Impact of the COVID-19 Pandemic on Barriers to Nursing Home Acceptance of Residents with Obesity

Research Objective: To study the challenges that the healthcare system faces in caring for people with obesity, we examined a high-acuity, low-resource environment sensitive to structural inadequacies for obesity care: nursing home (NH) care. We investigated the likelihood of NH acceptance of residents with obesity before and after the beginning of the COVID-19 pandemic, as well as the effects of the COVID-19 pandemic on barriers to acceptance.

Study Design: We developed a national survey on the effects of obesity on NH staff and services with the assistance of NH administrators (NHAs), nurses, gerontologists, and experts in survey design. An example resident with obesity was defined in the survey as someone weighing ≥300lbs and needing assistance with ambulation/transfers. The survey was distributed to a random sample of US NHs in 2021, stratified by obesity rate, bed capacity, ownership type, rurality, and US census region, and was addressed to the facility NHAs. Fielded surveys were accompanied by a $19 Amazon gift card and a prepaid return envelope. 12.0% of surveys were returned (301 out of 2503). McNemar’s Chi-Square test was used to compare paired categorical outcomes and statistical analysis was done using Stata 16.0.

Population Studied: NHAs from a nationally representative sample of US NHs in 2021 across the US.

Principal Findings: Among 299 respondents who answered the following questions, 24.4% of NHs reported that they were ‘very unlikely’ or ‘unlikely’ to accept a referral for a resident with obesity before the COVID-19 pandemic, compared with 34.1% after (p< 0.001). Among the subset of respondent NHs that had difficulty accepting residents with obesity both before and after COVID-19 (n=61), the contributions of various barriers to acceptance changed after the pandemic. Before COVID-19, 62.3% of these NHs chose lack of staffing as a main factor in their decision-making regarding accepting residents with obesity, compared to 77.1% after (p=0.007). NHs with concern for medical complications increased from 31.1% to 39.3% (p=0.06). The proportion of NHs that chose lack of equipment (77.1%), lack of large enough rooms (59.0%), lack of resident independence (26.2%), and financial concerns (16.4%) did not change significantly. Among nursing homes that reported new difficulties in accepting residents with obesity after the pandemic (n=41), the most common barrier to acceptance was lack of staffing (82.9%).

Conclusions: After the beginning of COVID-19 pandemic, the proportion of respondent US NHs that were unlikely to accept residents with severe obesity increased to more than a third. Among these NHs, staffing issues emerged as a greater barrier after the pandemic. Lack of equipment and room size remained considerable barriers.

Implications for Policy or Practice: The stress placed on NHs by the COVID-19 pandemic, especially in staffing levels, exacerbates existing weaknesses in obesity care. Interventions that improve effectiveness of care for people with obesity without requiring more staff may be particularly useful in improving capacity and outcomes for this population.