It is a common belief that obese individuals are obese because they are lazy, undisciplined and lack willpower. In the same way, many contend that individuals who are obese remain so because they choose to live this way. Poor diet, overeating, and lack of physical activity are indeed common causes of obesity, but there are other factors that are beyond a person’s control that have a powerful effect on body weight. These include genetics, environment, medication, mental health, as well as medical conditions or illnesses. Because of the significant role of these other factors in causing obesity, many organizations, including Obesity Canada, the Canadian Medical Association, and the World Health Organization now consider obesity to be a chronic disease.

In 1978, Government of Canada statistics revealed that 14 percent of Canadian adults were obese; that number doubled to 28 percent in 2014. Since then, the obesity rate in Canada has continued to rise. In 2017, research done by the Public Health Agency of Canada reported that 64 percent of Canadian adults over the age of eighteen were overweight or obese, and 30 percent of children aged between five and seventeen were overweight or obese. Clearly, there has been a consistent and alarming rise in obesity rates in Canada. Although obesity is treatable, there are limited inpatient bariatric facilities and programs that provide rehabilitation and resources to help treat Canadians with this disease.

According to Maria DeLeon, Patient Care Manager at The Salvation Army Toronto Grace Health Centre (TGHC), the Bariatric Program at the TGHC was established on the Post Acute Care Rehabilitation unit as a result of the need in the community and in the health care system in general.

Maria then told me to contact Walter Leahy, a Care Coordinator at the Toronto Central Local Health Integration Network (Toronto Central LHIN), who supported the TGHC in the development of the Bariatric Program at the TGHC.

Approximately three years ago, Walter and a colleague, along with personal support workers (PSWs), were providing care in the community for Ruby, a woman who suffers from obesity. Ruby had been discharged from an acute care facility and returned home, bed-bound, with a weight of almost 500 pounds. For the better part of three years, Ruby remained in bed, and month after month her body mass index (BMI) continued to increase. Supporting her care in the community was becoming increasingly unsustainable as her weight increased, eventually topping 780 pounds. Walter says, “Ruby was becoming at risk for medical complications — skin breakdown [wounds] and sepsis [life-threatening response to having an infection]; if her health trajectory continued downward there was the real possibility she would eventually die at home.”

In early 2018, Ruby was admitted to Sunnybrook Health Sciences Centre (SHSC) with pneumonia. After treatment at SHSC, Ruby became medically stable. Normally, once a patient’s health has been stabilized in acute care, the goal is to transfer the patient home or to a rehabilitation facility. Walter, through an integrated care approach, discussed Ruby’s complex needs with SHSC and it was agreed that, in her condition at the time, she could not be supported in her home. Sending her home would most likely result in a recurrence of the same health trajectory. Walter believed, “they needed to get Ruby into a health care setting where she could lose weight, participate in rehabilitation, and become more functional and independent.”

Walter made enquiries, contacting all the inpatient bariatric, as well as rehabilitation programs, across the Greater Toronto Area, but because of Ruby’s unique health status, it was a challenge to find a facility where her health care needs could be met. Bariatric programs and rehabilitation facilities have eligibility criteria — conditions that must be met and assessments patients must undergo to see if they are suitable candidates.

Finding Ruby a healthcare setting to meet her healthcare needs became imperative. Returning her home was not an option. Knowing the TGHC admitted patients from the community to its inpatient rehabilitation programs, Walter reached out to the TGHC. He recounted Ruby’s story, adding that he was out of options regarding where to place Ruby and asked if the TGHC could admit her. The TGHC responded by telling Walter that if the TGHC accepted Ruby for bariatric care that it would need assistance. Walter then asked what kinds of community supports the TGHC would require in order for Ruby to be admitted. The discussion led to the TGHC asking for community support, specialized equipment (a bariatric bed, a wheelchair, a special lift), and additional PSW support. Those conditions were agreed to, and the Toronto Central LHIN and TGHC formed a partnership. In May of 2018 Ruby was admitted. Her admission marked the beginning of the inpatient Bariatric Program at the TGHC.

