax: (03) 9616 8347 e-mail: vivien.adler@dhs.vic.gov.au

Lisa Basford, Project Officer, Continuity, Acute Health
Tel: (03) 9616 9804 Fax: (03) 9616 8347 e-mail: lisa.basford@dhs.vic.gov.au

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