Barriers to Transition of Obese Patients From Hospital to Community

Objectives: To identify barriers encountered by case managers in hospitals, home care agencies, and nursing homes in the transition of the obese patient from the hospital to the community.

Study Design: Exploratory descriptive design was used. Hospital case managers, nursing home administrators, and Medicare-certified home healthcare agency administrators were surveyed to identify barriers.

Methods: Hospital case managers in each licensed acute care hospital, directors of licensed nursing homes, and administrators of the Medicarecertified home healthcare agencies in 1 southern state were surveyed. The survey instrument was designed by the investigators based on variables identified in the literature or encountered within their practice. Instruments consisted of items related to the respondent’s experience with barriers such as patient size, degree of patient independence, patient care requirements, staffing levels, and the need for assistive equipment, as well as items used to collect basic demographic information.

Results: Both hospital case managers and nursing home directors reported as major barriers the equipment, the size of the patient, patient independence, and finances. Home care agency directors reported that the presence or absence of a competent caregiver was the major factor in the decision to accept or not accept an obese patient.

Conclusions: Transition of the obese patient presents major challenges. Further exploration is needed to identify the extent of problems and make policy recommendations toward a solution.

(Am J Manag Care. 2012;18(6):e234-e237)

• Hospitalized obese patients present particular challenges to case managers.

• Barriers to skilled nursing facility placement include increased costs without commensurate reimbursement, safety concerns, and need for increased numbers of staff.

• Requirements for referral to home care agencies include the presence of a competent caretaker in the home, which may be problematic.

• Inability to surmount these barriers can lead to extended hospital stays with gradual patient decline or skilled care facility placement at long distances from home.

The increase in obese patients within the hospitalized patient population has become a challenge for nurses. Providing care for obese patients necessitates the use of assistive equipment and requires more staff members and more time for nursing procedures. Specialized nursing techniques are frequently needed as well.^1,2

The transition of the obese patient from hospital to home or another care facility may raise additional concerns. The home situation may be deemed inadequate for patient care due to lack of caregiver support or inappropriate physical facilities. Similarly, nursing home placement may be difficult due to the inability or unwillingness of nursing homes to accommodate morbidly obese patients. When placement is not possible, anecdotal reports suggest that patients can become “stranded in the hospital,” and experience subsequent deterioration of vigor as well as increase in cost.

The purpose of this exploratory study was to identify challenges or barriers encountered by discharge planners or case managers in hospitals, home care agencies, and nursing homes when a morbidly obese patient is ready for transition from the hospital back into the community. Such knowledge would be useful for proposing solutions to these problems and enhancing the quality of care for morbidly obese patients.

Literature Review

There is little exploration in the literature regarding the transition of obese patients from the hospital setting to the home or nursing home setting.

Schafer and Ferraro found that over the past 20 years, obesity has been associated with increased hospital admissions and length of stay.³ Connolly and colleagues identified pressures surrounding the discharge process,⁴ and while they did not identify specific issues related to obese patients, they identified as a source of pressure the lack of community services available in general.

Lapane and Resnik⁵ studied the prevalence of obesity in nursing homes, identifying concerns about nursing home preparedness and access. After adjusting for sociodemographics, they found that the percentage of newly admitted nursing home residents who were obese rose from fewer than 15% in 1992 to more than 25% in 2002. In a commentary, Lapane and Resnik⁶ discussed relevant issues, such as the lack of federal regulations regarding nondiscrimination in nursing home acceptance policies, and noted the lack of information regarding the ways in which the nursing home industry is coping with the increase in obese patients.

There is also scant research literature describing the care needed for the obese patient in the home setting. Gallagher⁷ surveyed 25 registered nurses employed in a home care agency in California to identifychallenges encountered by the home care provider when caring for a morbidly obese patient. Challenges noted by the

nurses in the home care setting included acquiring the necessary equipment, reimbursement, access to resources, motivation, and the support of family or a significant other.

Pokorny and colleagues⁸ used a descriptive survey design to identify knowledge, experiences, and concerns of 75 home care and hospice clinicians who care for morbidly obese patients. The respondents reported a high level of dependency in their morbidly obese patients. Home health professionals identified the most frequent challenges in activities of daily living (ADL) to include bathing, skin care, toileting, getting out of bed, and dressing. While the study did not address admission decisions for such patients, there is the potential that such challenges will play a role in the acceptance of these patients.

The findings in the Pokorny study support the work of Rose and colleagues,⁹ who noted high demands made on the hospital staff when the morbidly obese patient attempted to walk. Pokorny suggested that acute care facilities should assure that adequate environmental factors are present prior to home discharge, such as adaptive devices for toileting, transfer, and ambulation, as well as family or agency support services to facilitate mobility, skin care, and hygiene. They suggested that acute care and home health agencies collaborate to procure needed devices and services to limit injury to family and caregivers.

