Navigating Homecare for Bariatric Needs

The human body comes in all different shapes and sizes, with various numbers of limbs, teeth, eyeballs, etc. (OK, the eyeball count is generally between zero and two, but you get the point.) As a matter of routine, we measure the body and its performance (height, weight, strength) almost as our primary way of studying and recording it along the length of its lifecycle.

When we talk about the bariatric population, we are typically looking at a few key measurements. One is body mass index (BMI), a ratio between height and weight that is relied upon to put weight in the context of height. Another important data point is hip width, a number that reflects the minimum distance needed to traverse a doorway or sit in a wheelchair comfortably.
A person’s build, or body habitus, may pose a set of unique challenges, including:

• Seating: Safe and comfortable seating in a wheelchair, recliner or other surface can be hard to find and may present an added expense for customization. Softer seating can make it harder to rise to standing or transfer.
• Sit-to-Stand: Finding reliable and safe surfaces or assistive devices to help with sit-to-stand motion can be frustrating and expensive.
• Movement Through a Home: Many homes are built with doorways measuring 30 inches or less, and essential spaces such as toilet rooms or showers may be even narrower.
• Toileting: Good perineal care depends upon how the upper extremities maneuver around the body to reach hygiene areas and perform a controlled motor task (such as wiping).
• Skin Care: There is more folded skin in contact with other skin, creating a nidus for moisture, bacteria and skin irritation or breakdown.

If I just threw out a BMI and hip width as an example, we would still know very little about how that person might optimally function in a home setting or move through their community. That part takes a bit of curiosity and creativity.

Using Curiosity to Understand

There is an assumption that it’s rude to ask a habitus-related question—and that leads to missed opportunities. In most situations, the question going unasked causes more harm than the risk of potential embarrassment or awkwardness.

Here are some tips on how to approach the conversation with curiosity. Don’t overthink it!

• “We’re always concerned about things like urinary tract infections and want to keep you safe. I’m curious about how easy or difficult it may be for you to clean yourself after using the restroom?”
• “Have you had any trouble accessing parts of your home, such as the bathroom or shower areas?”
• “I’m curious, which part of getting up in the morning is hardest for you and why?”
• “Are there any activities in your home that you enjoy but have found yourself avoiding? Would you mind if I ask why, and what, if any, solutions you have tried?”

These questions could apply to many impairments that older and homebound people experience (including low vision, cognitive impairment and general mobility issues), but also get at a few of the most common challenges faced in the bariatric population.

Practicing Creativity

Even with the strides we have made in the past several decades in making homes and communities more accessible to people with mobility challenges, we still have a lot of work to do in extending these same conveniences to our bariatric population. Some things that still need to change are doorways that are too narrow, low weight limits on vertical platform lifts, tiny elevators and bathrooms that just won’t work pragmatically.

We don’t have it all figured out, but there is a lot to learn from the population that has been iterating through the challenges themselves, either with or without a caregiver. This means acknowledging the limitations the client is facing and making ourselves part of the team trying to solve it. What local vendors have experience with the bariatric population? Which physical therapist can help modify the transfer techniques to avoid back injuries by the caregiver? Is this client open to using a $35 bidet system? It can’t hurt to ask.

Homes age with us, and sometimes not in a good way. Our bodies can change but the home can remain indifferent. For bariatric clients, we should start the conversation with a few key questions.

Those can incorporate:

• Big changes, such as widening a doorway
• Medium changes, like adding a sturdier chair with better armrests to make sit-to-stand efforts more manageable
• Small changes, such as training a family caregiver how to use a gait belt for transfers.

Conclusion

Homecare professionals are very well acquainted with taking a complex set of conditions and creating custom treatment plans for their clients. Clearly, there are sensitivities to be observed when discussing someone else’s physical appearance in any context, but the extent to which this precludes open and pragmatic problem solving can be limited if we practice some curiosity and creativity.

Helping someone move safely and more freely within their home, clean their bodies with more ease and sit with more comfort is a tremendous example of the power of homecare services and the professionals that deliver them.