Paying a Heavy Price: Costs of Care for People With Severe Obesity in Nursing Homes

Abstract

Background and Objectives

The prevalence of resident obesity in nursing homes has increased dramatically from 22% to 28% between 2005 and 2015. To provide care for people with obesity, nursing homes have changed their admissions, staffing, and equipment, but underlying these changes are increased resources and financial costs of care. The purpose of this study is to describe nursing home organizational aspects of caring for older adults with obesity, with a focus on economic factors, from the perspective of nursing home staff and leadership.

Research Design and Methods

This qualitative study used descriptive approaches; data were collected through semistructured telephone interviews. Of 77 nursing home staff and leaders identified as potential study participants, 6 were ineligible, and 71 participated in the study through interviews conducted from 2019 to 2022.

Results

A total of 4 primary themes described the issues surrounding the cost of care for obesity in nursing homes: inefficient and risky use of staff time in a setting of persistent staff shortage, expensive and unique equipment needs, inadequate general reimbursement with an absence of obesity-specific reimbursement supplements, and competing short- and long-term management solutions.

Discussion and Implications

This qualitative study of nursing home staff and leadership underscores a need for improved approaches to funding obesity care within existing nursing payment models. The increasing prevalence of obesity and the burden of the costs of obesity care for nursing homes will escalate this need over the coming decade.

Obesity (body mass index [BMI] ≥30 kg/m²) among older adults increases the difficulty of providing long-term care services (Bradway et al., 2008; Felix et al., 2010; Harris & Castle, 2019). It requires more time and staff to move residents into bed, help them transfer out of bed, and to assist them with personal care (Apelt et al., 2012; Felix et al., 2009; Harris et al., 2018). These services may involve special equipment not readily available in most facilities (Bradway et al., 2017; Felix et al., 2016). Providing this care may entail additional training for staff to accomplish routine services for people with obesity (Bradway et al., 2009; Holland et al., 2001). Extra caution is necessary to avoid workplace musculoskeletal injuries, which can limit staff productivity and cause staff turnover (Jordan et al., 2015; Trinkoff et al., 2005; Wipfli et al., 2012).

Obesity is increasingly common in nursing homes and among populations that frequently utilize nursing homes. Between 2005 and 2015, the prevalence of obesity in nursing homes increased from 22.4% to 28.0%, and severe obesity (BMI ≥ 40 kg/m²) increased from 4.0% to 6.2% (Zhang et al., 2019). Among a population of older adults in the last 2 years of life, the prevalence of obesity in older adults has been increasing; from 1998 to 2018, the diagnosis of obesity increased from 14.2% to 22.1% (Harris et al., 2023). Obesity among nursing home residents has been associated with increased diagnoses of diabetes, hypertension, wound infections, pressure ulcers, renal failure, and use of indwelling catheters as well as decreased diagnoses of cancer, pneumonia, hip fracture, cognitive impairment, and incontinence (Cai et al., 2013, 2019; Felix, 2008; Felix et al., 2010; Harris & Castle, 2019; Millson et al., 2010). Beyond health conditions, obesity has also been associated with increased stigma and bias in health care, education, and workplace settings (Phelan et al., 2015; Puhl & Brownell, 2001; Puhl & Heuer, 2009, 2010). In addition to such negative associations, nursing home residents with obesity struggle to receive optimum care for a variety of systemic, cultural, organizational, and pragmatic reasons.

Studies of administrative data, surveys, and qualitative studies have described the challenges related to obesity care in nursing homes, but what has not been directly addressed is the foundational challenge of resource and cost management. The low-profit margins of most nursing home care call into question the sustainability of long-term provision of care to residents with obesity, especially in the post-coronavirus immune disease (COVID) era (Grabowski & Mor, 2020; Sloane, 2022).

Several studies have examined the effects of resident obesity on nursing homes, but few studies have addressed specific financial costs. The overall cost of providing services to people with obesity in long-term care has consistently been estimated as far higher than for people without obesity (Yang & Zhang, 2014). A simulation study estimated that residents with obesity required 1.3 billion more total care days, and the total long-term-care Medicaid costs were $68 billion more than for a similar population of normal-weight residents (Yang & Zhang, 2014). In a study assessing differences in expenditures by classes of obesity, researchers found that compared to 2012 costs, the average total health care expenditures in 2025 will increase by 69% for individuals with normal weight, 76% for those with Class II obesity (BMI of 35–39 kg/m²), and 93% for those with Class III obesity (BMI ≥ 40 kg/m²; Cecchini, 2018).

