Episode 67: How to Transform Nutrition Support in Home Infusion with Marie Groves and Angie Walston

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Transcript: How to Transform Nutrition Support in Home Infusion

Amanda Brummitt: WeInfuse Podcast, Episode Number 67. Welcome to the WeInfuse Podcast, my name is Amanda Brummitt. In every episode, we give you a seat at the table as we talk to infusion center owners, operators, and experts so you can get the insight you need to run a thriving practice. In this episode, we talk with Marie Groves and Angie Walston, co-founders of Salt & Lyte Nutrition Services. They share incredible insights on developing successful programs for home parenteral and enteral nutrition, where patient outcomes are excellent and operations thrive.

Welcome Marie and Angie. Thank you so much to both of you for being here. We really appreciate you taking the time out of your busy day to share your story with us. Can you start by telling us a little bit about your backgrounds?

Angie Walston: This is Angie. I was a nerdy kid, a really nerdy kid growing up, and one of the things I loved to do was read the back of the cereal box and look at all the ingredients. I would wonder what riboflavin was and I was truly interested in that, so that led to just a love of the science of nutrition. And then also, my best friend growing up was type 1 diabetic and I spent a great deal of time with her family and saw firsthand the huge impact that appropriate nutrition had on her health and well being. And so, that sparked a lifelong love of nutrition.

Once I graduated from UT Southwestern with my degree in clinical nutrition, I started out in the acute care setting and very quickly fell in love with just nourishing the patient. I wanted to nourish the sick. I wanted to help them heal. I was never one for weight loss or that type of nutrition management. I wanted to help people heal and live their best life. So that quickly led to the field of nutrition support with the two feeding and the parenteral nutrition, in the ICUs and acute care. And then I managed to make my way over to the wonderful world of home infusion, where I was able to take care of these patients day in and day out for the last, almost 15 years. And that’s where I am today.

Amanda Brummitt: I also was a cereal box reader. I think maybe everybody in our generation was because we didn’t have anything else to do. Now I just read the back to see if it’s going to kill me or not. I love that you turned it into a meaningful career though. Well done.

Angie Walston: There were no smartphones in those days to keep us occupied.

Amanda Brummitt: Yeah, and I love it when the box would change because then I had something new to read.

Angie Walston: That’s true.

Amanda Brummitt: Marie, what about you?

Marie Groves: So I was also a nerdy kid. I loaded my chemistry set on the back of my bike and rode down the gravel road that went by my house into the pond behind my house to do water sample testing, even though I had no idea what I was doing whatsoever. It just brought me–

Amanda Brummitt: That’s amazing.

Marie Groves: It brought me great joy to use my chemistry set outside. And so that was one side of me. The other side of me is actually the very creative side of me, using my right brain. I thought when I went to college that the right side of my brain was going to feed me, and I actually started out as an interior design major in college. Very quickly I realized I did not want to do any of the projects that they assigned me. It seemed to squash my creativity more so than grow it. And so I realized that was not going to be a path for me, so I switched back over to the left side of my brain and took an intro to nutrition class and fell in love with the small intestine. As one does, right? I found it fascinating how the body metabolizes nutrients and how everything that we put into our body serves a purpose to nourish us and to keep us healthy to, as Angie said, to heal us. I fell in love with nutrition and so I switched my major to become a dietician.

My very first job was in pediatrics. I was very passionate about pediatric nutrition. I started out as an inborn errors and metabolism and genetics dietician for the state of Arkansas. From there I learned about home infusion because all my kiddos, my babies, needed very specialized formulas from a home infusion provider. So I built a relationship with my then-sales rep at the time. And then as paths would change, my path led me to changing jobs, and I was recruited over to pediatric home nutrition support. From there, I have not looked back. So I started out in pediatric home infusion, and then worked my way across the lifespan with nutrition support for both home parenteral and home enteral nutrition, and then from there my career just naturally progressed into a company that needed a program built. And that is where Angie and my paths crossed, is at a home infusion provider that was small that needed to grow.

