Currently Viewing:
The American Journal of Managed Care June 2012
Thromboembolism Prophylaxis in Medical Inpatients: Effect on Outcomes and Costs
Onur Baser, MS, PhD; Nishan Sengupta, PhD; Anne Dysinger, MA; and Li Wang, MA, PhD
Racial Disparities in Lipid Control in Patients With Diabetes
Darcy Saffar, MPH; L. Keoki Williams, MD, MPH; Jennifer Elston Lafata, PhD; George Divine, PhD; and Manel Pladevall, MD, MS
Automating Care Quality Measurement With Health Information Technology
Brian Hazlehurst, PhD; Mary Ann McBurnie, PhD; Richard A. Mularski, MD, MSHS, MCR; Jon E. Puro, MPA-HA; and Susan L. Chauvie, RN, MPA-HA
Role of Insurance, Income, and Affordability in Human Papillomavirus Vaccination
Nadereh Pourat, PhD; and Jenna M. Jones, MPH
Bowling Alone, Healing Together: The Role of Social Capital in Delivery Reform
Sachin H. Jain, MD, MBA; Riya Goyal, BA; Susannah Fox, BA; and William H. Shrank, MD, MS, HS
Quality Care Opportunities: Refining Physician Performance Measurement in Ambulatory Care
Kimberly M. Lovett, MD; and Bryan A. Liang, MD, PhD, JD
Unintended Consequences of a Quality Measure for Acute Bronchitis
Serena Roth, MD; Ralph Gonzales, MD, MSPH; Tammy Harding-Anderer, PhD; Frederick J. Bloom, Jr, MD, MMM; Thomas Graf, MD; Melissa S. Stahl, MPH; Judith H. Maselli, MSPH; and Joshua P. Metlay, MD, PhD
Impact of Positive Airway Pressure Among Obstructive Sleep Apnea Patients
Qian Cai, MS, MSPH; Hiangkiat Tan, MS, BPharm; and Joseph Singer, MD
Currently Reading
Barriers to Transition of Obese Patients From Hospital to Community
Jane Miles, MSN, RN, NEA-BC; Darren P. Anderson, MSN, RN, ACM; Martha Engelke, PhD; Mary K. Kirkpatrick, RN, MSN, EdD; Mary Lisa Pories, MSW; Wanda G. Waters, RN, BSN; Frank R. Watkins, RN, CCRC; Marie E. Pokorny, RN, MSN, PhD; and Mary Ann Rose, MSN, EdD

Barriers to Transition of Obese Patients From Hospital to Community

Jane Miles, MSN, RN, NEA-BC; Darren P. Anderson, MSN, RN, ACM; Martha Engelke, PhD; Mary K. Kirkpatrick, RN, MSN, EdD; Mary Lisa Pories, MSW; Wanda G. Waters, RN, BSN; Frank R. Watkins, RN, CCRC; Marie E. Pokorny, RN, MSN, PhD; and Mary Ann Rose, MSN, EdD
This study explored barriers to the transition of obese patients from hospital to community as perceived by case managers, nursing home directors, and home health directors.
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.

 
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up