NDIA Accountability Project

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Practice Guide – Nutrition Supports

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Practice Guide – Nutrition Supports

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Contents

  • Practice Guide – Nutrition Supports
    • Purpose: 3
    • To be used by: 3
    • Scope: 3
      • Younger People in Residential Aged Care (YPIRAC): 4
      • Nutrition supports: 4
      • When a support moves from being regular to acute: 5
    • Pre-planning: 5
      • Planning conversation: 5
    • Planning: 6
      • Mandatory advice from the Technical Advisory Branch: 6
      • Core supports: 7
      • Capacity Building supports: 10
      • Plan comments: 13
    • Case examples: 14
      • Example 1 – Joe: 14
      • Example 2 – Mary: 14
      • Example 3 - Heather: 15
    • Supporting material: 15
    • Process owner and approver: 16
    • Feedback: 16
    • Version change control: 16

Purpose

The purpose of this Practice Guide is to guide you through the considerations when planning for a participant who has disability-related nutrition support needs.

This Practice Guide is not a standalone document and should be used in conjunction with the following planning resources:

  • [Practice Guide – Disability-Related Health Supports](/foi-library/releases/725d17d6748d-foi-23-24-0538-decision-documents/document-001__practice-guide-disability-related-health-supports/)
  • Standard Operating Procedure – Include Disability-Related Health Supports in Plans
  • Practice Guide – Determine Reasonable and Necessary Supports
  • Standard Operating Procedure – Determine the Reasonable and Necessary Supports

To be used by

  • Plan Developers – Planners and NDIS Partners in the Community (Early Childhood Partners and Local Area Co-ordinators [LACs])
  • NDIA Plan Delegates.

Scope

An agreement has been reached between the Commonwealth, State and Territory Governments that the National Disability Insurance Scheme (NDIS) may fund specific disability-related health supports such as nutrition supports where the support need:

  • directly relates to a person’s ongoing functional impairment,
  • is a regular part of daily life,
  • is most appropriately funded or provided by the NDIS
  • is evidenced, meaning supporting information can generally be obtained.

For more information on how to determine if a health support is disability-related, refer to the Practice Guide – Disability-Related Health Supports.

The NDIS will not fund nutrition supports which are not directly related to the participant’s functional impairment such as poor diet where the participant has no functional impairment in their ability to understand nutritional needs, ability to eat, cook or prepare meals. The NDIS will not fund dietetic supports for issues related to food allergies, cardiovascular disease, renal disease, polycystic ovarian syndrome or irritable bowel syndrome, as these are not a direct result of the participant’s disability.

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The NDIS will not fund disability related health supports for the following cohorts. This is because for these cohorts all health supports, whether related to disability or not, are more appropriately provided by another service system:

  • People in hospital
  • Emergency or clinical care in community settings such as hospital in the home.
  • People in custody (in a correctional facility e.g. prison, remand centre, or youth detention centre), on remand, awaiting or following sentencing.

3.1 Younger People in Residential Aged Care (YPIRAC)

Typically, disability-related health supports will be provided by the residential aged care facility in an aged care setting for YPIRAC Participants. However, if a participant identifies a health support need which is not currently being met by the residential aged care facility, please refer to the Technical Advisory Branch (TAB) for advice.

3.2 Nutrition supports

Nutrition supports are used to help individuals with the way they eat or understanding the food nutrients they require. Nutrition supports include:

  • Dietetic consultations, development and implementation of a nutritional meal plan.
  • Home Enteral Nutrition (HEN) and Percutaneous Endoscopic Gastrostomy (PEG) equipment.
  • Supports to implement HEN and/or PEG maintenance and care when the participant is unable to complete these tasks due to ongoing functional impairment.
  • Supports to monitor the nutritional status of participants who have PEG and HEN.

Nutrition can be achieved orally or via alternative means, such as through a feeding tube directly into the gastrointestinal tract (PEG) or through the nose (NGT) or a combination of both oral and alternative means.