Amanda Brummitt: Fabulous. And before we get too far into the show, Angie, can you define for us home parenteral and enteral nutrition, and any other terms that are common in your world?

Angie Walston: Yeah, so there are three stops on the “nutrition train,” this is a phrase that Marie coined: oral nutrition, enteral nutrition, and parenteral nutrition.

Oral nutrition is what the majority of us are–that’s the way we receive our nutrition. It means we have a functioning swallow and our gut is able to absorb and utilize the nutrients that we take in by mouth. And so that is the preferred method for all of us.

When something happens and that mechanism fails–for example, if a patient has had neck cancer or they have some type of neurological disease like ALS or they’ve had a stroke, and they can no longer swallow safely but their gut is still functioning–then we move into the world of enteral nutrition. That is providing the feeding via a tube inserted into either the stomach or the first part of the intestines. Many patients live their lives, their entire life, with the tube feeding. Sometimes it’s just for a short period while they are recovering from something like radiation therapy. And so when that happens, they are hooked up with a home infusion or a DME provider for their nutrition to be provided at home and they administer that to themselves daily through that tube.

Okay, parenteral nutrition is the third stop on the nutrition train. That is when the patient may have a functioning swallow, but their gut is not able to absorb or utilize the nutrients that they are given. So this may be due to a surgical resection, losing part of the intestines and colon. This may be due to a disease state or intestinal failure. When that happens, the patient has to be placed on an IV nutrition therapy called PN or TPN, which are the abbreviations for parenteral nutrition. This sterile formula is infused directly into the bloodstream and it meets all of the patient’s nutritional needs. This is usually where the pharmacist and dietician collaborate in the home infusion industry: to prepare the formula and get it sent out to the patient and the dietician helps to manage the patient in the home care setting.

The enteral nutrition and parenteral nutrition are collectively called nutrition support. And so nutrition support doesn’t sound very significant. It sounds like we’re just kind of supporting somebody like a vitamin supplement. But if you think of life support, nutrition support is exactly the same thing; it is a component of life support and without it these patients would die. Nutrition support is the basis for all other therapies for these patients. If their nutrition isn’t adequate, they cannot have surgery. They cannot have their chemotherapy. They cannot participate in rehab. And so that is the basis for maintaining the patient and getting them back to the life they used to have. Parenteral nutrition can be used short term or long term. We have many patients who are on TPN for life. And that is where the dietician really comes in to manage these patients and keep them functioning and being able to do life with their family.

Amanda Brummitt: So that is a really, really helpful explanation. So how did you two go from being clinical dietitians to starting Salt & Lyte Nutrition Solutions?

Marie Groves: Angie and I had our paths crossed within a home infusion company in the Texas market that had a vision of building a nutrition support program built on integrity, built on nutrition support team involvement becoming an extension of that treating practitioner to truly give that patient that has never been on a tube feeding before, has never been on parenteral nutrition at home before in their life, the best opportunity to be successful in the home. Our roles at that particular company were sales and operations, and we very much believe that combining sales and operations is extremely important to maintain the integrity of the program. So we built a dietician team that worked directly, as Angie said, with the pharmacy. And we grew that program from three pharmacies in Texas to across the country with a foundation of being able to take that program into wherever we landed. So whatever state we were going into, we had a foundation nutrition support program that would survive and be sustainable.

Once we did that and we left that particular company, we realized that we had so many years of knowledge and experience built up between the two of us. And we have very distinct strengths between the two of us that are very different that work so beautifully in synergy that we decided that it was time for us to give back to the home infusion community and offer our consulting services. So we built Salt and Lyte, L-Y-T-E, Nutrition Solutions. It was incorporated last year and we have just been busy since the day we opened our doors. So it’s been very, very exciting.

Amanda Brummitt: Great. Very clever name. I love it. So tell me what does Salt and Lyte Nutrition Solutions do? And then specifically, how do you work with home infusion companies?

