Organization

The organization and management of HETF and HPN has evolved over time. For example, delivery of feeds and equipment to the first patients who received HPN or HETF was undertaken by the hospitals that initiated the treatment. As the number of patients receiving such treatment increased, commercial organizations have established an organizational infrastructure for delivering feed and ancillary equipment through a national and international network. Some companies employ doctors, nurses, and other staff so that they can provide most of the care, although this practice varies from country to country. In many countries, there is joint care between commercial companies and the national health care systems.

HETF is initiated by many centers or hospitals, and some patients are followed up as outpatients. However, it is impractical to follow up many severely disabled patients in hospital, because they are house bound. Patients receiving HPN are often managed by centres with expertise in nutritional problems (e.g., in France, Denmark, and the United Kingdom). It has been suggested that all patients on HPN should be managed at such centers, but travelling to distant centers may require considerable time, effort, and expense. It is possible for patients to be managed more locally, especially if they are uncomplicated. It remains to be demonstrated if locally managed patients have better satisfaction and similar outcomes as those managed by larger centers. Of course, it is possible to have a system that combines local care and more distant specialist care when required.

Funding arrangements also vary. In several countries, home nutritional support is either totally or partially funded by the national health service, but payment may also be provided by private insurance and individual patients. The overall pattern of funding differs considerably among countries. Sometimes, confusion exists about the funding arrangements even in the same country, and this may limit and delay the use of HETF or HPN.

Patient organizations have developed in some countries, such as Patients on Intravenous and Naso-gastric Nutrition Therapy (PINNT) in the United

Kingdom. This organization provides support and information to people on home feeding, and it contributes to all levels of the operation of the British Association for Parenteral and Enteral Nutrition (BAPEN), through which it influences policy and decision making. Furthermore, since the feeding equipment for use at home was found to be impractical because it was originally designed for hospital use, PINNT has redesigned the equipment specifically for home use.

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