Appendix B Home Parenteral Nutrition HPN Medicine Pathway

Appendix B Home Parenteral Nutrition (HPN) Medicine Pathway A medicines pathway shows the expected course of treatment, diagnostic tests, clinical reviews and other interventions for a patient group. This medicine pathway outlines the expected treatment to be provided for patients receiving home parenteral nutrition. The pathway is based on the format used within the NICE pathway for nutrition support in adults https: //pathways. nice. org. uk/pathways/nutritionsupport-in-adults. It is presented as a single pathway diagram and uses numbers to link the boxes in the diagram to associated specification points in the national framework document, Royal Pharmaceutical Society Standards for Homecare Services, and/or additional pathways. Where there is an additional pathway for a point this is noted by the following symbol. All options are available to all patients unless otherwise indicated.

Appendix B 1 Home Parenteral Nutrition (HPN) Medicine Pathway Patient identified by Purchasing Authority as needing HPN or IV fluid 2 Patient suitable for homecare Patient needs assessment (Appendix C) 3 Does patient require homecare nursing? No Yes 4 Patient accepted by Contractor (Home Care Company) 5 a 5 b Compounding slot allocated 6 Patient registration form and consent completed 7 8 Ancillary list completed (Appendix O) Patient home assessment (Homecare Handbook) 9 10 Nursing resource allocated Patient medically fit for discharge Contractor receives formulation request and arranges parenteral nutrition/fluid compounding on receipt of signed and screened prescription 11 Pre discharge hospital visit by Contractor 12 Discharge date co-ordinated between Purchasing Authority, Contractor and patient 13 Delivery of equipment, parenteral nutrition and any prescribed medication 14 Patient discharged. Installation visit by Contractor 15 Patient receives HPN services +/- nursing 16 Ongoing patient review by Purchasing Authority 17 Governance

1 Patient identified by Purchasing Authority as needing HPN or IV fluid Patient with Type 2 or Type 3 intestinal failure identified by Purchasing Authority 2 Patient suitable for homecare Complete Appendix C Patient Needs Assessment Form for HPN Does the patient have any comorbidities that may result them being unsafe at home? Yes Action plan to address needs* No Action plan to address needs* Yes Are there any concerns that the patient may be unsafe with a CVC? No Are there any concerns here such as self harm, neglect or abuse? Yes Action plan to address needs* No Action plan to address needs* Yes Is there family support for the patient going home on HPN? Are there any concerns? No Are there any safeguarding issues? Yes Action plan to address needs* No Action plan to address needs* Yes Are there any concerns regarding mobility, dexterity, vision, or hearing? No Are there any communication barriers, written or spoken? Yes Action plan to address needs* No Action plan to address needs* Yes Any other health care concerns, for example stoma care, palliative support No Patient suitable for homecare * If any action plans for the points above cannot resolve the identified concerns then the patient is not suitable for homecare. The Contractor and Purchasing Authority should have processes in place to identify and respond to any change in the patient's circumstances that impact on the patient suitability for homecare.

3 Does patient require homecare nursing? Refer to General and Clinical Services & Home Visits tab on framework specification. Not all patients will require nursing. 4 Patient accepted by Contractor (Home Care Company) Refer to General and Clinical Services & Home Visits tab on framework specification 5 a Compounding slot allocated Refer to Manufacturing Sites (Specials) Cold Chain and Custom Made Meds (Specials) tabs on framework specification 5 b Nursing resource allocated Refer to Clinical Services & Home Visits tab on framework specification 6 7 Patient registration and consent form completed Refer to General and Governance tabs on framework specification. See RPS Guidance Appendix 4 Ancillary list Refer to Equipment & Ancils tab on framework specification. See Appendix O. 8 Patient home assessment Refer to General tab on framework specification. See RPS Appendix 7. 9 Patient medically fit for discharge Purchasing Authority inform Contractor that patient is medically fit for discharge 10 Contractor receives formulation request and arranges parenteral nutrition/fluid compounding on receipt of signed and screened prescription Refer to General and Prescribing & Dispensing tabs on framework specification. The patient's details should be recorded on the Contractor's systems and be ready for service activation within 5 working days subject to the timely receipt of the initial formulation request and purchase order ( if appropriate ) as detailed in the specification. 11 Pre discharge hospital visit by Contractor Refer to General tab on framework specification. The pre-discharge hospital visit by the Contractor, will review the patient needs assessment and should be undertaken within 3 working days of receipt of registration documents. 12 Discharge date co-ordinated between Purchasing Authority, Contractor and patient See General tab on framework specification. Installation, delivery of PN and commencement of nursing should be on the 5 th working day at the latest.

13 Patient discharged. Installation visit from Homecare Company Refer to Clinical Services & Home Visits tab on framework specification. 14 Patient receives HPN services +/- nursing Refer to General, Delivery, Prescribing & Dispensing and Clinical Services & Home Visits tabs on framework specification. HPN Services Patient receives HPN services Does patient still require HPN? No Yes Is prescription still valid and clinically appropriate No Yes Purchasing Authority arranges termination of the homecare service with Contractor Purchasing Authority coordinates new prescription with Contractor arranges delivery of HPN Governance Homecare nursing Patient receives homecare nursing Is nursing still required? No Yes Do number of visits need to be altered? No Nursing visits scheduled Contractor provides weekly report to Purchasing Authority Governance Yes Purchasing Authority arranges termination of nursing service with Contractor Purchasing Authority liaises with nursing service for adjusted visits

15 Ongoing patient review by Purchasing Authority Patient receives HPN Patient attends outpatient review by Purchasing Authority No Patient’s weight within expected parameters? Yes Patient reports any signs of fluid overload or dehydration? No Yes Any abnormalities detected on blood and urine monitoring? No Any changes to HPN prescription required? Treatment plan to address concern Yes No Yes Patient reports any catheter related problems? No Any other healthcare issues? Treatment plan to address concern Yes No Action plan to address concerns Yes Purchasing Authority coordinates new prescription with Contractor Any concerns re compliance or suitability for homecare? No Is HPN still required No Yes Any additional monitoring and/or investigations required? No Outpatient appointment scheduled Any changes to treatment communicated to Contractor Governance Yes Purchasing Authority arranges termination of the homecare service with Contractor Purchasing Authority arranges additional monitoring and or investigations

16 Governance Refer to Governance tab on framework specification. See Royal Pharmaceutical Society Professional Standards for Homecare Services in England Royal Pharmaceutical Society Handbook for Homecare Services in England. References Royal Pharmaceutical Society (2013). Professional Standards for Homecare Services in England www. rpharms. com/. . . /professional-standards-for-homecare-services. asp Royal Pharmaceutical Society (2014). Handbook for Homecare Services in England www. rpharms. com/support-pdfs/homecare-services-handbook. pdf Royal Pharmaceutical Society (2014) Homecare handbook appendices www. rpharms. com/professional-standards-for-homecare-services/appendices. asp Appendix 4 – Patient registration and consent form Appendix 7 - Home suitability and needs assessment checklist