Marie Groves: Salt and Lyte is a consulting firm specifically dedicated to the home infusion space. We recognize that there are challenges, especially within the home infusion space as a whole right now. We want to be able to provide those solutions. So our company focuses on three pillars of service. Those pillars are clinical excellence, optimized revenue cycle performance, and sustainable growth within your nutrition support program in your home infusion pharmacy.

Within our clinical pillar, that does include a staffing model for temporary, intermittent, or even longer term staffing options for nutrition support dietitians. All of our dietitians that are on our team are trained specifically in home nutrition support, which is very different than other consulting companies that are out there that offer amazing dietician services. But we specialize in the niche of home nutrition support so that our dietician can come into a home infusion pharmacy and know all the foundations of managing that home infusion patient, whether it be enteral or parenteral nutrition. We also offer training for dietitians that are on staff at home infusion pharmacies that may have never been in that home infusion space before. There’s a pretty big learning curve when you come over from a hospital into the home infusion setting: managing the patient is very different; working with a nutrition support team; how you even just–even the tweaks and the changes that you make to, say a TPN formula, is different than it is in the hospital. So our team can come in and actually train your dietitians, train the dietitians at the company to decrease that learning curve so that that nutrition support team can function like a machine early on. We also offer competencies, competency training, building out competencies that are customized for your teams, and also really digging into documentation and how best to document in the medical record for a home nutrition support patient.

Within the optimized revenue cycle performance and support pillar, this is where we get really excited because we know building out amazing, streamlined processes from field and intake all the way to audit is explicitly important within this nutrition support space. We specialize building audit-resilient pathways for both enteral and parenteral nutrition therapies. And then we also have a team that can actually come in, train the team on audit preparation, how to submit an audit for nutrition support to a commercial or government payer, and then help you prepare those packets–really understand that foundation skill so that you can apply that maybe even to some other therapies that you have in your home infusion umbrella.

Amanda Brummitt: Okay, before we get to the third pillar, I have to know, how do two dietitians get into audit and get so excited about it? You all can’t see Marie’s face, but she is grinning from ear to ear talking about audit.

Angie Walston: Well, I’ll tell you, we were not excited about it when we first got into the audit realm. Back in 2019, Marie and I found out that our entire nutrition program was receiving several government audits, Medicare audits, several hundred dates of service. This was new to us and the billing team asked us to come in and help. So we pulled together our entire nutrition team, and it was grueling. We had very little time to come up to speed on how to put together these packets, what needed to go into them. There was a looming deadline, and we hated it for the first two weeks. But by the end of that time, we realized we were really making a difference, and the clinical component that the dietitians brought to the review and packet compilation made a huge difference, and the pass rate for that audit was way above industry standard. So that led to the next audit and the next audit and the next audit. And before we knew it, Marie and I and our team had worked over a thousand audit packets and had it down to a science. And so this is now just easy for us, and we love going in and helping other people make it easy and seeing that their audit pass rate increases quite a bit. What was just the bane of our existence in the beginning is now–as you said, Marie’s face got excited–is now something we quite enjoy doing.

Amanda Brummitt: That’s incredible. When you started that story, it sounded very scary and I’m glad that it had a happy ending and that you’re able to use those skills to help other people perform better.

Marie Groves: And we absolutely understand the reason for audits. All the payers want their money to go where it’s supposed to go. So we must follow those pathways. We must follow their rules. We must understand their criteria. And that is a complex path when you look at enteral and parenteral nutrition pathways for criteria for commercial payers, for government payers. They’re all different. And so if you don’t understand how to build that foundation packet, how to build that foundation into your pathway at the very beginning–I always say, billing, clean claims, all of that, it starts at the beginning of the referral, not when it hits the billers desk for claim submission. Really helping people understand how to build that out, it just, it really takes that stress away. And so that’s what we love. That’s why I grin from ear to ear because we know what happens when you have a solid process in place.

Amanda Brummitt: Yeah, that totally makes sense. All right. And what was that third pillar?

