A National Framework for Home Parenteral Nutrition in the United States: Accreditation, Reimbursement, Registry

The United States delivers home parenteral nutrition (HPN) for chronic intestinal failure through a fragmented mix of hospitals, home-infusion companies, and individual clinicians, with no national accreditation pathway and no mandated standards for prescriber expertise or institutional capability. This review proposes a national framework for accountable, outcomes-driven HPN care and a phased path to its implementation.

Claims-based analyses of approximately 24,000 U.S. adults on parenteral support show that most orders are written by clinicians managing very few patients over short intervals, with expertise concentrated in a small minority of providers and substantial travel burden in rural regions. A recently published international framework proposes principles for centralizing adult intestinal failure services but does not address implementation within the U.S. regulatory and payment architecture. Long-standing centralized systems in Denmark and the Czech Republic demonstrate what an organized system can achieve and what it can observe about its own performance. The fundamental problem is not that decentralized U.S. HPN care is demonstrably worse, but that the absence of national data makes the question unanswerable. There is no national registry, no standardized outcome reporting, and no national figure for infection, readmission, or weaning. We propose three pillars to centralize accountability rather than geography: tiered accreditation distinguishing Level I hubs from Level II regional spokes, with volume measured as network accountability; reimbursement reform funding longitudinal clinical management separately from supply; and a national registry with participation tied to payment.