As HME providers, we are often the bridge between high technology, unfamiliarity, confusion, and fear. We know we are connected when our customers tell us they no longer feel like inanimate objects or numbers within a complicated system. How we respond in the complex provision of enteral nutrition is an opportunity to showcase our expertise, demonstrate integrity, and honorably serve our customers. A well-developed enteral nutrition program requires the cooperation of consumers and caregivers, along with behind-the-scene coordination of a team of experts by the HME provider.

Getting to Know All About You
Balanced nutrition is essential for general health and well-being. For those who are medically compromised, the enteral nutrition and subsequent supplementation become vital building blocks for recovery and sustenance. Regardless of the precipitating situation, effective enteral nutrition intervention, total or supplemental, starts with the HME company compiling a genuinely individualized nutritional profile. The profile, obtained from a variety of health professionals, should clearly reflect the medical needs of that person. It should also identify measurable outcomes that can be reasonably expected.

A thorough, recent history and physical examination, as well as a nutritional assessment, should provide the medical information necessary to determine an appropriate formula, a safe method of administration, and benchmarks that would justify the plan’s continuance or adjustment.

With so many products available, some of which combine benefits of older products, it is even more important that attending physicians use HME providers as knowledgeable health care professionals when creating flexible, reasonable care plans. We may need to contact attending physicians to inquire about orders if they do not coincide with a product’s usual and customary utilization.

For example, the prevalence of simultaneously or alternately administering two different formulations has decreased substantially over the past 5 years. In addition, due to the cost of nutrition therapy, it is important that HME providers work with primary and secondary insurances to optimize therapy. The delivery of a customized enteral nutrition and/or supplementation plan should ultimately enhance a patient’s total quality of life.

Alternate Care Settings
Use of enteral nutrition and medically ordered supplementation is occurring more frequently in the alternate care settings. Each week I hear conversations about going to the store to pick up nutritional supplements.

Why? Family members may have noticed a loved one’s waning appetite or weight loss. Media ads suggest that drinking a dietary supplement will be the solution. What alarms me is that the public is more inclined nowadays to self-prescribe than seek reliable medical advice.

What is our responsibility then when we receive unsolicited calls for nonprescribed nutritional supplements? Are we obligated as licensed providers and community resources to ask triage questions?

My company believes that every call is an opportunity for reciprocal education. Meaningful dialogue with callers may result in long-term business relationships. We frequently take names, review options, and always mention the benefits of medical advice from physicians or nurse practitioners. We call to follow up and often there is a doctor’s order. When the consumer and/or caregiver understands the significance of the nutritional plan, compliance and success are more likely to occur.

Through the Door
My company provides individuals and their care providers with a comprehensive enteral nutrition program, comprised of all the resources and products necessary to sustain life day in and day out. Our focus is on continuity of care that provides the right product, at the right time, in the right amount, for the right reasons.

Our best referral source continues to be word of mouth, based on our performance and, more notably, the respect, concern, and understanding we demonstrate. Telephone calls come from discharge planners, social workers, family members, dieticians, nurse case managers, manufacturer representatives, specialized physicians, surgeons, and other adjunct health care personnel. We have streamlined our HIPAA-compliant intake process to obtain all the necessary information during the initial contact, reducing the need for callbacks, which may inadvertently cause annoyance or raise unfounded questions about our credibility.

Obtaining all information right away gets the ball rolling. Sometimes the foremost challenge we experience is extracting vital information from caregivers or nonmedical consumers. Many times what is not being disclosed is just as important as what is being said. Is there a language or cultural barrier? If this is an established enteral nutrition treatment, what products and supplies have worked or not worked? Why is the patient seeking another HME provider? If a change is indicated, what can be done to enhance the service and treatment and eliminate problems? Will extra documentation and physician contact be required? What support systems must be established or strengthened in the place of service?

In addition to clearly understanding the medical treatment plan, we are also required to possess reliable and up to date product knowledge, medical determination policies, and coverage requirements for each insurance program. We know how to immediately access missing yet necessary information that may be required before services can legally be dispensed.

After a thorough intake, we get a written validation of medical need, detailed physician orders, supporting documentation, and insurance coverage verification. This entire process depends on respectful, professional relationships we have diligently developed with local physicians, nurses, insurance payor sources, and industry policy-makers. Some ways we support consumers and caregivers in the home are through:

• new customer information packets;
• customized product information;
• easy-to-understand trouble-shooting guides;
• courtesy calls;
• on-site education and training to level of competency;
• disbursement of after-hours emergency contact numbers;
• nurse and registered dietician consultant services; and
• even active participation in the appeals process for insurance coverage issues.

