Lifts/Bathing Feature: Thinking BIG

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Nursing homes are bracing for a new population: the morbidly obese. Heftier equipment is just the beginning of their caregiving needs

The "horror" stories were the trigger: Tales of hospitals without the wherewithal to deal with 800- and 900-pound patients.
After more than 20 years in business, Denmark-based Guldmann decided two years ago to venture into a new U.S. market: bariatrics.
"There was no way to get them on their feet, to tend to the washing, the cleaning and the changing of clothes," explained Linda Bowman, vice president at Guldmann in the U.S. "All the basic things you and I take for granted were a tremendous challenge for these people."
The morbidly obese may be ushering in a new era in long-term care. As baby boomers begin to enter the long-term care system, they are not only large in number but also increasingly large around their waistlines. Some are tipping the heaviest scales. While a 500-pound person may have been considered an aberration a few years ago, today lift companies and nursing homes are gearing up for an even heftier group of people — those who are 700 pounds or more.
This plus-plus-sized population poses a host of challenges to facilities. Heavier residents require special equipment to accommodate their needs. Higher-capacity lifts, which require extra space, are just the beginning. A suite of special equipment, such as beds, walkers and even toilets, will be necessary.
The possible costs to long-term care are daunting. Besides the expense of equipment, facilities have to worry about other capital expenditures, including oversized rooms with larger entrances. And with additional weight comes a host of medical conditions that tax facilities, such as diabetes, wounds and other complications.
The long-term care obesity problem is "booming with the boomers," said Dr. Mary C. Vernon, president of the American Society of Bariatric Physicians. "It's the tail end of the World War II generation and the beginning of the boomers where the trend starts to go up."

Expanding segment
Lifting companies have been seeing the rise in demand for bariatric equipment in recent years.
"Obesity has dramatically increased in the last decade so that it's becoming more and more a part of our business," said Mary Landhuis, vice president of EZ Way Inc. of Clarinda, IA.
In years past, facilities were asking for lifts and stands to accommodate 300 pounds, she said.
"Now they want more of an insurance capacity, so they ask for
600 pounds because they have
more residents who qualify or need equipment."
Many lift companies have added a new, heavier lift to their stable of products in the last five years.
For example, Mangar International, which is based in the United Kingdom, in 2005 introduced the Camel (Complete Air Moving Elevating Lift), a state-of-the-art inflatable cushion designed to sit up and lift a fallen person, small or large.
Besides creating new lifts, companies have noticed a sharp uptick in sales of existing models. Vancare Inc. of Aurora, NE, built a lift for a maximum weight of 1,000 pounds almost a decade ago. It sold only one the first year and one or two the following year. Now it's selling that many each month. While most have gone to hospitals, Vice President Pat Vanderheiden said he is starting to see more demand from long-term care providers. He sounds a bit baffled by the sudden surge in sales for the higher-capacity equipment.
"With long-term care, the money is not there for it," he said. "But in my conversations with [facilities], I feel like they are more open to it, which is why our sales are beginning to increase."
Bathing delay
Still, nursing homes may be more comfortable buying lifts at this point than bariatric bathing equipment, some experts say.
Penner Patient Care of Aurora, NE, has created some buzz in the market with its 1-year-old bariatric bathing spa — one of 12 models. The spa already is responsible for 25% of the company's sales.
There are two good reasons to buy a bariatric spa, according to the company's president, Lee Penner. The heavier resident needs it and the lighter resident enjoys the additional space, he says.
It "accommodates the bariatric and non-bariatric easily," he said.
Penner's tub notwithstanding, the market for bariatric spas "is not big enough yet," according to Jack Armstrong, president of Rane Bathing Systems, which is based in Ephrata, PA. The need for larger- sized tubs will hit nursing homes in about five years, he predicted.
Right now, most facilities are making do with smaller-sized tubs because they are more practical and cater to more people. A bariatric model that requires 100 gallons of water and suits one or two residents may not be worth the additional dollars.
"The rule of thumb is buy the tub that is good for the majority," Armstrong said.
Also, tub manufacturers are relatively constrained by the width of bathing room doorways. Most tubs are 22 inches wide and fit within a 351⁄2-inch doorway. Rane has a tub that is 28 inches wide to accommodate someone in an extra-wide wheelchair. But some residents may need an even bigger bathing model.
When facilities start expanding their doorways to 40 inches, "that's when we'll reach a tipping point," Armstrong said.

