Accommodating bariatric residents
When it comes to providing care for LTC residents, one size does not necessarily fit all. In today’s nursing homes, care is provided to people from a variety of backgrounds who suffer from diverse conditions, including chronic diseases like obesity. Obese residents present a different set of needs than others. Although much of the current focus among LTC professionals is on person-centered care, a broader perspective can help managers serve the more diverse populations in nursing homes.
To illustrate this, the analysis department at Primaris—the federally appointed Quality Improvement Organization for Medicare in Missouri—looked at resident-level data for nearly 80,000 Missouri nursing home residents living in 521 facilities from February 2008 to January 2009. Among the findings:
|Table 1. Weight, Obesity, and Gender Among Missouri Nursing Home Residents (click for larger image). Source: Minimum Data Set, February 2008 – January 2009|
|Table 2. Weight, Obesity, and Age Among Missouri Nursing Home Residents (click for larger image). Source: Minimum Data Set, February 2008 – January 2009|
|Table 3. Weight, Obesity, and Race/Ethnicity Among Missouri Nursing Home Residents (click for larger image). Source: Minimum Data Set, February 2008 – January 2009|
● A higher percentage of female residents were obese (27.2 percent vs. 24.9 percent in males). In cases of severe or morbid obesity, the data showed an even higher percentage of women (see table 1).
● Nearly half (46.8 percent) of residents aged 64 years or younger were obese. Younger residents, compared to other age groups, are more likely to have severe or morbid obesity. Age and body-mass index (BMI) were related: the younger the age, the higher the BMI. By comparison, the data showed obesity in only 14 percent of the residents aged 85 or older (see table 2).
● Nursing home residents of Asian or Pacific Islander origins had the lowest obesity rate (11.6 percent). In comparison, the obesity rate among black residents was nearly three times as high (33.4 percent), closely followed by Hispanic (27.9 percent) and white (25.8 percent) residents. The difference in obesity rates among various race and ethnicity groups was statistically significant. Black residents also had the highest proportions across most classes of obesity (see table 3).
Findings like these could be applied to other states and illustrate the benefits of looking at the big picture. Determining facts like a facility-level obesity rate would help LTC managers design care delivery systems that meet the needs of this special resident population. “Data often makes the difference between simply having a hunch and actually knowing the specific challenges your home may be facing,” says Deborah Finley, nursing-home director for Primaris. “Homes can use this information to prioritize resources, design care practices and train staff to serve their residents more effectively.”
Nursing homes with high obesity rates will require additional resources in developing these care systems. For example, a nursing home manager may want to appoint a Quality Improvement Team to find ways to change facility culture.
This interdisciplinary team should include individuals with expertise related to the care of obese residents. Dietitians and dietary staff members, nurses, medical directors and even maintenance workers are some suggestions. A good starting point for the team is to focus on assessing the facility’s current practices as they relate to culture change principles. But involvement is not limited only to team members. Dietitians can assist residents to set healthier nutrition and activity goals. They may even ask the resident’s family for support or organize residents with common goals to work together.
Nursing staff and the medical director should evaluate existing skin care and positioning protocols, modifying them for their obese population. And the team should look at work practices, especially as they relate to the number of staff needed to care for an individual resident during routine care delivery, such as bathing and transfers. But no effective strategy would be complete without preparing staff. Specialized staff training to meet these residents’ needs consistently will not only prevent untoward effects for the residents, but also for the staff.
Environmental issues should be examined. For example, the facility should acquire wheelchairs and beds in sizes appropriate for the size of residents, doorways to facilitate large wheelchairs entering and exiting rooms, and lift devices able to withstand bariatric weights. Handrails must be securely attached to walls and able to support increased weight. Another environmental aspect is to add flowers or fountains to a facility’s landscape, encouraging residents to move about the grounds.
Managers may want to also consider what foods or beverages are available outside of mealtimes; one approach is to allow only healthier food options, like water, fruit or vegetable juices, and diet sodas to be stocked in vending machines. Managers also may coordinate with community providers of other services targeted to this special population such as transportation, health, and education. When making these changes, managers will need to remember that many residents living with obesity are younger than traditional nursing home residents, so their interests may vary from the current services provided.
Individualized care is the best practice for nursing homes. Staff will be most effective in providing individualized care when nursing home leaders recognize the populations served and develop procedures for appropriate care delivery systems for special populations in their facilities.
Betty Markway, RN, MSN, is a Program Manager in the Nursing Home Services Section of Primaris, the Medicare QIO for Missouri. She provides consultation to nursing homes with the goal of improving resident care through QI principles.
Yishih J. Chang, MSIE, CQE, CPHQ, is a Research Associate at Primaris. He provides informatics to various teams to facilitate behavioral change and performance improvement.
Donna Mehrle, MPH, RD, LD, is an Extension Associate at the University of Missouri. She coordinates the Missouri Council for Activity and Nutrition, an organization that promotes policy and environmental changes to facilitate improvement in residents’ nutritional intake and physical activity levels.