METHODS

Design and Setting

Based on a framework that considers the interactions between the morbidly obese patients, nursing, and the institutions of care, an exploratory descriptive design was used. Hospital case managers, nursing home administrators, and Medicare-certified home healthcare agency administrators were surveyed to identify barriers and other issues related to the transition of obese patients from one care setting to another.

Sample: A list of hospital discharge managers or case managers for each licensed acute care hospital in 1 southern state was obtained from the Internet. Names of the directors of licensed nursing homes in the state were obtained online from the state’s Division of Health Service Regulation. Names of administrators of the Medicare-certified home healthcare agencies licensed in this state were obtained from a membership list held by the state’s association for this group.

The combined institutional review boards of the university and the hospital approved the study. No identifiable patient information was collected as part of the research project.

The research group designed 2 survey instruments to incorporate the variables either suggested through the literature review or experienced in practice by the team members. One team member had significant management experience in home care, and 1 team member had significant experience managing the case management program in a large tertiary medical center. One survey instrument was designed for responses from the hospital case managers, and the other instrument was designed for responses from the home care agency and nursing home administrators.

The instruments consisted of items related to the respondent’s experience with barriers such as patient size, degree of patient independence, patient care requirements, staffing levels, and the need for assistive equipment, as well as items used to collect basic demographic information regarding the respondents. Additional items were included to obtain information unique to the type of facility. For example, the instrument for the hospital case managers contained an item related to the course the case managers followed if they were unable to place the patient locally. The survey for home care agencies contained an item regarding the availability of a caregiver in the home and the practice of home safety assessment, as well as items related to the degree of knowledge the home care agency had concerning the obesity prior to acceptance of the patient.

The survey instruments were pilot tested with experts from each target population, and no significant changes were recommended. The surveys contained a brief scenario used as a reference for completing the survey. The scenario read: “Imagine that you have a morbidly obese patient in hospital. By morbidly obese we mean someone with a [body mass index] BMI of 35 or more.” Since nursing home and home care agency directors may not have access to the BMI when considering acceptance of a patient, we added the sentence “For simplicity, let’s say the patient weighs about 325 lb.” This weight was chosen because data from an earlier study by the research group1 suggested that approximately 300 lb is the weight at which problems begin to be encountered in providing care. Respondents were asked to complete the survey with this scenario in mind.

Return of the completed survey signified consent. Surveys instruments were numbered upon return only and contained no information that could identify the individual participant or agency. Survey data were analyzed using descriptive statistics, as well as analysis by the research team of the qualitative comments included on the surveys.

RESULTS

There were 31 surveys completed by hospital case managers (28% return rate), 90 surveys by nursing home directors (23% return rate), and 62 surveys by home care administrators (27% return rate). Thirty (97%) of the hospital case managers, 70 (78%) of the skilled nursing facility directors, and 37 (61%) of the home care agency administrators reported that encounters with obese patients occurred at least monthly.

All 3 groups reported barriers affecting discharge from the hospital and acceptance to either the skilled nursing facilities or home care agencies. Table 1 provides information regarding the percentages of both hospitals and skilled nursing facilities reporting barriers associated with transitioning patients to skilled nursing facilities.

Qualitative comments from the hospital directors indicated that the problems encountered in terms of size were primarily related to equipment and staffing. One respondent noted that facilities would only take a “certain number of large patients.” Another noted that facilities might not accept the patients due to a concern over staff injury. Comments related to the level of patient independence as a barrier also indicated concerns over staffing and equipment. One hospital respondent stated there were concerns regarding potential falls and difficulty removing the patients from facilities in case of emergencies.

Qualitative comments from the skilled nursing facilities were also focused on equipment and staffing concerns. Both hospitals

and skilled nursing facilities suggested a need for specialty beds and equipment. Problems with availability of beds and lifts begin to occur for patients around 350 lb and greater. There were suggestions of a need for specialty beds and equipment accommodating patients with weight greater than or equal to 600 lb as well. Respondents indicated that immobility of the patient increases the need for lifts and causes transfer issues.

Fifty-two percent of the hospital case managers reported that there were times when they had great difficulty placing the patient in a skilled care facility within a reasonable distance of the patient’s home. When asked how they handled this problem they said that they either kept looking farther away from the patient’s home until they found a facility (9 respondents) or they found a way to send the patient home (3 respondents), sometimes asking the family to keep looking for placement.

Table 2 provides information regarding the percentage of both hospitals and home care agencies reporting barriers associated with transitioning patients to home with a referral for home care.

Qualitative comments from both the hospitals and the home care agencies focused on patient level of independence and the availability of a caregiver. Hospital directors indicated awareness of many factors that may make the home situation unsafe, including access, as well as other concerns such as patient needs for assistance with nutrition and ADLs.

DISCUSSION

It is evident that case managers, nursing home administrators, and home care agencies are all dealing with the issues of obese patient transition on a regular basis. Case managers, nursing home directors, and home care agency administrators reported dealing with these issues at least monthly. With the current level of obesity in this country, one would not expect this to diminish.