Marie Groves: And the third pillar is within sustainable growth. So that could be out in the field and within the pharmacy, both collectively working with that full program development. So how do we handle that referral from the very second that it comes through our door, all the way till it hits claim submission? How do we communicate with our referral sources? We have dietitians on our team that actually are trained within field support for nutrition support, for home infusion. So a very specialized way of how to sell out in the field is selling a service. We don’t have a product to hand or a sample to hand out. You have to understand the referral source. The treating practitioner has to understand that your company is competent to take care of that very complex patient. Having that sales and clinical combination out in the field, it’s just a tried and true way of helping people understand how to make a referral, how to get their patient the help that they need. So we do offer subject matter expertise out in the field, and then offer training within the pharmacy as well. So offer training to the salespeople, to the liaisons of the team. We love that as well. We completely know what happens when you combine a solid sales team with a solid operations team and a solid revenue cycle team.

Within those three pillars, we have clients that need all kinds of things: maybe just something out of one pillar, maybe the whole program and the whole enchilada, if you will, a program development, if you’re a new startup. This is the perfect opportunity for you.

The way that we approach is we offer a consultation to really understand what the company needs within the services that we provide. And then we take all of that information and create a proposal to then review with the client. Once we all agree at the proposal stage, we initiate a contract for Salt and Lyte. And then we execute. And that’s where we have so much fun getting to know our clients and helping them realize all of their potential within their nutrition support business.

Amanda Brummitt: Awesome. Sounds like a great program and I love that you pointed out in there getting information back to your referral sources. One of the things that I feel like so many places we miss an opportunity on by not sharing that information and then that patient is back in front of them and they’re embarrassed because they don’t have that information. Just the fact that you guys think about all those little steps. Brilliant. Love it.

So, I also understand that you all have recently started collaborating with WeInfuse. What can you tell us about that?

Marie Groves: We have, and we are so excited. We are working with WeInfuse on some potential revolutionary technology that will help nutrition support teams manage TPN patients a little bit more efficiently, or a lot more efficiently. And we’re very, very excited about it. We’re in the beginning stages of that collaboration. Before we met for that first meeting, we actually were invited to demo WeInfuse’s new home infusion software that does include a parenteral nutrition or TPN component. We were over the moon to be able to work with Kourtney at WeInfuse, to look at that software and provide feedback. I think that after an hour of a little bit of Marie and Angie reviewing that software, Kourtney probably needed a little break, but it is phenomenal software. It’s so intuitive and we were just really excited to look at that as well. So we look forward to continuing our collaboration discussions.

Amanda Brummitt: Very exciting. Well, one thing that was really clear when I was researching your organization is that you all put patients first. Patient outcomes are clearly the most important thing. Efficient operations are also really important though, so that we can stay in business to provide set clinical services. So what can home infusion companies do to find that perfect intersection of patient care and sustainable operations?

Marie Groves: Well, we have seen firsthand the absolute difference that a global program that has a team that works in synergy makes. And so when you have type processes that are all aligned with all departments, all divisions, it takes a lot of people to work through taking care of home nutrition support patients, be it enteral or parenteral nutrition. Each one of those team members need to be aligned with what that expectation is–how the program works, what is my role within this team–so that we can work as a machine. When a patient sees that you have a united front between the time they meet a field person at bedside, talk to an intake person over the phone, talk to their pharmacist and then dietician, and then even a billing specialist within the same team, and everyone is aligned–that is the best opportunity to provide the best patient care that you possibly can. Believing in each other, supporting each other within that process.

Traditionally, there can sometimes be misaligned expectations amongst multiple teams when you have multiple people working together. Great leadership within that nutrition support program will lead to and yield that amazing patient outcome. That is the result that we’re all looking for, is for that patient who, for whatever reason, we have crossed paths with may be having some of the most challenging time of their entire life–cannot eat, cannot absorb, whatever the issue is–we need to be a united front for that patient, no matter what. Excellence in competencies, excellence in clinical care, and then excellence amongst the team itself.

Amanda Brummitt: That harmony of all of those things really, really does make a difference.