Although Ruby’s admission was a trial, it presented the TGHC with the opportunity to explore the feasibility of establishing an integrated Bariatric Program in an inpatient rehabilitation setting with 24/7 access to an interprofessional health care team. In establishing the Bariatric Program, the TGHC would be able to address a healthcare gap for patients with obesity, who would be otherwise left to live at home with access to community home care. Bariatric patients in home care require a great amount of assistance, including considerable human resources, such as PSWs, and other support services. For example, Ruby, while living at home, would receive two daily visits from the care coordinator, four PSWs in the morning and two PSWs in the evening, to assist with toileting, bathing, dressing, grooming, laundry, and meals (activities of daily living).

“This becomes very taxing on the health care system,” says Walter. “The challenge is that bariatric patients frequently end up in a downward medical spiral. Patients continue to gain weight, [which results in] increases in the number and severity of medical comorbidities. In some cases, patients could potentially die if they do not receive adequate bariatric care.”

Bariatric patients require help navigating the health care system’s comprehensive care programs in order to ensure that there is proper integration of the multiple services available to address their needs. In Ruby’s case, she received comprehensive care coordination services. Prior to receiving these intensive care coordination services, Ruby’s health and support needs were met on an intermittent basis by acute healthcare teams. This was, of course, an unsatisfactory situation as it resulted in care that was more akin to an effort to put out fires than treatment that addressed the entirety of her personal situation.

Today, the Bariatric Program at the TGHC offers comprehensive healthcare services, including mental health support, customized meal plans (developed with a dietitian), as well as occupational therapy and physiotherapy rehabilitation. The TGHC’s Bariatric Program allows patients to be admitted from an acute care facility or directly from the community, and encourages them to actively participate in the program with the goal of weight loss, healthy eating, and an exercise regime. Each patient’s success is based on their commitment to lifestyle changes. This program educates the patients, teaching them how to be self-directed, encourages them to make the right choices related to eating habits, and shows them coping skills, all with the goal of behaviour change. The interprofessional health care team is sensitive to the patients’ needs and helps guide them to meet their goals in a supportive and caring environment. The inpatient team also works with outpatient services to establish a successful transition back to the community, providing the appropriate support services for them, and following up after the transition to monitor the patient’s progress.

Ruby will be discharged home shortly. The Bariatric Program has helped her lose approximately 340 pounds. The rehabilitation team supported her in regaining her independence, and she is now able to transfer with some assistance from her bed to her wheelchair and motorized scooter. She is also able to transfer with assistance to manage her toileting. She is no longer bed-bound and is able to independently leave the hospital and navigate the surrounding community on her scooter, where she can take herself shopping.

Ruby expressed that the TGHC’s health care staff feel like family, and believes her rehabilitation team are excellent. She acknowledges that “TGHC helped me, and, was willing to take me on. They helped save my life.”

In preparation for Ruby returning home, Toronto Community Housing fully renovated her apartment so that she will have easy access to her bathroom, as well as her kitchen and her appliances. When she returns home, she will continue to receive care, including occupational therapy and physiotherapy, as well as personal support services. Also, in preparation for her returning home, the health care team at TGHC is currently working on sourcing mental health support for Ruby within her community.

The TGHC continues to develop and improve the Bariatric Program. Currently, there are three other bariatric patients in the program, with a growing wait list. The collaborative partnership has allowed for the development of a program that addresses a healthcare gap by providing bariatric patients with a continuum of care to transition patients to the community safely. The Bariatric Program at the TGHC improves the quality of life for bariatric patients in a supportive and caring environment where they can lose weight and participate in rehabilitation, all of which helps them to become more functional and independent in the community and at home, where they continue to receive a variety of services.

By Gerry Condotta