HEN is a way of supporting the nutritional needs for people who have difficulties orally eating or drinking to consume adequate nutrients to keep them healthy. Provision of HEN is supported by a holistic team, including medical staff, nursing staff and dietitians. The decision to proceed with HEN is decided by the medical team in the hospital or clinical setting. Once a HEN pathway has been decided, the dietitian from the hospital will determine the initial appropriate feeding regime of formula type, volumes and frequency. The team will also determine what care support is needed, including nursing if required, to monitor the state of the PEG site. If determined that the care support is to take place in a hospital or clinical setting the NDIS will not fund disability related health supports as it is more appropriately funded by another service system.

PEG is a medical procedure where a tube is inserted through the skin and abdomen directly into the stomach. It allows for food and fluids to be transferred directly into the stomach,

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bypassing the mouth and oesophagus. It is a way to support people who have difficulty chewing, swallowing or an inability to receive adequate nutrition through the mouth. PEG feeding is common for people diagnosed with dysphagia. For further dysphagia guidance, please refer to the Practice Guide – Dysphagia Supports.

When a support moves from being regular to acute

If the participant has an acute episode where there is significant change in their nutrition support needs (e.g., inflammation of the PEG site or if the PEG needs to be removed or replaced) where the participant needs to be managed or treated in a hospital or other clinical setting, these supports will be funded by the relevant State or Territory health care system or private health system. The NDIS will not fund nutrition supports during this acute episode while the participant is in the hospital or clinical setting.

The NDIS will recommence funding when the support ceases to be acute, but continues to be regular as defined in the Practice Guide – Disability-Related Health Supports.

Pre-planning

Planning conversation

The planning conversation allows you the opportunity to gather detailed and concise information regarding the participant’s disability-related nutrition supports.

The following points can support you to have a high quality conversation.

  • Check the System for any information recorded or uploaded during access and pre- planning.
  • Refer to Disability Snapshots, Disability Navigator and any relevant Practice Guides in preparation for your planning conversations.
  • Encourage the participant to explain how their nutrition support needs are directly related to their ongoing functional impairment or impairments.
  • Ask about health issues and other related aspects that may influence their need for nutrition support.
  • Ask the participant to provide details of the nutrition supports they are currently accessing including details such as:
    • What specific nutrition support/s are provided
    • How often the support/s are provided
    • Who the supports are provided by (dietitian, support worker via Registered Nurse (RN) delegation of care, RN, family member etc.) and the service provider name
    • If this support is able to continue during the next plan, e.g., if provided by informal supports

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  • Copies of any current treatment plans, feeding regime plans or assessments.

• Ask the participant about any disability-related nutrition supports they need, but are not currently able to access.

• If the participant provides you with supporting documentation/evidence, such as a nutritional diet plan or feeding regime, upload a copy to the System and return the original to the participant.

• Explain what the NDIS will now fund in relation to disability-related nutrition supports and what will remain the responsibility of the health system.

• Consider discussing with the participant if they have any capacity building goals in relation to their health supports, or if there are any supports that will assist them to be more independent in relation to their disability-related nutritional health support needs.

• If the participant requires a support that is not funded by the NDIS, explain that the support may be provided by the health system or other mainstream or community services. If possible, link the participant to other relevant services.

• For children under 7, the above information will be provided by the child’s representative. Plan developers will undertake information gathering ensuring a family centred approach with required sensitivity.

Planning

All supports funded under the NDIS, including disability-related health supports, must be considered reasonable and necessary under the NDIS Act, and meet all criteria under s34 of the Act. You will need to consider and record your decisions in relation to s34 of the Act in the justifications.

Under rule 7.5 of the NDIS (Supports for Participants) Rules 2013, a health support can be funded if it relates to a functional impairment, is required as an ongoing support for activities of daily living and is provided in the community.

Refer to Practice Guide - Determine Reasonable and Necessary Supports.