Angie Walston: Also, whenever you have amazing patient outcomes, this drives referral source loyalty and it grows your business. If you have a referral source or a physician who knows that your company is taking excellent care of their patient, then they’re going to feel very comfortable referring to you. Excellent patient outcomes drives repeat business and leads to referral source loyalty. This is one of the things that we really try to instill into our teams as well.

Amanda Brummitt: Absolutely.

Marie Groves: And I would like to add to that as well. That is an excellent point. A lot of treating practitioners don’t get a lot of training within the enteral and parenteral nutrition management space, especially for home, on the home side. They may see it in the hospital, but never really manage it on the outside. And so, having a team and having outcomes that you can depend on for your patients gives you the confidence as a treating practitioner to continue to recommend life saving therapies like nutrition support. That is also extremely important within that, as Angie said, that loyalty piece: really trusting your home infusion provider to be the best at what they do.

Amanda Brummitt: Yep, that makes total sense. Shifting a little bit more on the financial side, Marie, when it comes to revenue cycle management, you two have seen a ton of centers and companies and how they run things: what’s the biggest mistake that you see home infusion companies make and how can they avoid it?

Marie Groves: The biggest mistake that we see is treating home nutrition support just like any other therapy, any old drug therapy. It is very, very different. Angie always says, if you’re treating it like a drug, you’re probably already losing money. We say that because there are so many intricate details that have to be met in order for those claims to be clean going all the way through. And again, as I mentioned before, it starts at the beginning. It starts with understanding what your payer criteria is, gathering that from the very beginning. For example, when you submit a Medicare claim and you submit for payment, then you are saying that you have that criteria in your hand, in your chart, ready to go in the event that you were audited or a documentation request comes in the mail. Essentially, understanding what that criteria is, the differences in that, your documentation reflects what you say that you have in your chart, is extremely important. Your ability to bill and collect then becomes much cleaner. Sometimes when you have to submit for an appeal, even in authorization space, it can take days and weeks to work through those issues. Meanwhile, you’ve got a very sick patient at home that has to have their TPN or tube feeding every single day. Making sure those processes are tight at the front, on the front end, all the way through to where you can defend that chart in an audit, it’s very important.

Amanda Brummitt: Okay, so we now know we definitely shouldn’t treat nutritional services like a drug. That’s a big mistake. What are some other lightbulb moments that you’ve had?

Marie Groves: So over the years, we’ve had many lightbulb moments, but one of the biggest ones was when we took a step back and we looked at the sheer volume of processes, technology, and people it takes to take care of parenteral and enteral nutrition patients. It was staggering. And again, it goes back to everything that Angie and I have discussed throughout this presentation. There are just so many details that go into this life saving therapy. And so when we took a step back and saw that it takes a number of people, processes, technology, it was kind of like, an “aha” moment of if you have issues amongst your processes, if you have issues amongst your people, more than likely it’s due to misaligned expectations because you’ve got so many groups and so many divisions of people doing one little part but not understanding the big picture. A flicker of that little light bulb was when we started asking people, do you know why you’re doing this job? And they’re like, well, because it’s on my job description, or it’s because the way I was trained. No, do you understand why you do this?

Amanda Brummitt: Right. Right.

Marie Groves: We started putting in a section within our training as to the why, describing what that patient looks like, what that diagnosis actually looks like–not going into grave details, but just really helping people, everyone from intake to our mixers to our billers to our dieticians, our nutrition support technicians, everyone–why we are doing this, what this patient is actually having to go through each day just to infuse one bag of TPN or one day of enteral nutrition. Once we started really explaining that why, teams started working together in complete synergy.

Truly, I get chills every time that I talk about this because that is why we come to work every day. That is why your work matters every single day, is because you are a piece of a puzzle that is truly keeping a patient alive, trying to get to that next surgery, trying to recover from cancer, whatever that piece of the puzzle may be. Once we started really incorporating that in our training processes and in services and just really reminding people of that, it was just like light bulbs going off everywhere and the amount of times we have been thanked for including that in our training since we started Salt and Lyte has been amazing. “Thank you. My team functions better because they know why they’re doing what they’re doing now. It’s not just a task .It’s a part of a machine that works together.”