Housing considerations
Nursing homes have a lot to consider before investing in bariatric equipment. Bariatric lifts alone can cost 30% to 40% above the cost of a typical lift. And bariatric residents require more than an extra-large lift when they enter a facility. Special-sized commodes or toilets, shower chairs, beds and stretchers might all be parts of the package.
"It's more of a suite-type situation, where they need a whole host of items that are designed for the bariatric patient," said EZ Way's Landuis. "If you have a 350-pound patient, they may be able to use smaller-sized items, but some may not."
Operators also should be aware that morbidly obese residents often come with complex comorbidities that require advanced medical care, according to Vernon of the American Society of Bariatric Physicians.
"The thing that an administrator or admitting officer has to look at is, in addition to physically caring for this person, can we medically take care of their needs?" she said. "Many of these people have extensive medical problems that can't be cared for in the skilled setting."
These problems include cardiac issues, diabetes, kidney and renal problems, skin problems and conditions such as lymphedema, which is swelling due to a build up of fluid in the leg.
"Many normal bodily functions can't be performed by these people," she noted.
Linda Farrar, vice president of health services at Brewster Place, a continuing care retirement community in Topeka, KS, currently does not serve any bariatric residents in the skilled nursing area. But she has contemplated the costs -- financial and otherwise -- of housing them.
She is sizing up rental companies for equipment. She is also thinking about space. Bariatric lifts are large, complicated types of equipment that require plenty of room to operate.
Just housing the resident requires space, as well, she noted. A morbidly obese resident would require a private room, which would normally house two residents. If a facility has to give up the reimbursement of another potential resident, such an arrangement might be not economically feasible.
Farrar also raises the point about the psychosocial needs of the resident. A morbidly obese person who is a youthful 40 needs a different kind of attention than the dementia resident who is obese.

Gearing up
Overall, many nursing homes have not yet had to deal with the challenge of bariatric residents, but they should be anticipating the need.
The problem could confront facilities sooner than they expect, according to Brian Wright, vice president of marketing and education for Liko. They may not know how many bariatric residents they might have if those residents are currently mobile and independent.
But it takes "only one complication to sideline them," he said.
Genesis HealthCare has a subcommittee that is looking into the issue of housing the extremely obese population. Committee member Mark Santoleri, who is the head of the chain's safe resident-handling program, said there are a lot of thorny issues to consider.
"In addition to lift and transfer equipment, there is the furniture, for example," he said. "In some nursing homes, you can't get a regular bed through the room entrance, let alone a bariatric bed, unless you turn it on its side."
He said the chain currently has a moratorium on admitting residents over a certain weight. Currently, 400 pounds is the limit at which facilities start assessing how well the residents can care for themselves, Santoleri said. He added that the chain had not had to turn anyone away yet.
Safety is a prime concern, he added. How would staff evacuate such a resident in the case of an emergency? Should all the bariatric rooms be on the first floor? Do staff use a transfer gurney?
The costs of caring for the morbidly obese could be prohibitive for many facilities, particularly those in rural areas.
"If I were an administrator in a community and I didn't have a campus and residents I had loyalty to, I would look very hard before I took someone with this high level of need. The expense and level of care make it prohibitive for many community-based facilities," Vernon cautioned.

Weighty terms:

— The word "bariatrics" comes from the Greek word baros, meaning "weight." An extremely obese person has a body mass index (BMI) of 40 or more.

— BMI is a calculation of body weight adjusted for height. A person with a BMI of 25 or higher is considered overweight. To calculate your BMI, multiply weight in pounds by 703. Then divide that result by height in inches squared.

— For more, visit www.who.int/dietphysicalactivity/en.


Sources: The American Society of Bariatric Physicians, the Centers for Disease Control and Prevention and the World Health Organization