Mandatory advice from the Technical Advisory Branch

You will need to seek advice from the Technical Advisory Branch (TAB) prior to including some disability-related health supports in a participant’s plan, even if you consider the support to be reasonable and necessary. This will help to:

• ensure Scheme financial sustainability

• confirm the support is most appropriately funded by the NDIS

• monitor risk to the participant.

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First, you must consider if the support meets the reasonable and necessary criteria and is directly related to a participant’s functional impairment. Then, check if the support requires referral to TAB for advice prior to including in the participant’s plan.

You must seek advice from TAB for the following nutrition supports:

  • Capacity Building supports:
    • requests for more than 20 hours/year for assessment and development of a meal plan
    • more than 3 hours per day for RN direct care for PEG/HEN maintenance.

For guidance on how to request advice and for the full list of DRHS supports that require advice from TAB refer to the TAB DRHS Intranet page.

Once you have received the advice from TAB, use this in your considerations when determining the reasonable and necessary funding for the disability-related health support to include in the participant’s plan.

Core supports

Include all reasonable and necessary core supports as per the Standard Operating Procedure – Determine Reasonable and Necessary Supports. Use the following guide and Table 1 (includes hrs and frequency of support) to support your reasonable and necessary decision making in relation to nutrition supports.

Consumables

PEG and HEN equipment and consumables may include:

  • Enteral feeding tube
  • Administration reservoir such as a feed bag or bottle
  • Giving set
  • Syringes
  • Enteral pump and maintenance

Some HEN formula and nutritional supplements are covered under the Pharmaceutical Benefits Scheme (PBS) (see 5.1.1.1).

When the HEN formula prescribed for a participant is not covered under the PBS, the cost of $23.66 per day is considered reasonable and necessary to include. While food is an everyday living cost, it is recognised the cost of HEN formula has been determined to be more than the average cost of food. The inclusion of $23.66 per day is the cost determined to support all participants requiring HEN formula, whether they are on full or partial HEN feeds. Funds need to be included at the budget level in accordance with plan duration. If there is a request for the NDIS to fund more than $23.66 per day, contact the Technical Advice Phone Services (TAPS) for further guidance.

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Some participants may also be prescribed nutritional supplements or formulas that are consumed orally to meet their daily nutritional needs. Similar to HEN formula, some nutritional supplements are covered under the PBS. When nutritional supplements are prescribed and they are not covered under the PBS, these costs may be considered reasonable and necessary for the NDIS to fund.

All of these items will require a written recommendation and regular reassessment from the dietitian based on the participant’s specific requirements such as weight, nutritional intake and blood micronutrient levels. For the NDIS to consider and fund HEN formula and nutritional supplements, the prescribing health practitioner should complete the Nutrition and Dysphagia Supports Assistive Technology Assessment, which details this information.

Food and fluid thickeners are a different product and have a different purpose to HEN formula or nutritional supplements. Thickeners are not covered under the PBS and may be considered reasonable and necessary when they are required as a result of a disability related health support need. Thickeners will require a written recommendation from the prescriber outlining what thickener brand is most appropriate based on International Dysphagia Diet Standardisation Initiative (IDDSI) thickness levels. This recommendation will also need to justify the standard of thickener being prescribed for example, whether it is the basic standard or the gold standard. Some participants may:

  • require the gold standard due to allergies

  • require pre-packaged thickeners that are already mixed, e.g. due to physical impairments.

These pre-packaged products are more expensive. Clinical justification should be sought and the delegate will be required to undertake a reasonable and necessary decision.

The prescribing health practitioner should detail the recommendation/prescription using the Nutrition and Dysphagia Supports Assistive Technology Assessment.

Dietitians can provide further information such as method of administration and whether the participant is fully HEN fed or combined with oral eating.

For further line item details, please refer to the Assistive Technology and Consumables Code Guide (DOCX 225KB) available on the NDIS website.

Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Scheme (MBS)

Several of the consumables that would be NDIS funded under the new Disability-Related Health Supports policy are already funded through the PBS.