A case study based on an individual resident with a BMI of 50 extrapolated the annual staffing costs for bathing (Felix et al., 2009). The additional annual bathing cost for residents with obesity in a typical nursing home was estimated at about $40,000, due to the extra 60 min of staff needed per resident with obesity per bathing episode to provide care. The additional costs incurred for the care of residents with obesity exacerbate the issue of insufficient reimbursement, which has been noted as a barrier to nursing home placement in several surveys (Bradway et al., 2017; Felix et al., 2016). These studies address costs in terms of Medicare reimbursement, using a single case study, or qualitative assessments by hospital discharge coordinators or nursing home administrators. However, they do not address the breadth and depth of the nursing home-related resource issues that plague obesity care.

To address these concerns, we conducted a large qualitative study to understand the organizational adaptation strategies that nursing homes use in response to the demographic, technical, and financial challenges related to obesity. As an integral component of a more extensive study, discussions of obesity and care costs in nursing homes were common subjects. The purpose of this study was to describe the nursing home organizational aspects of caring for older adults with obesity, with a focus on economic factors, from the perspective of nursing home staff and leadership.

Method

Study Design

We performed a qualitative, semistructured interview study of nursing home staff and leadership personnel. This study explored organizational aspects of caring for older adults with obesity, with a focus on economic factors. We received approval for the study from the University of Pittsburgh Institutional Research Board (STUDY19020268).

Study Sample and Settings

Eligible personnel participating in this study included nursing home administrators, directors of nursing, medical providers, registered and licensed vocational nurses, nurse aides, corporate leaders, and other professional staff with direct resident interaction (e.g., physical and occupational therapists and activity directors) in U.S. nursing homes between 2019 and 2022. Participants must have worked in a nursing home for at least 6 months, cared for residents with obesity, and felt comfortable communicating in English. The sample was recruited using a purposeful sampling strategy, by asking for people who were considered experts in their field, as well as people who felt that they had specific memorable experiences related to caring for persons with obesity (Patton, 2015). As a part of this sampling process, we contacted the board members of nursing home professional organizations (e.g., the American Health Care Association, the National Association of Directors of Nursing Administration of Long-Term Care, and the Society for Post-Acute and Long-Term Care Medicine). In addition, we conducted in person, use of flyers, and email outreach to nursing home providers in Western Pennsylvania. Participants who completed the study were provided a $50 incentive payment.

Data Collection

To collect data, we relied on semistructured interviews, using a qualitative descriptive approach drawing from traditional social science interviewing (Patton, 2015). We structured the data collection using a prepared interview guide developed with input from clinical experts, a systematic review of the literature, and pilot interviews. The interview guide included questions in the following areas: admission considerations, equipment needs, staffing issues, pertinent policies, facility limitations, equipment financing, and resident reimbursement concerns. Participants were also asked follow-up questions on which they could elaborate and clarify their answers and provide stories from their own experiences (see Supplementary Material). The interview guide also included a question about how resident obesity affected nursing home finances, but much of these results come from spontaneous discussions of costs and nursing home financing that came during questions about staffing, equipment, and facility concerns. Questions on costs and reimbursement occupied between 10% and 20% of the interview time and were not prioritized over other questions. Although interviews were planned to be completed in person, the beginning of the COVID-19 pandemic required a change to telephone interviews for the duration of data collection. Verbal consent was obtained beforehand, and at the end of the interview, we completed a short survey to collect information on participant demographics, experience, and nursing home characteristics (see Supplementary Material).

Reflexivity

Interviews were performed by two individuals. One interviewer was a physician specializing in outpatient care for women with disabilities; some of whom live in nursing homes and have a diagnosis of obesity. The second interviewer was a nursing PhD with clinical and research experience in nursing home care. None of the authors or analysts were living with obesity or disability or living in a nursing home, but all were familiar with obesity stigma and have reflected on how their life history and body size affect their interpretation of obesity-related and nursing home issues.

