Kathy Dubowsky (left), president of Great Lakes Home Healthcare Services (GLHHS) and Karen Schnaekel, clinical nutritionist and registered dietician at GLHHS.

At Great Lakes Home Health-care Services (GLHHS), Erie, Pa, nutrition is serious business for patients experiencing chronic illness or acute injury. From a financial standpoint, nutrition also contributes to the health of the organization’s bottom line.

It starts with enteral therapist Bobbi Kraft, LPN. Referral sources call her up on behalf of patients who need nutrition via various methods. Kraft is responsible for obtaining all patient demographic information and for ensuring that a physician order is on file. She then prepares the information for evaluation by the rest of the nutrition support team —a pharmacist, two registered dietitians, and an infusion registered nurse. At times, the referring physician and/or medical director may participate on the team. If the patient receives respiratory services or private duty nursing, the team would flex to accommodate these disciplines as well.

Before forming the nutrition support team, the information would have been received by customer service and passed on to the warehouse for simple delivery that would include an enteral pump and nutrition product as prescribed. If indicated, the patient may have also received a nursing visit (or two) for education related to the use of the pump. After that initial setup, the patient’s contact would only be through periodic delivery of their nutrition product. Patient questions were directed to infusion registered nurses who attempted to answer with limited information. Many times, the patient was referred back to his physician for further information.

Intake Coordinator/Reimbursement Specialist
In her role as intake coordinator for the nutrition support team, Kraft does much more than just pass along patient information and physician orders. She is also a reimbursement specialist that obtains proper insurance authorizations. This information is needed to draft a “clean bill” that will be paid in a timely manner. To make this happen, she coordinates with the billing and collections staff who are also specifically assigned to the nutrition support team.

Kraft says her services are valued by patients and families because she gets to know them on a personal level. She is not only aware of their current health conditions but clinically understands their underlying disease processes. “It helps to have clinical staff for patients to talk with regarding their concerns or problems, rather than clerical in-take staff,” she says. “I or our dietitians are available to help them identify potential problems and offer solutions.”

Karen Schnaekel has the daily task of completing assessments on all patients who receive enteral nutrition (orally or via tube feeding).

Kraft provides phone follow-up using a case management model for all enteral patients established at predetermined intervals. These phone calls include assessing height, weight, tolerance for feeding, and product availability. Checking on the patients regularly helps resolve problems early, even when the patient may not understand the symptoms they are experiencing. Serious problems can be addressed, and it further provides Kraft with an opportunity to assess the patient’s compliance. “Since the nutrition support team was put into place, there is no unused product sitting in a patient’s home because too much was sent, the patient is not tolerating it, or he or she is simply refusing to follow therapy,” Kraft says. “I think patients are more compliant because we are following them more closely and we share their interest in attaining their goals for long-term health.”

Inventory Management
In addition to taking up a lot of space, nutrition formulas expire. Unlike most HME products, enteral products must be rotated and discarded once an expiration date is reached. Sloppy management can cost a lot of money. The dietitian and LPN enteral therapist must work closely with the warehouse and purchasing staff conducting weekly reviews of each patients’ needs, product availability, and purchasing requirements.

Helping the Poster Child
With the development of the nutrition support team, GLHHS can now offer extensive clinical nutrition services, not just product management. The team is under the direction of Karen Schnaekel, the clinical nutritionist, who is a registered dietitian. She has the daily task of completing assessments on all patients that receive enteral nutrition (orally or tube feeding), as well as all patients ordered to receive total parenteral nutrition (TPN). “I determine the patients’ acuity level and the need for follow-up, which can range from every 4 weeks to every 4 months. Home visits can be provided for patients requiring extensive education or trouble-shooting of formulas or equipment,” Schnaekel says.

She recently worked with a patient and family at home regarding an episode of sudden elevated blood sugars. “One of our success stories is Jack Armbruster. He is a 7-year-old patient we have been caring for since October 2002 when he started receiving oral supplements,” says Schnaekel. “He has muscular dystrophy and gastroesophageal reflux. He eventually had a g-tube placed in September 2003, along with the Nissen fundoplication procedure, and started enteral nutrition.”