For consumables currently funded under the PBS, this will continue to be most appropriately funded by the Health System through the PBS.

The NDIS will fund non-PBS consumables where a consumable product is required as a part of a participant’s disability related health supports and is considered reasonable and necessary, this includes thickeners and some nutritional supplements and HEN formulas.

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Several of the supports provided by allied health professionals, which will be funded under the new Disability-Related Heath Supports policy, are also funded under certain MBS programs.

Where a participant is accessing supports through a MBS program, this continues to remain the most appropriate program to fund the supports. Where the maximum amount of MBS services under a MBS program have been reached, and ongoing support is required, a referral to the TAB should be made for further advice.

A participant factsheet is being developed to support participants to understand the options for supports covered under the PBS and MBS programs. In the interim a referral to TAB should be made for further advice.

Daily Activities

  • Where a participant or their child representative is unable to independently manage their HEN requirements, personal care hours may be included for a support worker to administer HEN, and to assist PEG maintenance and care as part of their daily personal care. The maintenance and care should include cleaning and flushing the PEG tube, cleaning and drying the stoma site and troubleshooting problems. If there is a higher need for care and maintenance above this level please contact Technical Advice Phone Services (TAPS) for further guidance.

  • Support workers may be funded to assist where a participant has cognitive difficulties to implement a nutritional meal plan, where it is directly related to their disability-related health support and where there are no informal supports available to provide this support.

Note: Generally, it would be expected that supports to manage HEN are a delegated task but there may be rare occurrences where a nurse is recommended (see Capacity Building below). Medical evidence would be required as to why a Registered Nurse would be recommended in these cases.

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5.2.3 Table 1: Summary of disability-related Core supports

Support category Supports for consideration
Consumables - PEG and HEN equipment and consumables including enteral feeding tube, administration reservoir such as a feed bag or bottle, giving set, syringes, enteral pump.
  • Health consumables can be included in plans multiples of $500 using line item - Disability-Related Health Consumables - Funding Only.
  • Consider all of a participant’s health related consumable needs when including in the plan.

• HEN formula - $23.66 per day can be included at the budget level. | Daily activities | • Personal care hours to:

  • Administer HEN, and assist PEG maintenance and care where a participant or their child representative is unable to independently manage due to their functional impairment.
  • Attend individualised training by a nurse to implement the HEN regime under delegation of care – up to 3 hours, 2-3 times a year. The frequency will depend on the participant’s individual circumstances and needs.
  • Assist where a participant has cognitive difficulties to implement a nutritional meal plan.

• Consider additional time required for the support workers to travel to provide daily activities as per NDIS Price Guide and Practice Guide – Determine reasonable and Necessary Supports. | Note: Hours will vary depending on the participant’s other disability-related support needs. |

5.3 Capacity Building supports

Include all reasonable and necessary Capacity Building supports as per the Standard Operating Procedure – Determine Reasonable and Necessary Supports. Use the following guide and Table 2 (includes hours and frequency of support) to support your reasonable and necessary decision making in relation to nutrition supports:

  • Dietetic consultations to develop a standard nutritional meal plan.

  • An example of a standard nutrition plan; is a healthy eating meal plan for a participant with a spinal cord injury or intellectual disability where as a direct

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result of their functional impairment or impairments, they require a plan to assist, guide and build their capacity to eat a healthy diet.

  • Training specific to the participant’s individual nutritional needs that enable supports, including family members and support workers, to implement the nutritional meal plan (including performing any required daily maintenance and care) for participants with a standard nutritional meal plan.

• Dietetic consultations to develop a complex nutritional meal plan for HEN – i.e. HEN feeding regime for participants with HEN or combination of HEN and oral diet.