Data Analysis

All interviews were audio-recorded, transcribed, and analyzed via Atlas.ti (Version 8.0). Based on a systematic literature review, we identified potential areas where obesity affected nursing home care: admission considerations, equipment needs, staffing issues, pertinent policies, facility limitations, equipment financing, and resident reimbursement concerns. We used these concepts to begin to understand obesity care but remained open to discovering new concepts, relationships, and structures to understand the dynamics of obesity care. We used constant-comparison qualitative methods to analyze the data and build this theoretical structure. Constant-comparison analysis is a development within grounded theory that explores relationships within the data. The goal was to produce a reasonable interpretation of the processes underlying the provision of nursing home obesity care (Urcia, 2021). The relationships examined included concepts described within a single interview, between interviews and within a similar job category, and between different job groups of participants (Fram, 2015).

Interviews were coded using a data-driven approach in which new codes were constantly created, and after ten interviews, the team worked to consolidate many codes into a shared, finalized codebook (see Supplementary Material). The senior author discussed and arbitrated conflicts between the two main coders. Due to the large sample size, we reached thematic saturation and informational redundancy on the resource and cost concerns related to obesity by noting minimal new themes after 50 interviews (Guest et al., 2020). Data collection continued after this due to the multiple research questions related to the larger research project.

Results

Participant Characteristics

Of the 77 recruited individuals, 71 met the eligibility criteria and completed the research interview. Six recruited individuals declined to participate in the research activity. In addition, 74% of the participants were female participants, with the most common age group being 35–44 years old (23%). The most common participant type was nurse aide (36%) and other participants included a broad range of positions within the nursing home environment: staff nurses, directors of nursing, other administrators, and corporate leaders. Roughly half (49%) of the participants had worked in a nursing home setting for at least 10 years. Additional information collected from the participants is shown in Table 1.

Four primary themes described the issues surrounding the cost of care for obesity in nursing homes: inefficient and risky use of staff time in a setting of persistent staff shortage, expensive and unique equipment needs, inadequate general reimbursement with an absence of obesity-specific reimbursement supplements, and competing short- and long-term management solutions.

Inefficient and Risky Use of Staff Time in a Setting of Persistent Staff Shortage

Participants from all positions emphasized the need for additional staff when providing care for residents with obesity. According to one director of nursing, “We have a few residents that are morbidly obese, and from a logistic standpoint, it is more manual manpower, and more staff is needed to care for that resident.” The number of additional staff needed was said to depend on various factors aside from obesity, such as mobility, weight distribution, attitude, and existing comorbidities of the resident. One administrator described situations in which the number of additional staff necessary was effectively unachievable, “… we have had situations where we have had to do care of 4 or 5 [residents with obesity], and that is nearly impossible to do especially on the 3–11 or 11–7 shifts where the staffing is lighter.” Regardless of the number of additional staff required, there was consensus across participants from all groups that, for large, nonambulatory, and relatively immobile residents, assistance with activities of daily living, such as transfers, transportation, and daily evaluations, required more staff than a typical resident. In addition to requiring more staff due to the obesity of a resident, participants believed many activities of daily living, such as bathing and skin examinations, require significantly more time.

When one resident requires extra staff time, interviewees were concerned that there may be consequences, including reduced staff availability to other residents. For example, some participants stated, “[Certified Nursing Assistants (CNAs)] felt guilt or distress over providing unequal care time to their residents.” It seemed participants believed this situation was not easily remedied due to the lack of funding for more staff and the scarcity of available labor, exacerbated by the pandemic. Not only did this affect the care that residents received but it also took an emotional toll on the nurses and CNAs. According to one administrator, “If it takes twice as long to care for that client, then the CNAs get stressed out because now they feel they are neglecting their other clients or residents.” These issues led to discussions of the costs of extra time and staff it takes to provide obesity-related nursing care; as one administrator noted, “Then the staffing costs, you know, takes longer to get somebody up when you have a lot more area to clean. It takes a lot to keep those areas dry and um you know, just time consuming.”

Obesity care-related staff burnout, turnover, and morale were also frequently brought up and asked about in the interviews. Many administrators, corporate leaders, directors of nursing, and medical providers explained that most of the hands-on resident care was performed by nurse aides. Some participants described the nurse aide position as challenging and under-compensated. One administrator stated, “The CNAs, they have the hardest job. Moreover, are the most underpaid. And so, if you have residents that are heavy and [require] a lot of care, then they will go home physically exhausted … If you don’t give them a break and rotate staff taking care of that client [with obesity], you are going to see more call offs or burnout factor.” According to the participants, many nurse aides were relatively small female participants, so assisting in transferring a resident who may be three or four times their weight can be physically challenging. In addition, respondents believed the complexity of care required for many residents who are obese, given their comorbidities such as skin breakdown, urinary tract infections, etc., took a mental toll on the direct care staff. These challenges contributed to the high turnover rate in nursing homes, which one corporate leader described this way: “But the real care is with the nursing assistants and that, I mean, the turnover is hideous … it is just absolutely hideous.” Participants considered that the high turnover rate led to inefficient use of time and resources during onboarding and having staff that may be suboptimally trained.

Many participants in leadership roles expressed worries over worker’s compensation claims, such as one corporate leader who mentioned, “… the main issue that I have seen affects staff with heavier patients is the risk of worker’s comp claims.” The same participant pointed to back injuries as the source of most of these claims.

Expensive and Unique Equipment Needs

Nursing home residents who are obese may require different equipment than most other residents. For instance, they may need a bariatric bed, special mattress, chair, wheelchair, or lift with a higher weight maximum. Many of our participants stated that their nursing homes rent the necessary equipment once the facility admits the resident and before the resident’s arrival. Other participants explained renting as financially unwise given current reimbursement policies, so their nursing homes purchased limited amounts of bariatric equipment. However, interviewees thought that prospective bariatric residents would not be admitted if this equipment was already in use, or the nursing home could not obtain the additional needed equipment. For example, when asked how a nursing home determines who is admitted, a director of nursing said, “If we can meet their needs. Like our beds take up to 350 pounds, so we have not taken anybody past 350,” and another administrator said, “When we have no equipment, I’m not going to rent because that is not cost-effective for what we are being paid.”

From responses, it seemed that purchasing varying equipment for each resident creates a significant financial burden, and thus there have been innovations in nursing home equipment to help solve this issue. The topic of beds was an issue that several respondents raised. One staff member in a corporate position mentioned that their facility had begun trialing a multifunction, high-capacity, bariatric bed that can automatically assist with helping a resident sit up in bed and has a 1,000-pound weight limit. Other staff mentioned they have begun using a bed that also serves as a scale, allowing them to weigh heavier residents without the lengthy and staff-intensive process of transferring a nonambulatory bariatric resident to a standard scale. The bed style mentioned most often in interviews was an expandable bed, that stretches from a typical bed size to one able to accommodate larger people. With this equipment, the same bed can fit many more residents than a typical nursing home or bariatric bed. However, these expandable beds are still not ideal for all residents. On this point, one corporate leader described their facility’s choice to transfer a resident from an expandable bed to a bariatric bed: “We actually went ahead and rented a bariatric bed for her because the (expandable) bed width is great for someone who is going to live in it for two weeks while they are doing rehab, it is another thing for someone who is morbidly obese and probably doesn’t do well with turning and repositioning themselves anyway …”

Inadequate General Reimbursement and Absence of Obesity-Specific Reimbursement Supplements

Participants familiar with funding methods noted that, despite residents who are obese and who require more staff and expensive equipment, nursing homes are not given additional reimbursement for providing care to these residents. Many participants described how nursing homes would often lose money when providing care for residents with obesity, as the costs of equipment, staffing, and the standard nursing home overhead charges exceeded the allowable reimbursement amounts. For example, one corporate leader explained, “On average it costs us $750 in Medicare for that person with a specialty stuff [equipment and staffing], and if they are Medicaid, we got reimbursed $150.” This reimbursement deficit was complicated by the small margin on which nursing homes operate, according to participants. One corporate leader described how the additional costs posed by such residents may push the margins past the limit: “… the reimbursement that a skilled nursing facility gets and assisted living … makes it very difficult to maintain a business margin and not even a margin, we cannot even cover our costs in most cases, and then when you add on to it, these additional expenses related to equipment and wound care products and that sort of thing, it is impossible to cover your expenses with the amount that we are being reimbursed.” Many corporate leaders spoke about reimbursement issues with similar urgency, for example: “Overall, the post-acute long-term care finance system in the country is actually collapsing … what we are seeing right now is that most nursing homes are actually starting to turn negative in terms of their profit margins.”

Multiple corporate leaders and administrators explained that occasionally they admit a resident that does not make financial sense because their referral source, most likely a hospital, cannot find another facility to accept that resident. As one administrator stated, “When we get referrals of individuals who are obese, 9 out of 10 times they have been refused by other facilities, and more than likely, it is probably because of that issue [cost].” According to participants, maintaining positive relationships with their referral sources was also very important, even if it would result in a financial loss. One corporate leader explained the challenging situation by stating, “You know your referral sources are very important, and if you only want the best residents, whatever those are, I mean you will lose referrals, so everyone has to do their best to take care of what I’ll call challenging residents/patients.”

Participants judged that one reason nursing homes may not be adequately reimbursed for residents with obesity revolves around obesity’s status as a diagnosis and how it is coded. When asked how to improve care for residents with obesity, a corporate leader responded, “Well I think it is really having obesity and bariatric patients being a real true diagnosis. Now I know that it is a diagnosis, but at the same time, there is not additional reimbursement attached to it.” Part of the complexity with diagnoses and reimbursement is the variation in needs of residents with obesity; as one corporate leader explained, “When you have a bariatric resident coming in, and you don’t even know all of their needs until they actually get in, you may not have a true weight on that patient or a true understanding of what all their clinical needs are going to be … And it is variable because it is going to be different for somebody who weighs 400 pounds and someone that weighs 800 pounds.” The equipment also presented an issue regarding reimbursement because bariatric equipment does not have the Health care Common Procedure Coding System (HCPCS) codes necessary to bill the equipment correctly, according to some participants. One corporate leader mentioned, “The problem becomes that there is really not HCPCS codes for a lot of this bariatric equipment.” In order to cope with this, nursing home staff reported “[getting] creative with miscellaneous codes” to try to identify these special needs within existing billing systems.

Additionally, a few participants, primarily corporate leaders, seemed to be hopeful that the new Patient-Driven Payment Model (PDPM) reimbursement system would do a better job at taking obesity into account and providing more appropriate reimbursement. Because obesity increases the complexity and time needed for nursing care, it was possible to increase reimbursement through careful billing and documentation, according to a participant, “one of the [Non-Therapy Ancillary Classifications (NTA)] for PDPM … which means we get more money to take care of those who are, who qualify as obese.” As one administrator explained, in PDPM, obesity needs “may not add to your formal acuity numbers, um it does add to your acuity in a way, because it just takes longer to take care of somebody and their needs may be more.” Although the PDPM reimbursement model was still relatively new at the time of the interviews (it was implemented starting on October 1, 2019), a medical provider noted that, because of this model, “places that were not willing to take obese patients, now, I think, are actually saying hey, ok, you know, we probably can accommodate some of these patients. Maybe we can’t take the 600-pound patient, but we can take people who are 300.” Furthermore, one corporate leader speculated about certain facilities accepting more patients with obesity that they might not be ready for, saying, “So you have to be prepared from a management standpoint, under the PDPM program … you have to make sure you provide the best care possible to make sure your outcomes are the best that they can be.”

Competing Short- and Long-Term Management Solutions

Throughout the participants’ responses, there was variation in how each facility approached the care of residents who were obese. Some participants described renting all the necessary equipment, while others had already purchased bariatric equipment. Some individuals justified renting by explaining that they often do not know how long a resident will stay or how their condition will change during their stay. Additionally, while renting bariatric equipment could be very expensive, especially when one adds up all the equipment that might be necessary (bed, mattress, wheelchair, etc.), it was often still cheaper than purchasing those pieces. One corporate leader explained that a bariatric bed is a large investment, “you are talking about a $3–4,000 investment for that bed.” Participants considered one downside of renting new equipment for each bariatric resident was that nursing homes had to wait for that equipment to be delivered. They described that when there was a problem with the delivery, there could be a resident in the nursing home who did not have the needed bed or the wheelchair. For example, one medical provider explained how sometimes “… we are waiting for materials to bring in the right bed and the person is sitting on a stretcher for an hour … that adds to the stigma when they are sitting in the hallway on a stretcher because we didn’t have the right equipment.” Overall, there was disagreement among the participants on whether purchasing or renting was the more financially wise decision.

When participants were asked how nursing homes could improve care for people with obesity, many responded with investments in infrastructure changes. Many spoke with praise about other facilities that have installed much more accessible showers and bathing facilities. One corporate leader said, “… the rooms were built with a roll-in, you know flush-height shower where, if you got that resident who was on a Hoyer lift, in the Hoyer, you could actually just roll the Hoyer into the shower. Shower them in a sling, dry them off, take them right back to the bed and lay them down …” Many others mentioned overhead ceiling tracks so that a ceiling-mounted Hoyer could easily transport a patient without that lift taking up space in the room. However, ceiling mounts seemed to be an option for newly built nursing homes only. As one administrator mentioned, “We cannot accommodate a ceiling Hoyer as such, as they do have, sometimes, in hospitals. I have not ever had a building that could accommodate a ceiling Hoyer.” Other commonly mentioned changes included wider door frames and larger rooms. It seems these changes were all recognized to be very expensive to implement, especially as most nursing home care is within older buildings, and totally new buildings are rare.

Discussion

This study investigated the nursing home organizational aspects of caring for older adults with obesity, with a focus on economic factors, from the perspective of nursing home staff and leadership. Our results indicated that nursing homes face several resource obstacles when providing care, including increased staff demands in an environment of scarcity, expensive and unique equipment needs, unchanged and inadequate reimbursement, and competing short- and long-term management solutions. These obstacles likely make it more difficult for residents with obesity—who have trouble gaining admission to nursing homes, have many medical comorbid conditions, and have higher rates of adverse outcomes—to receive the high-quality care that would be most beneficial to them and the nursing homes that care for them (Felix et al., 2018; Harris & Castle, 2019).

A recent qualitative study of 15 Directors of Nursing reported obesity-related issues and noted concerns with admissions decisions, daily care, and adverse outcomes for residents and staff (Sefcik et al., 2022). Our study described some of the same issues among a larger sample of participants, including nursing aides, corporate leaders, and nursing home administrators.

Issues with costs and nursing home obesity have been mentioned in previous work. For instance, in a survey administered to nursing home directors in Pennsylvania and Arkansas, 30% of respondents reported finances as a serious concern when admitting residents with obesity. These financial concerns were related to common concerns of inadequate staffing (31.4%) and equipment concerns (68.1%; Felix et al., 2016). Staff turnover and injury rates resulted in additional costs, reduced efficiency, and decreased staff morale in a nursing home, which can severely affect the care of all residents (Day et al., 2006). With the high staff burnout rates and a shrinking labor force, the costs of hiring and retaining staff are increasing (Cooper et al., 2016; Genworth Financial Inc, 2021). Therefore, any modifiable factor within a nursing home, including admitting a resident with severe obesity, is a likely target for cost-related considerations.

The concerns about expenses raised in each theme we described could be offset by increased revenues from higher reimbursements for residents with obesity. Participants in this study reiterated that reimbursement for this care was, at present, woefully inadequate for short-term resident expenses or to offset the larger, long-term capital costs of buying equipment.

Despite continual changes to nursing home payment methods, we are concerned that the estimated reimbursement for those with obesity is the same as for a resident without obesity. Obesity has been a factor in Resource Utilization Groups and PDPM, with morbid obesity (BMI ≥40 kg/m²) receiving 1 point in the NTA comorbidity score (Centers for Medicare & Medicaid Services, 2019). Of the 50 conditions, 1-point comorbidities include morbid obesity, immune disorders, narcolepsy, diabetic retinopathy, pulmonary fibrosis, and psoriatic arthritis. Although all these conditions can increase care needs, it is reasonable to conclude that obesity care may require the most comprehensive staffing and equipment needs compared with these other conditions.

When considering solutions to the increased costs associated with obesity, it is helpful to compare them to the nursing home care problems and solutions for people with HIV and AIDS in the early 1990s. For nursing homes, reimbursement concerns were the most commonly reported issues, so now residents with HIV/AIDS have relatively generous reimbursement benefits: in the PDPM, the presence of HIV/AIDS has scored eight NTA points and an 18% add-on to the nursing component of the payment (US Department of Health & Human Services, 2019). This is an example of a thoughtful policy response that has alleviated some financial difficulties for necessary service providers through additional reimbursement (Linsk et al., 1993). The presence of severe obesity in a resident, with its associated staffing, equipment, and management costs, should also necessitate increased reimbursement, like HIV/AIDS in the PDPM.

This study points toward the obvious question: Will the costly adaptations related to obesity care continue to be underfunded within the current system, or will obesity care require a more targeted strategy with higher funding within the PDPM? As obesity is one of many complex patient conditions that challenge the U.S. nursing home system; it is unlikely that this population, though ubiquitous in nursing homes, will draw the advocacy, empathy, and system changes needed. A hybrid approach that increases the value of obesity in the NTA within the PDPM and targeted global payment increases for people with severe obesity may be the most feasible. This is not a population that has a strong advocacy position, though organizations such as the Obesity Action Coalition do advocate for people with obesity to receive better care and escape discrimination, and they offer community support (Obesity Action Coalition, 2023). Obesity research in nursing homes can address the limited information on how the various payers and states reimburse nursing homes for the care of people with obesity and offer solutions that increase nursing homes’ efficiency and capacity to provide this needed and specialized care.

Limitations

Our study has some limitations. Even though this was a relatively large sample compared with many qualitative studies, we could not sample participants representing the full spectrum of U.S. nursing homes or all geographic regions. For example, very small or very large nursing homes, VA nursing homes, or those with bariatric specializations were not included. All participants volunteered to take part in this study and, therefore, might represent only a select group not entirely representative of nursing home staff populations. Our interview guide focused on the challenges staff experienced while caring for residents with obesity, and those challenges tended to occur, or seem the most difficult, with residents with severe obesity as opposed to residents with normal weight ranges (BMIs 18.5 to <25 kg/m²).

Additionally, most of our interviews took place during the months and years following the onset of the COVID-19 pandemic. First, this required all interviews to be completed by telephone, rather than in person. This change of format may have led participants to be more cautious with sharing personal, sensitive concerns over a more impersonal mode of communication. Also, the pandemic posed serious psychological, financial, emotional, and physical strains that had a tremendous impact on nursing homes, where additional isolation measures were required (even if not always available) due to the vulnerability of these populations to COVID-19 (Grabowski & Mor, 2020; Sloane, 2022). Consequently, some interview responses may have been affected by the extreme situation prevailing at the time they were conducted.

Conclusion

The literature provides evidence that obesity care has been a serious issue related to staffing, equipment, and facility design in U.S. nursing homes for over two decades. Obesity rates will likely continue to increase, further affecting the nursing home industry in the coming years (Zhang et al., 2019). Ultimately, the voice of nursing home care providers is clear—obesity-related care is costly to nursing homes. Additionally, while the problem is not being adequately addressed from a policy and reimbursement perspective, residents with obesity will suffer the greatest consequences, including poor resident outcomes.

Funding

This work was supported by the U.S. Agency for Health care Research and Quality (1R01HS026943 to L. Fernandez, B. Shieu, A. Trinkoff, N. Castle, D. G. Wolf, S. Handler, and J. Harris) and the Pennsylvania Department of Health (4100088553 to J. Harris ).

The views expressed do not necessarily reflect the official policies of the U.S. Agency for Health care Research and Quality or the Pennsylvania Department of Health, nor does mention by trade names, commercial practices, or organizations imply endorsement by the U.S. Government. The funding sources were not involved with the study design, data collection, analysis, manuscript writing, or submission decision.

Conflict of Interest

None.

Data Availability

The data sets generated and analyzed during the current study are not publicly available due to privacy and ethical concerns but are available from the corresponding author for reasonable and appropriate requests. The study was not preregistered.

Acknowledgments

We gratefully acknowledge the nursing home staff participating in the study. We appreciate the skilled manuscript editing provided by Bruce Campbell.

Author Contributions

Luisa Fernandez (Data curation [Equal], Formal analysis [Equal], Methodology [Equal], Writing—original draft [Equal], Writing—review & editing [Equal]), Bianca Shieu (Data curation [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Writing—review & editing [Equal]), Alison Trinkoff (Conceptualization [Supporting], Data curation [Supporting], Funding acquisition [Supporting], Investigation [Supporting], Methodology [Supporting], Writing—review & editing [Supporting]), Nicholas Castle (Conceptualization [Supporting], Formal analysis [Supporting], Funding acquisition [Supporting], Investigation [Supporting], Project administration [Supporting], Writing—review & editing [Supporting]), David Wolf (Conceptualization [Supporting], Investigation [Supporting], Methodology [Supporting], Project administration [Supporting], Writing—review & editing [Equal]), John Harris (Conceptualization [Lead], Data curation [Lead], Formal analysis [Equal], Funding acquisition [Lead], Investigation [Lead], Methodology [Lead], Project administration [Lead], Resources [Lead], Supervision [Lead], Visualization [Equal], Writing—original draft [Supporting], Writing—review & editing [Equal])

References