Building lifelines: A narrative review and pragmatic implementation framework for developing centralised adult...

Home parenteral nutrition (HPN) is life-sustaining for patients with chronic intestinal failure (IF), yet access remains inconsistent worldwide. HPN has evolved into a complex, multidisciplinary service that requires coordinated planning, durable investment, and strong governance to deliver safe, equitable care from hospital to home. This narrative review integrates clinical, organisational, and policy evidence and translates it into a pragmatic implementation roadmap for adult chronic IF health systems at different stages of maturity. We synthesise the volume-outcome signal linking higher-centre caseloads and structured nutrition support teams (NSTs) with lower mortality and complications; consolidate contemporary quality standards (minimum volumes, team composition, governance); and appraise health-economic analyses pertinent to HPN. International exemplars translating guidance into implementable actions enable the development of a four-domain framework to develop cohesive and practical chronic IF services globally: (1) identify and connect the network - map expertise, align professional societies and patient organisations, and establish referral communications; (2) develop the structure - formal centre designation, referral criteria, core infrastructural elements; (3) operationalise care - standardised shared-care/remote-discharge protocols, defined escalation to accredited centres with requisite governance and NST expertise and telehealth-enabled regional support (4) measure and improve - registry participation, routine audit, patient-reported outcomes, and transparent feedback loops. Cross-cutting enablers include robust governance, diagnosis-adjusted reimbursement aligned to NST resourcing, and policy mechanisms (designation, commissioning, funding) that secure access and consistent performance across geographies. Applied iteratively, this framework supports phased, resource-conscious scale-up of safe, high-quality, and equitable chronic IF/HPN services, aiming to reduce complications and mortality while strengthening patient experience, system resilience, and accountability.