  • The frequency of consultations may vary depending on the age, functional impairment, nutritional status and type of HEN formula used. It is important to take into account whether the participant’s health is stable.
  • An example of a complex meal plan for HEN, may be for a participant whose nutritional needs are met through a combination of HEN and oral feeding. The Nutrition and Dysphagia Supports Assistive Technology Assessment should be provided as evidence to support the reasonable and necessary decision making.
  • Training specific to the participant’s individual nutritional needs; that enable supports, including family members and support workers, to implement a nutritional meal plan (including performing any required daily maintenance and care) for participants with a nutritional meal plan – HEN feeding regime with cognitive and/or physical needs,
  • Support workers can be trained by a nurse to implement the HEN regime under delegation of care.
  • If additional hours are requested beyond what is referenced in this guide, please contact TAPS to discuss.

• Nursing consultations to develop a PEG maintenance care plan, which informs the daily management and care of the PEG and surrounding tissue, should consider the HEN regime by the instructing dietitian. Please refer to Delegation of Care in the Practice Guide – Disability-Related Health Supports for the time required to develop the maintenance care plan. If additional hours are requested beyond what is referenced in the Practice Guide –Disability Related Health Supports, please contact TAPS to discuss.

• Funding dietitians in Early Childhood Early Intervention as per Table 2.

• RN to deliver training specific to the participant’s individual disability related health support needs in PEG maintenance and care. It is important to note that PEG general maintenance and care is a standard competency skill expected for disability support workers and the NDIS will not fund training for staff to attain basic competency. It is the responsibility of a provider to employ suitability qualified staff with these basic level competencies. Currently there are national inconsistencies with standard levels of competency, such as Western Australia. Please contact

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TAPS if it appears the request for training includes standard level competency for a support worker.

The plan developer/delegate is responsible for ensuring there are sufficient funds included in the plan to cover a participant’s nursing support needs. However, it remains the responsibility of the provider to ensure the most appropriately qualified nurse is assigned to deliver each task.

5.3.1 Therapy

The frequency of therapy will depend on the participant’s individual circumstances, identified need and therapeutic approach. You will require clear supporting information from the dietitian that outlines clinical trials and outcomes already achieved as well as the expected outcomes achieved in the requested therapeutic support to make a reasonable and necessary decision.

Support category Supports for consideration
CB Daily Activity Composite nursing hours for a RN to train a support worker in the individualised needs of the participant in relation to their PEG maintenance and care.
  • Consider inclusion of provider travel as per NDIS Price Guide and Practice Guide – Determine reasonable and Necessary Supports
  • If the level of nursing is not known at the time of planning, include all nursing hours together using the line item – Composite Funding For Delivery Of Health Supports By A Clinical Nurse Consultant.
  • If the level of nursing is known at the time of planning use the relevant composite line item from the following list:
  • Composite Funding For Delivery Of Health Supports By An Enrolled Nurse
  • Composite Funding For Delivery Of Health Supports By A Registered Nurse
  • Composite Funding For Delivery Of Health Supports By A Clinical Nurse
  • Composite Funding For Delivery Of Health Supports By A Clinical Nurse Consultant
  • Composite Funding For Delivery Of Health Supports By A Nurse Practitioner |

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Support category Supports for consideration
CB Health and Wellbeing Dietitian hours for:
  • Standard nutrition plan
    • Initial consultation, assessment and report: 2 hours
    • Development of the plan: 1-2 hours
    • Re-assessment: 2 hours
    • Training 2-3 family members or support workers specific to the participant’s individual nutritional needs - 1-2 hours of training once a year (more frequently if the nutritional plan is updated).
  • Complex nutrition plan (e.g. HEN feeding regime plan)
    • Initial consultation and assessment: 2-3 hours
    • Report and development of the plan: 2-5 hours ▪ 2 hours = fully HEN fed, stable nutritional status and constant feeding regime. ▪ 5 hours = a combination of HEN and oral feeding, unstable or declining nutritional status and changes to the feeding regime in terms of formula type and pattern.
    • Re-assessment depending upon the above varying factors: - 2 hours.

