Caring for Obese Individuals in the Long-Term Care Setting

Older obese adults are more likely to report fair to poor health as compared to those of normal weight. Excessive weight in residents of LTC facilities will have profound effects on care delivery and resource utilization. Model programs for bariatric and obese resident care do exist in some LTC facilities; however, universally agreed upon standards for education, staffing, and resources have not yet been established, and financial costs associated with providing bariatric care are not readily apparent. This article describes the challenges of caring for obese individuals residing in LTC facilities and includes strategies for addressing the specific clinical needs of this population. Experiences from the Genesis HealthCare Corporation are highlighted. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[7]:17-21)
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Introduction
The United States is currently in the midst of an obesity epidemic affecting all segments of the healthcare system, including long-term care (LTC) residents, their caregivers, and associated financing and delivery systems.^1,2 A recent study of U.S. LTC facilities indicates that the percentage of newly admitted, obese residents has risen 15-25% over a 10-year period (between 1992-2002); nearly one-third of these obese individuals were under age 65.³ Older obese adults are more likely to report fair to poor health as compared to those of normal weight,⁴ and for middle-aged individuals, obesity is a risk factor for predicting future nursing home (NH) admission.⁵

Although the impact of a changing LTC resident population has not been fully appreciated, it is anticipated that excessive resident weight will have profound effects on care delivery and resource utilization. Few publications describe how LTC corporations have responded to these challenges. Clinical reviews and anecdotal reports to some degree have outlined specific aspects of care that require additional staff education, including issues around sensitivity to the needs of obese residents and their rights, skin, hygiene and wound care, mobilization complicated by excessive weight, and promotion of self-care.^6-9 Model programs for bariatric and obese resident care do exist in some LTC facilities¹⁰; however, universally agreed upon standards for education, staffing, and resources have not yet been established, and financial costs associated with providing bariatric care are not readily apparent.

A critical review of the literature has identified important gaps in research and clinical care of obese NH residents, such as the lack of evidence-based guidelines and “best practices” to support protocols and models of care.¹¹ To address these gaps and elucidate the complexity of care for obese residents, we present a model recently instituted by Genesis HealthCare Corporation (GHC). Recommendations are proposed for integrating care strategies and preparing staff to provide optimal care to obese residents.

GHC Experience

Drawing on experiences from GHC, one of the nation’s largest LTC providers with more than 225 skilled nursing and assisted living facilities in 13 states, it is possible to better understand the problem of obesity in the LTC setting. Each year, GHC facilities admit obese and morbidly obese individuals who require either long-term placement or extended recovery periods to regain independence and return home. The Figure depicts weight categories for all obese and morbidly obese residents admitted to GHC facilities during a 6-month period (N = 87). Although ages range from 20 to 90 years, most (n = 69) are between 41 and 70 years of age and, as in other published reports,¹² are generally younger than the “typical” newly admitted nonobese GHC resident (average age, 76 yr).

Extensive experience within the GHC system has shown that admissions of obese residents to facilities not prepared or designed to accommodate these residents result in numerous challenges and barriers to care, such as inadequate staffing levels, need for additional training and specialized equipment, alterations in the physical environment, and the absolute importance of interdisciplinary care. The GHC model was developed by examining anecdotal reports, as well as evidence-based literature regarding care of obese individuals in LTC and other settings, particularly with regard to resident and staff safety and use of equipment and supplies. Evidence suggests that certain patient care activities (eg, turning, lifting) may predispose staff to physical injury, and in turn, lead to the reluctance of staff to provide a basic level of care.¹³ Several strategies and environmental modifications have been shown to promote resident safety and prevent or reduce work-related injuries.^7,9,13,14 These include: providing extra space for staff to maneuver; training in proper body mechanics and ergonomics; adjusting the environment to expand doorways, hallways, and toileting and bathing areas; installing ceiling lifts and sturdier support bars; and purchasing bariatric equipment. Importantly, all existing apparatus, such as wall-mounted commodes that do not support more than 280 pounds, must be replaced to sustain increased weight.^7,13 Tables and seating accommodations for obese residents must be available.

Furthermore, commonly used supplies such as oversize gowns and injection needles needed for hospitalized obese patients are also needed in other care settings.¹⁵ Because obese residents are at greater risk for developing pressure ulcers, incontinence supplies appropriately sized for larger individuals are needed just to provide the most basic care.¹⁰ Advances in bed technology, such as those with built-in scales, allow weight measurements for residents who are confined to bed; however, this equipment is extremely costly and not affordable for most LTC facilities. Continuous positive airway pressure (CPAP), pulse oximetry, and end-tidal CO2 monitoring devices may be needed for residents with obstructive sleep apnea and those at risk for respiratory complications and desaturation.¹⁰

Components of the GHC Model
The GHC model consists of six interrelated components. The first component enforces an admission process that designates an obese resident as a “nonstandard” admission and is based on total body weight (over 400 lb), combined with staff ability to provide the necessary level of care. Therefore, before accepting an admission, a “Bariatric Care Addendum to Pre-Placement Assessment” (Table I) must be completed. Admission decisions are made jointly by the regional Manager of Clinical Operations, Director of Nursing (or designee), and other staff. Given the geographic density of GHC, if one facility is not prepared to care for a potential resident, he or she is admitted to another GHC facility where adequate staffing, training, and equipment are available. Individuals identified in this manner can only be admitted to a particular facility if five additional components are in place. These include:

1. Injury reduction program: An essential element of the model includes training of all direct care workers via the GHC Safe Resident Handling Program (Prevent, Inc, Hickory, NC), which utilizes a fully integrated delivery of care for mobilizing obese residents through adequate staffing, training ergonomics, and appropriate equipment. This has enabled GHC to accept residents of excessive weight and to optimize work efficiency and resident and staff safety.