Death Spurs Questions
We received a referral from one of the local insurance companies. A single, young woman in her early 30s had recently been diagnosed with cancer and was receiving radiation and chemotherapy at a nearby hospital. The treatments caused a loss of appetite, weight loss, and wide fluctuations in blood chemistries.

The physician wrote an order for protein, peptide-based nutritional supplementation. In our telephone intake we talked about the method of supplementation she would find both convenient and also palatable, because she was continuing to work in a large office environment while being treated. The four cases of prescribed formula were expensive. With her first monthly order, her private insurance policy paid for two cases and she paid cash for the other two cases. Over the next several months, we talked each time she picked up her order. I also noticed that her orders decreased to the two insurance-paid cases. She lost even more weight and, being a rather tall woman, was starting to look gaunt. In our private conference room, she told me that she was no longer able to work full-time and every activity was an effort.

She was continuing her treatments and voiced hope for remission. I asked about her use of the supplements and the change in her monthly orders. Being at home rather than at work, she was now eating more regular food, in smaller amounts, spread out over the course of the day. Hence, she did not need all four cases.

A month later, when she did not respond to our multiple courtesy calls, customer service asked me to phone her emergency contact. The contact told me that the patient was at the hospital in a coma because she had fallen at home, hitting her head while in the bathroom. I was told that she had been consuming half the prescribed supplementation because she was unable to work, had exhausted her financial resources, and was unable to pay for the other two cases.

She was not eating regular food as she had told me. Her progressive weight loss resulted in a depletion of nutritional reserves and homeostasis. Despite aggressive, acute medical intervention, she died shortly thereafter.

I struggled for a long time wondering if I could or should have done more for her. What I realized is that my concept of professionalism, my respect for privacy, and her right to choose—along with my perception of the scope of HME providers—kept me from pursuing a respectful confrontation with her. What was her reality? How could she have fully accessed resources to obtain complete nutrition? Had we known, we would have advocated for her to obtain relevant funding and/or insurance coverage.

Recently, we have noticed local insurance payors removing nutritional supplement products from their formularies because of general public, retail-based availability. If the consumer has access to purchasing nutritional supplements in a “store”—cash and carry—the insurance company may no longer pay for such products, stating they do not cover “food available in a commercial and retail setting.” The cost is now being shifted to the consumer, regardless of the medical need.

Language and Culture Challenges
In one case from a county case manager, the patient was a minor of Southeast Asian heritage. A medical crisis secondary to lead ingestion resulted in irreparable brain damage and required permanent total tube feeding. The primary caregivers did not speak English and did not answer the phone while their school-age children were away.

We set up an in-home appointment to observe the current provision of tube feeding and had a bilingual company interpreter. We learned a lesson that when providing services for Southeast Asian people, your customer is comprised of the entire extended family.

We spoke first to the man of the house and then obtained permission to talk with the women. We were able to have them show us their routine and what products they used. We also noted the condition and storage of products. They took great pride and were attentive in their care-giving. With the interpreter, we determined that the formula being used was not providing adequate nutrition and that persistent diarrhea was resulting in the child’s failure to maintain, much less gain, weight.

We contacted the primary physician in writing to request and obtain a new order for a formula that would eliminate the diarrhea. Fortunately, we worked with the primary physician on a regular basis, and had the opportunity to discuss our observations with him by telephone. We created an itemized in-home order form that detailed the frequency and quantities required for the monthly orders.

We called the home every 3 weeks to follow up and check their current on-hand supply. The delivery was scheduled for an agreed-upon time when the older sibling would be home. Several times over the next year, I made the delivery so I could personally talk with the family in their home.

Joan M. Nerz, RN, is founder and CEO of Phoenix Medical Services Inc, Roseville, Minn (recipient of this year’s Midwest Association of Medical Equipment Services [MAMES] HME Provider of the Year Award). She is on the Board of Directors and is Minnesota State Chairperson for MAMES, and represents MAMES on the Minn HCPCS Committee and the Minn DHS DME Advisory Committee. Nerz is a professional member with the Association of Residential Resources in Minnesota (ARRM) and an active participant in their finance, intermediate care facilities/MR, and public affairs committees. She can be reached via e-mail: joan@phoenixmedicalservices.com.