Use line item - Dietitian Consultation And Diet Plan Development. |

Case examples

Example 1 – Joe

Joe is a 4-year-old boy diagnosed with leukodystrophy. He lives with his mother and 6-year-old brother. Luke is currently fed through a nasogastric tube.

Planning Meeting

As part of the planning conversation, Joe’s mother has provided supporting documents including his letter confirming his upcoming PEG surgery.

Outcome

Joe’s NDIS plan provides funding for the following reasonable and necessary health supports for his nutritional needs:

  • Initial consultation and assessment (x3 hours)
  • Development of complex nutrition meal plan (x2 hours)
  • HEN formula - $23.66 per day
  • Individualised training for his mother to support him with PEG maintenance and care
  • HEN or PEG equipment including pump, tubing and connections. Funding for the surgery or other hospital costs was not determined to be reasonable and necessary.

Example 2 – Mary

Mary is 36 years old and living with her husband. Mary has a spinal cord injury as a result of a motor vehicle accident 10 years ago.

Planning Meeting

As part of the planning conversation around her goals, Mary said that she would like to “improve her weight”. Since becoming a wheelchair user, she said that she has gained substantial weight. She has sought assistance from her General Practitioner around her weight, providing documentation confirming that there is no medical reason for her weight gain and that it is as a direct result of her functional impairment.

Outcome

Mary’s NDIS plan provides funding for the following reasonable and necessary health supports:

  • Initial consultation, assessment and report by a dietitian (2 hours)
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Example 3 - Heather

Heather is 45 years old with cerebral palsy (GMFCS level 5). She resides in specialist disability accommodation. Her parents, who are also her NDIS plan nominees, visit her regularly and will go for walks or to the local coffee shop. Heather uses a wheelchair with specialised seating to mobilise. She communicates using a mixture of a few single words and low-tech symbol boards.

Planning Meeting

Heather, her parents and key worker from her home attend the planning meeting. As part of the planning conversation, her key worker informs the planner that Heather has dysphagia and while she is able to eat and drink some things orally, the majority of her nutritional needs are through alternative feeding HEN via a PEG into her stomach. The planner asks if there are any additional reports that outline Heather’s HEN regime or an oral eating and drinking care plan. Heather’s parents provide consent for the key worker to share these documents with the NDIS.

It is explained in the meeting, that the NDIS may fund disability-related health supports such as dietitian support to monitor Heather’s’ HEN feeds, HEN consumables and training of support workers who assist her with her HEN feeds and oral feed.

The planner is aware of Heather’s weekly routine and asks further questions about the variety of locations to understand where training of support workers may be required.

Please also refer to the Practice Guide – Dysphagia Supports for further information.

Outcome

Heather’s NDIS plan provides funding for the following reasonable and necessary health supports:

  • Consumables, as per the Nutrition and Dysphagia Supports Assistive Technology Assessment
  • Dietitian assessment (x3 hours), report and development of plan (x5 hours)
  • Dietitian re-assessment/review (x2 hours)
  • Training provided by nurse (as identified in the care plan) to support workers at her specialist disability accommodation and day program

Supporting material

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Process owner and approver

General Manager Participant Experience and Design.

Feedback

If you have any feedback about this Practice Guide please email Service Guidance and Practice. In your email, remember to include the title of the resource you are referring to and to describe your suggestion or issue concisely.

Version change control

Version No Amended by Brief Description of Change Status Date
0.1 BDM533 New PG to guide staff through the considerations when included disability-related nutrition supports in a plan. DRAFT 2019-07-24
1.0 P19702 Class 3 approval. APPROVED 2019-09-26
2.0 ZWECKM Class 2 approval. APPROVED 2019-09-27
3.0 ZWECKM Included reference to the Nutrition and Dysphagia Supports Assistive Technology Assessment. Updated references to HEN formula. Class 2 approval. APPROVED 2019-11-18
4.0 EMN960 Class 1 Approval. Updates to mandatory TAB advice process. APPROVED 2020-07-02

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