2. Competency-based education and training: Optimal bariatric care is further facilitated through staff competency and sensitivity training focused on developing and sustaining skills required for a higher level of resident care. This is operationalized through ongoing education, as well as through the GHC Safe Resident Handling Program described above. Educational offerings (Table II) focus on developing staff understanding and adherence to GHC safety protocols and acknowledging the physical and psychological complexities of bariatric care.

3. Proper equipment: GHC facilities caring for obese residents are equipped with state-of-the-art devices, including bariatric beds, reinforced bed trapezes, appropriate bedside lift and transfer equipment, extra-wide wheelchairs and walkers, and reinforced toilets designed to accommodate obese individuals. In addition, GHC works with a national LTC respiratory health service to provide CPAP, pulse oximetry, and end-tidal CO2 monitoring devices as needed.

4. Redesign of the physical environment: GHC has invested resources in selected facilities to renovate the physical environment and meet environmental standards to effectively, efficiently, and safely care for obese residents.

5. Appropriate staffing and support for an interdisciplinary care model: Higher staff-to-resident ratios are often needed to ensure better coordination and safety with mobilization. An interdisciplinary care model supports active involvement of professionals from nursing, medicine, nutrition, social work, therapeutic recreation, and rehabilitation. From admission to discharge, the interdisciplinary team strives for continuity and consistency of care based on residents’ individual needs (Table II).

Recommendations

Based on our experience, three areas are recommended as foci for corporations or individual facilities embarking on a program aimed at caring for obese LTC residents. First, resident and staff safety must be a priority. Since instituting the GHC Safe Resident Handling Program, a 20% overall reduction in work-related injuries, as well as a 46% decrease in GHC workers’ compensation costs associated with resident handling activities, has been documented. This represents potential cost savings in the millions of dollars, but more important, priceless improvements in employee health.

Second, appropriate equipment and supplies to prevent or minimize complications associated with obesity must be provided. We have accomplished this by assuring that GHC facilities accepting “nonstandard” admissions maintain a small inventory of bariatric equipment (eg, 2-3 bariatric beds and 1 lift) and have timely access to additional rental equipment as necessary. GHC also maintains a relationship with a national LTC respiratory health service to provide CPAP, pulse oximetry, and end-tidal CO2 monitoring devices on a case-by-case basis.

Finally, accommodations for appropriate staffing, support of an interdisciplinary team approach, and financial implications of caring for this population must be addressed. Costs of care for obese LTC residents include expenditures for extensive renovations and equipment purchases, as well as the effect of obese resident admissions on staffing budgets. While it is highly unlikely that any of these costs will ever be recovered in reimbursed care, all of these must be considered.2 In our experience, the incremental cost of obesity-specific staff training is difficult to quantify. To offset costs associated with educational content, GHC incorporates as much of this training as possible into general staff education programs provided by a team of regional educators and individual NH–based staff development coordinators. Moreover, rather than renovating a NH specifically to accommodate bariatric residents, these changes are made when routine renovations are done. Equipment costs vary greatly; for example, the cost of one bariatric bed with a weight capacity of 600 pounds is $3810; a bariatric wheelchair cushion (up to 700 lb capacity) is $152; and a shower gurney with a weight capacity of 450 pounds is $534.

Conclusions
LTC facilities face new challenges in addressing the care of obese residents. Failure to prepare for this increasing population can lead to significant issues with quality of care and resident and staff safety. Although the GHC model has begun to address some of these challenges, going forward it will be important for GHC and other LTC facilities and corporations to not only disseminate but also begin to test models associated with the greatest improvements in care, and to advocate for public policies that recognize the additional costs incurred in caring for an obese LTC population.

The authors report no relevant financial relationships.

Dr. Bradway is Assistant Professor of Gerontological Nursing and Director, Gerontology Nurse Practitioner Program, University of Pennsylvania School of Nursing; Mr. DiResta is Business Development Director - Specialty Units, SunBridge Healthcare Corp, Chadds Ford, PA; Ms. Miller is Senior Director of Clinical Operations, Dr. Edmiston is Director, Nursing Education and Practice, and Ms. Fleshner is Senior Vice President, Clinical Operations, Genesis HealthCare Corporation, Kennett Square, PA; and Dr. Polomano is Associate Professor of Pain Practice, University of Pennsylvania School of Nursing, and Associate Professor of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia.