facility responsibility to the obese

[onthemark]

In my LTC facility, there are a few woman (in their 50's and 60's) who weigh over 400 lbs. Despite their morbid obesity, they eat as much as they want including desserts, and also order take-out food! Doesn't the facility have a responsibility to monitor and curb their intake just as they do with diabetics? What do you think?

[Altra, BSN, RN]

I guess I just don't understand the difference.

Hubby's elderly aunt was in a skilled facility post hip fracture. She was terribly depressed and her pain was not properly managed. She refused to participate in PT due to these factors, and was notified by Medicare that her stay would no longer be funded. She had X number of days to move out or arrange to be self pay. I realize that her Medicare in general was not cancelled and she did have coverage for other health needs.

However, I don't understand how her refusal to participate in PT was any different than the diabetic patient next door who circumvented her treatment plan (she was there for wound care) by eating any and everything she chose, without regard to her meal plan and whose stay continued to be funded.

Medicare covers rehabilitative LTC/SNF. It does not cover true long-term care. The facility must continually re-verify that the patient is receiving rehabilitative services, e.g., PT x hours per day, x days per week. Any of the LTC nurses here can explain that in much more detail and much better than I can.

So in hubby's aunt's situation, the only circumstance that allowed her SNF stay to be covered by Medicare was if it was a rehabilitative stay with documented progress toward rehab goals.

In this way, Medicare reimbursement is very different for rehabilitation vs. management of chronic disease, even complications/exacerbations of chronic disease.

Again -- an LTC nurse can probably explain this much better!

[Jolie, BSN]

I appreciate the explanations and understand the need for progress and participation towards a rehabilitation goal.

I'm probably either dense or hard-headed, but I still don't understand how a diabetic engaging in behavior which is documented and which is contrary to the goal of her rehabilitation (wound healing) is any different, other than the need to connect a few more dots.

Refusing PT = lack of progress toward mobility.

Refusing ADA diet and consuming multitudes of sweets = elevated blood sugar = lack of progress in wound healing.

Again, thanks for the information. As another posted pointed out, these are government regulations, which ought to explain right there the inconsistencies and lack of sense.

[nursejoed]

When I was a new CNA in a LTC facility, I asked one of the nurses why a diabetic was going to town eating goodies brought in from home. I didn't think it made sense. I was told at that time about the fact that patients have the right to do what they wanted, even it meant a bad time for everyone all the way around. That lesson stuck with me all these years, even though it doesn't necessarily make much more sense today than it did then.

...then they should have the RIGHT to endure the consequences of their actions without the taxpayer being beholden to pay for the medical expenses of cleaning up their behavioral messes.

[onthemark]

Jolie, I agree with all you're saying here. We're spending a great deal of our time, energy and taxpayer money on these residents and we let them work against us....something's wrong here!

I certainly appreciate all the feedback here. I'm learning so much from XTXRN about both government regulations and causes of overeating. But I still feel there must be some way to fix this problem.

Last night one of our morbidly obese residents needed 6 people to get her in the hoyer which required aides from other units going to her. Then, those units were shorted their aides leaving their own residents without the help they needed. Crazy!

Is it unreasonable to consider placing morbidly obese people into special bariatric facilities where their meds and diets could be more closely monitored, they'd receive more counseling to help them through, and staffing and equipment would be geared just for them? It doesn't seem fair to anyone to place them in regular rehab or LTC if we are really seeking the best health for everyone.

[onlyserendipity9]

Whereas you may control their blood glucose with diet and insulin when the client is an inpatient, you are not going to help them to a normal BMI during an inpatient stay. I agree with many of the posts above. Lastly, we don't want to insult the patient by giving them a skimpy diet that is TOO terribly far from their baseline diet. We have to remember holistic care ... psychosocial can be very important in bariatric care.

[diva rn, BSN, RN]

Is it unreasonable to consider placing morbidly obese people into special bariatric facilities where their meds and diets could be more closely monitored, they'd receive more counseling to help them through, and staffing and equipment would be geared just for them? It doesn't seem fair to anyone to place them in regular rehab or LTC if we are really seeking the best health for everyone.

In theory this is a great idea! However, while they exist, bariatric facilities are few and far between, very expensive and have waiting lists. I only know of two in the country without doing a search, I am sure there are more.

[chevyv, BSN, RN]

Even if this were to happen the pt would eventually be released and how many would remain thin? There are television programs on all of the time that show how people gained all the weight back and more.

I educate my patients constantly and am a bit on the heavy side myself so I can relate a little. I do try to teach my diabetic pts that yes, they have the right to eat whatever they want and how much they want. I also try to let them know that eyesight is affected, wounds are already slow to heal and amputations are much more common and taking care of themselves is so important. 5-10 yrs down the line is going to be more difficult if good habits aren't followed now. I also let them know I will be letting them know the same information everytime they tell other staff they can eat and do whatever they want. I can too, but I'm trying to walk a better path.

Most of the time, it doesn't work because many can't see themselves actually going blind or losing toes, then feet, then legs. It always happens to someone else...... :crying2:

[Dixielee, BSN, RN]

We are putting ourselves on a very slippery slope when we try to require people to comply "for their own good, or the good of the collective". I, personally want to keep my individual liberties while allowing others to keep theirs. I know that a lot of these folks are receiving some sort of assistance such as Medicare or Medicaid, but where does it end if we set this dangerous precedent?

Can private insurance companies then refuse to pay for someone who has an MI because he was overweight and had high blood pressure?

Should we eliminate dental insurance because some people don't brush and floss properly?

Do we refuse to pay for trauma care because the patient wasn't wearing a seat belt, was not in a car with an airbag, or was sleep deprived from working night shift?

Do we refuse to pay for any medical care for anyone over the age of (any arbitrary number here) because they are no longer paying into the system?

What about premature babies or those with birth defects? Shouldn't we just kill them off or abort as many as possible because they may not lead perfectly productive lives?

Or maybe we should just ban all food that is not essential and good for you, close all of the McDonald's and Dairy Queens. Of course no more tobacco or alcohol could be allowed either.

Be careful what you wish for, we may be dangerously close to the edge of that slippery slope.

[leslie :-D]

We are putting ourselves on a very slippery slope when we try to require people to comply "for their own good, or the good of the collective". I, personally want to keep my individual liberties while allowing others to keep theirs. I know that a lot of these folks are receiving some sort of assistance such as Medicare or Medicaid, but where does it end if we set this dangerous precedent?

i agree contextually what you're saying...

but i'm also for incentives and consequences, reflecting decisions made.

health insurance/medicare/medicaid benefits can either be more or less costly, depending on decisions/lifestyle.

of course all the kinks would have to be worked out, but let's face it:

there are too many of us who make bad, bad decisions...all in the name of retaining our liberties.

kind of the "because we can" attitude.

and it doesn't just affect them, it affects all of us in the long run.

why should that be allowed to continue?

leslie

[Dixielee, BSN, RN]

i agree contextually what you're saying...

but i'm also for incentives and consequences, reflecting decisions made.

health insurance/medicare/medicaid benefits can either be more or less costly, depending on decisions/lifestyle.

of course all the kinks would have to be worked out, but let's face it:

there are too many of us who make bad, bad decisions...all in the name of retaining our liberties.

kind of the "because we can" attitude.

and it doesn't just affect them, it affects all of us in the long run.

why should that be allowed to continue?

leslie

I am ALL for consequences and personal accountability. I see people everyday who come into the ED with frivolous and certainly non emergency complaints. Many are just drug seeking, many want free meds, dinner, warm blankets and a cab ride home on the taxpayers dollar. We as a society allow it, but I firmly disapprove. I don't think a lot of things need to be allowed to continue, but I really don't know how we can get off this merry go round. We as a society, while trying to help people and provide safely nets, have instead created a dependent and entitlement mentality.

I don't have the answers....but I have a lot of questions! If I was Supreme Being, there would be a lot less fraud and waste, but alas, it is a good thing that I am but a cog in this wheel of life :)

[Esme12, ASN, BSN, RN]

Jolie, I agree with all you're saying here. We're spending a great deal of our time, energy and taxpayer money on these residents and we let them work against us....something's wrong here!

I certainly appreciate all the feedback here. I'm learning so much from XTXRN about both government regulations and causes of overeating. But I still feel there must be some way to fix this problem.

Last night one of our morbidly obese residents needed 6 people to get her in the hoyer which required aides from other units going to her. Then, those units were shorted their aides leaving their own residents without the help they needed. Crazy!

Is it unreasonable to consider placing morbidly obese people into special geriatric facilities where their meds and diets could be more closely monitored, they'd receive more counseling to help them through, and staffing and equipment would be geared just for them? It doesn't seem fair to anyone to place them in regular rehab or LTC if we are really seeking the best health for everyone.

You never know what your future holds when you become old and debilitated. Would you want to be singled out ostracized and all your freedoms removed because a stranger thinks you are over indulged?

What choice do the disabled/elderly have in health insurance options when private insurance is cost prohibitive? I haven't worked at any hospital yet that offers health insurance to it's retiree's as a part of a pension to act as a supplemental. How is medicare "some sort of assistance" when you've paid for it your entire career. How can you get insurance when you no longer work because of a chronic illness and are no longer insurable because your diagnosis is chronic and progressive.

Remember you too shall grow old and may encounter an illness beyond your control and wind up just like these patients you so want to rid yourself of because of their disease.......

There but for the grace of God go I.

[CapeCodMermaid, RN]

You never know what your future holds when you become old and debilitated. Would you want to be singled out ostracized and all your freedoms removed because a stranger thinks you are over indulged?

What choice do the disabled/elderly have in health insurance options when private insurance is cost prohibitive? I haven't worked at any hospital yet that offers health insurance to it's retiree's as a part of a pension to act as a supplemental. How is medicare "some sort of assistance" when you've paid for it your entire career. How can you get insurance when you no longer work because of a chronic illness and are no longer insurable because your diagnosis is chronic and progressive.

Remember you too shall grow old and may encounter an illness beyond your control and wind up just like these patients you so want to rid yourself of because of their disease.......

There but for the grace of God go I.