Amanda Brummitt: Yeah, and my guess is when you go through that you also figure out there’s some steps in there we may not need to do anymore?

Marie Groves: Absolutely. Yes. Because people start talking and collaborating, “If I do this better in this particular process, the process that comes before your process, then we can be stronger together.” That helps people connect the dots, which ultimately, which is why we come to work every day to provide excellent patient care.

Amanda Brummitt: Love that. All right, Marie, you’ve shared a lot of exciting stuff today. What are you most excited about right now in the industry?

Marie Groves: Actually, I’m most excited about being able–from a Salt and Lyte perspective–being able to just really put fresh eyes on processes for our clients and offer solutions, offer that pathway to being better and stronger together. That is very, very exciting to me. Angie and I have seen a lot of things in our 20 years–20 plus years in nutrition support, in the nutrition support space, and in the home infusion space. We are very excited about the opportunity to help teams be stronger.

It’s tough out there. Reimbursement is tough. Criteria is tough. Cost of goods are tough. We recognize that. We understand that and we want to be able to provide solutions that our companies can still take care of these patients in the long term. I’m also excited about the new research and evidence-based practice that’s coming down the pipe. And we’ve seen some great posters recently. We’ve seen some great white papers and articles. These are actually being geared toward home infusion, which is very exciting because for years and years, clinicians such as ourselves (pharmacists, dieticians) there hasn’t been a lot of specific home infusion recommendations. Everything is extrapolated from critical care guidelines and Aspen does an amazing job with guidelines.

The future is bright for home infusion, for TPN and enteral.

Amanda Brummitt: Very exciting. All right, Angie and Marie, what is your one last piece of advice for our listeners?

Angie Walston: We are seeing in the industry, in the home infusion industry, we are seeing companies get out of providing nutrition support. They don’t see it as profitable. They feel like it takes up a lot of manpower to provide the service. And what I’d like to convey, what we would like to convey is it doesn’t have to be that way. That with the right processes in place, this can be a very profitable therapy line, and it can be something that your team can do efficiently without overtaxing your team. This is where we really want to come in and help people understand this. It would be very sad to see the majority of the industry get out of the nutrition space. Anything we can do to shine a light on how this therapy can be successful is something that we would like to pursue.

Marie Groves: And I’d like to add to that, just to take a fresh look at your processes, take a fresh look at how you’re doing things. Just because you’ve always done it that way doesn’t mean it’s the best way. Getting out of that comfort zone and really challenging your processes to see if that is profitable or if this is what’s causing you a little bit of drain over here. Again, as I mentioned, there are new things. New research is coming out. People are interested in making it a better place for home infusion for nutrition support. And there are so many amazing consultants out there, not just Salt and Lyte, but there are people completely passionate and dedicated to the home infusion space ready to help. And so I would say my last piece of advice would be to just take a step back and try to see the trees, not the forest for a change and see what happens.

Amanda Brummitt: Yeah, that’s great advice. Well, thank you both again for your time today, but also thank you for your passion for patients and for the industry. I really feel like you’re both cheerleaders for both sides for making sure the patients get well taken care of, but also that these home infusion businesses can be really successful. So we appreciate you and look forward to seeing what you guys do in the future.

Angie Walston: Thank you.

Marie Groves: Thank you, Amanda.

Amanda Brummitt: That was great information from Marie Groves and Angie Walston of Salt & Lyte Nutrition Services about delivering expert patient care, optimizing revenue cycle, and sustaining growth for home infusion companies offering nutrition support. And it’s certainly exciting to have them collaborating WeInfuse. If you aren’t familiar with the WeInfuse software platform and RxToolKit’s web-based resources, I strongly encourage you to schedule a test drive. These tools can save time and money in your practice while making infusions safer for patients and caregivers. My name is Amanda Brummitt, and we’ll catch you in the next episode.

Guest Speakers:

Marie Groves, MS, RD, CNSC, LD and Angie Walston, RD, LD, CNSC – Co-Founders of Salt & Lyte Nutrition Solutions.