Schnaekel worked closely with Jack and his family on getting the right nutrition products and educating them on the feeding pump. “His mom is now the expert on the pump and supplies. He weighed only 20 pounds at the time he started tube feedings and is now up to 47 pounds,” says Schnaekel. “He is our little poster child.”

In fact, Armbruster actually was the Muscular Dystrophy Association poster child in northwestern Pennsylvania for the past 3 years. He is also a Pennsylvania MDA Junior Goodwill Ambassador.

Contracts With SNFs
Having a registered dietitian on staff gives GLHHS an edge in obtaining enteral contracts with skilled nursing facilities (SNFs). Many facilities do not have full-time dietitians employed. The clinical consulting services provided by the GLHHS dietitian becomes a value-added service to the contract. Nutrition services are also contracted to skilled nursing home health agencies for nutrition consultation visits when required. Nurses at these agencies also contact Schnaekel as a “free” resource for feedback following any nutrition assessments they might conduct.

For Kathy Dubowski and GLHHS, nutrition services can serve as a portal for generating additional business.

Another critical role of the nutrition support team is to work with an agency’s facility-based pharmacy and IV nursing staff to provide a comprehensive service for TPN patients. “It has been helpful to have a dietitian as part of the team,” says Bob Buzas, director of pharmacy. “We collaborate on a daily basis, but also have a weekly chart review of our TPN patients to assess lab values, patient symptoms, and reactions.”

This type of “case management” has also allowed GLHHS the opportunity to start patients on TPN at home. This would have normally been completed through admission to the hospital to begin therapy, and then discharging the patient home to complete their TPN therapy. Systematic review also allows the team to make recommendations to physicians.

Diabetes and More
Several dietitians are also on staff at GLHHS to focus solely on the diabetes population. These diabetes education services are promoted as the Great Lakes Diabetes Institute under the umbrella of GLHHS. The dietitians dedicated to this area focus on education for patients with diabetes, which includes carb counting, meal planning, inpatient and outpatient education, and support. The Great Lakes Diabetes Institute uses an extensive library of educational modules, which were developed by Diane Harbaugh, the manager of the institute, and her professional staff.

Since GLHHS has a nutrition support team, many physicians request nutrition consults, other than for enteral therapy or diabetes. Within the past year, an additional dietitian was recruited to focus on medical nutrition therapy consults for patients diagnosed with conditions such as hypertension, heart disease, chronic respiratory conditions, severe obesity, cancer, and eating disorders. Some of these consults are reimbursed by insurance, others are self-pay. “The need for new nutrition-based services seemed to surface each day,” says Kathy Dubowski, president. “GLHHS was most recently approached by a medical assistance HMO to design a specialized weight management program for their patients who may be candidates for bariatric surgery, to help determine eligibility. It is exciting to be positioned in a home care environment that can continue to hire new staff who are eager to build new programs and grow the business.”

Ultimately, nutrition services can serve as a portal for generating additional business. For example, a bariatric patient may be in need of other products or services such as heavyweight wheelchairs, CPAP mac-hines, or special vitamin products that are carried in the retail showroom.

Rather than just delivering product to the patient’s door, GLHHS is now able to offer patients and physicians a new resource for trouble-shooting, from equipment problems to patient intolerance of formulas. “We can now offer physicians outcomes re-garding their patients, de-monstrating increases or decreases in weight and improvement in the patient’s condition,” says Schnaekel. Having this type of value-added service is a key marketing point.

Offering a team approach to nutrition management has further changed the relationship with hospitals in regard to discharges. Hospital dietitians now routinely interface with GLHHS dietitians prior to patients being discharged for TPN or enteral tube feedings. “They feel much more comfortable speaking one on one with the dietitian because it decreases any chance of miscommunication and the potential for error,” adds Schnaekel.

There were some minor growing pains, most of which stemmed from the rapid growth of the nutrition business. Space for inventory was one of the biggest issues that immediately faced the warehouse staff, as well as working out a system for quick response to new referrals. “We built it and they came quickly,” says Schnaekel. “Be sure you have all your ducks in a row, which includes good clinical staff with knowledge of everything from formulas to insurance reimbursement, and adequate space.”

Laurie Schneider is director of marketing for Great Lakes Home Healthcare Services, an HME provider in Erie, Pa, with a branch office in Bradford, Pa.