Equipment concerns seemed to be a major barrier for nursing home placement, reported by both the hospitals and skilled nursing facilities. Equipment issues were reported by a lesser percentage of home care agencies. Although there is reimbursement for obese patients having bariatric surgery, Medicare reimbursement is the same for nursing home patients regardless of weight. The additional costs associated with either renting or buying bariatric equipment can be a challenge for these facilities.

The patient’s level of independence was also a major factor. All 3 types of respondents identified this as a barrier to care transition. However, since home healthcare is an intermittent service, home care agencies consider the overall independence and ability to be safe in the home environment for any patient when making a decision to accept a patient for service. Home care agencies indicated that the condition of obesity was less of an issue than the availability of a suitable caregiver for an obese patient who would be unsafe if left alone in the home. The overriding barrier affecting the ability of the home care agencies to accept a referral for a morbidly obese patient was the availability of a suitable caregiver (reported by 95% of respondents). These findings support the importance of addressing caregiver availability and equipment needs early in the discharge planning process.

The study has policy implications. The fact that Medicare reimbursement for skilled nursing facilities does not take into account the additional costs associated with care of the obese patient should be brought to the attention of legislators. It creates care inequities for the obese patient.

There were limitations to this study. It was conducted in only 1 state and thus the findings cannot be generalized readily to patients in other states or areas of the country.

Because data were collected from 1 state the data could not be differentiated to determine if the problems were greater in rural versus metropolitan areas. There are many rural areas in the state, and further study should better identify the type of geographic location. In addition, the survey instrument for hospital case managers did not request data about size, finances, or equipment as barriers to transition to home healthcare. The instrument should be modified to obtain the data for these variables as well.

The data suggest the need for further study. We do not have concrete data on the higher costs associated with caring for the obese patient in a skilled nursing facility, nor do we know the extent to which patients are simply unable to be transitioned, remaining in the hospital for lack of an appropriate referral. If patients are sent home because of lack of appropriate nursing home facilities, what impact does this have on the caregivers and the patient in the home situation? Further study is indicated.Author Affiliations: From College of Nursing (JM, ME, MKK, MEP, MAR), East Carolina University, Greenville, NC; Pitt County Memorial Hospital (DPA, WGW, FRW), Greenville, NC; College of Human Ecology, East Carolina University (MLP), Greenville, NC.

Funding Source: Partial funding provided by the East Carolina University College of Nursing and Pitt County Memorial Hospital Collaborative Research Award.

Author Disclosures: The authors (JM, DPA, ME, MKK, MLP, WGW, FRW, MEP, MAR) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JM, DPA, ME, MKK, MLP, WGW, FRW, MEP, MAR); acquisition of data (JM, DPA, MLP, MAR); analysis and interpretation of data (JM, DPA, MKK, WGW, FRW); drafting of the manuscript (JM, DPA, ME, MLP, MEP, MAR); critical revision of the manuscript for important intellectual content (JM, DPA, MKK, MLP, FRW, MEP); statistical analysis (JM); obtaining funding (JM); administrative, technical, or logistic support (MLP, ME, WGW, MAR); and supervision (MAR).

Address correspondence to: Jane Miles, MSN, RN, NEA-BC, Clinical Assistant Professor, East Carolina University College of Nursing, Office # 3153, Health Sciences Bldg, 600 Moye Blvd, Greenville, NC 27834. E-mail: milesja@ecu.edu.1. Drake D, Engelke M, McAuliffe M, Dutton K, Rose, MA. Challenges that nurses face in caring for the morbidly obese patient in the acute care setting. Surg Obes Relat Dis. 2005;1(5):462-466.

2. Drake D, Baker G, Engelke M, et al. Challenges in caring for the morbidly obese: differences by practice setting. South Online J Nurs Res. 2008;8(3).

3. Schafer MH, Ferraro KF. Obesity and hospitalization over the adult life course: does duration of exposure increase use? J Health Soc Behav. 2007;48(4):434-449.

4. Connolly M, Grimshaw J, Dodd M, et al. Systems and people under pressure: the discharge process in an acute hospital. J Clin Nurs. 2009;18(4):549-558.

5. Lapane K L, Resnik L. Obesity in nursing homes: an escalating problem. J Am Geriatr Soc. 2005;53(8):1386-1391.

6. Lapane K L, Resnik L. Weighing the relevant issues: obesity in nursing homes. J Aging Soc Policy. 2006;18(2):1-9.

7. Gallagher S. Needs of the homebound morbidly obese patient: a descriptive survey of home health nurses. Ostomy Wound Manage. 1998;(4):32-42.

8. Pokorny ME, Scott E, Rose MA, et al. Challenges in caring for morbidly obese patients. Home Healthc Nurse. 2009;27(1):43-52; quiz 53-54.

9. Rose MA, Baker G, Drake D, et al. Nurse staffing requirements for care of morbidly obese patients in the acute care setting. Br Nurs Surg Patient. 2006;1(2):115-121.

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