Integrated Healthcare at JFK Medical Center Bariatric Wellness and Surgical Institute: A Best-Practice Model

| May 15, 2013

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

Column Editor and Interviewer: Karen Schulz, RN, APN
President of the Integrated Health Section of the ASMBS; Clinical Nurse Specialist, University Hospitals of Cleveland, Cleveland, Ohio

This month: An interview with Melodie K. Moorehead, PhD, ABPP, JFK Medical Center, Lake Worth, Florida.

ABSTRACT
During the 3rd Annual Cleveland Clinic Florida Allied Health Symposium, Dr. Melodie Moorehead discussed a best-practice model utilized by The Bariatric Wellness and Surgical Institute at JFK Medical Center, Lake Worth, Florida. Here, in an interview with Karen Schulz,RN, APN, President of the American Society for Metabolic and Bariatric Surgery Integrated Health Section, Dr. Moorehead shares this best-practice model, which includes the routine delivery of psychological care within an integrated healthcare program. In addition, she shares various direct quotes, collected from the JFK ‘veterans’ of bariatric surgery during a monthly support group meeting, regarding patients’ perspective of such care.

Photo: The JFK team discusses patient cases together during weekly interdisciplinary meetings.

Sidebar: Patient Testimonials on Integrated Healthcare at JFK Medical Center

Bariatric Times. 2013;10(5):22–24.

KS: Dr. Moorehead, please tell us about your history and position at JFK Medical Center.

MM: First, thank you for your service to the American Society for Metabolic and Bariatric Surgery (ASMBS) and for the opportunity to share our program’s integrated healthcare approach to bariatric surgery with the readership of Bariatric Times.

After I joined JFK’s hospital-based program, we applied, were properly surveyed, and became a Centers of Excellence program. Soon after, I applied to become board certified by the American Board of Professional Psychology (ABPP), the oldest credentialing body for psychology in North America, in the specialty field of Clinical Health Psychology. I felt strongly that while working in integrated healthcare with the surgical members, board certification was a must. I would encourage colleagues, who are licensed psychologists and providing services to the bariatric patient population, to seek board certification with ABPP as well by visiting www.abpp.org.

KS: Please walk us through the typical process a bariatric surgery candidate goes through at your center.

MM: Once bariatric surgery candidates at the center have an initial consult with the surgeon, they are scheduled with both the psychology and nutrition departments. I initially see bariatric candidates in the preoperative period for a psycho-educational behavioral health interview and screening.

Approximately two weeks before surgery, each patient attends a two-hour education class conducted by our nursing department specific to each patient’s procedure (e.g., laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy)

Patients are seen by each member of the integrated team during hospitalization and in each of the subsequent surgical follow-up appointments. Immediately following the patient’s postoperative follow-up visit with the surgeon (and throughout his or her involvement with the JFK program), the surgeon or nurse escorts patients to either the nutritionist or myself. Following this disciplinary consult (if seen by the nutritionist first), nutrition will escort the patient to me or visa versa.

KS: How does JFK practice multidisciplinary care for the bariatric patient? What have you found are the benefits of this approach?

MM: Historically, I have provided multidisciplinary care when working closely with different surgeons and programs that were not housed under one roof. In that setting, a patient might come to my office after visiting his or her surgeon and dietitian preoperatively. Typically, and very early in my career, I would not see the patient postoperatively one-on-one. When service delivery is provided by different disciplines under the same roof it is seen more as interdisciplinary care. This type of care is beneficial to our patients and, as evidenced by patient testimonials, we find that they appreciate it.

At JFK, we view bariatric surgery as a behavioral surgery. We do everything possible to reduce the prejudice often times associated with psychological services for bariatric patients. The field of psychology can, at times, seem mysterious and thus be very misunderstood. We make every effort to present ourselves as a unified team during all stages of bariatric care (e.g., the monthly public information session, initial surgical consultation, patient education class, routine follow-up appointments, support groups). Implementing this model of care provides patients with an opportunity to have a healing, corrective experience that can promote long-term maintenance. The team, in psychological terms, can represent to the patient a recapitulation of their original family or caretakers (i.e., people who were responsible for their early childhood care and development). We have learned through evidenced-based research that globally the bariatric patient has often experienced different forms of abuse and neglect. It is important to further consider the damage of living life with obesity (e.g., the burden of weight, prejudice, and loss of quality of life) and encourage the patient to be as part of the unified bariatric team, thus fostering a healthy healing environment. Despite our best efforts to provide excellent care and encourage long-term success, there will always be patients who are challenged and lost to follow up. In these instances, we establish a safe environment in which we welcome back the patients with dignity and appreciation. This builds upon the cohesiveness of the program and the recapitulation factor can be one of healing. In this way, all our staff members get to know the patient and his or her individual circumstances; the patient senses his or her value, worth, and being cared about. I always feel rewarded when I hear a patient comment to another that they feel their program is like a family. Providing the psychological arm in this integrated care specialty format has proven life enhancing, if not lifesaving, while it offers us at JFK an opportunity to more safely serve a broader patient population.

Valuing life and understanding the importance of professional collaboration, integrated healthcare delivery of service achieves the following: 1) promotes safer environments in which to practice, 2) increases access of care for patients, and 3) increases safety and feelings of safety for patients.

KS: In your opinion and experience, where does psychology fit into the care of bariatric patients? What methods do you use in psych evaluation of bariatric candidates?

MM: In 2008, Bariatric Times conducted an interview with Dr. Kelvin Higa.[1] He replied to a question about the role of psychology in bariatric surgery with the following answer, “I think that the use of psychological evaluation as a barrier to care is ethically wrong.” I agree with this.

Rather than performing psychological screening to rule out individuals from having bariatric surgery, our focus is to help prepare individuals for safe and needed surgery while establishing a therapeutic alliance that can be advanced over time. The establishment and availability of a clinical health psychologist that learns the motivations, fears, values, and goals of patients can help address and resolve barriers to the healthy long-term use of surgery and promote weight loss maintenance. Routine in-house psychological services can be especially powerful and cost effective during rocky times, when challenges and negative consequences impact or threaten the psychological makeup and/or relational dynamics of our patients.[2]

When a patient comes into our program with established mental health providers, we request letters of support. This step helps broaden the safety net of care while providing documentation for the chart.[3]

Sometimes individuals present for bariatric surgery with significant underlying psychological issues or medical problems that dramatically influence his or her emotional/behavioral presentation. Rather than rule out even the most difficult patients—some of whom may be most in need of surgery—we strive to either identify what help is essential and establish an individualized safety net of care or help patients self-select out, thus protecting dignity. The patient’s ability to cooperate and secure such cooperation is paramount. Cooperation, with proper supports, can help the patient avoid unwanted derailing from program protocol, encouraging them to remain on track with surgical goals and help pave the way for positive long-term outcomes as defined by the Bariatric Analysis and Reporting Outcome System (BAROS).[4] Each and every time a person comes into the center, following their initial psychological interview and with each routine surgical follow-up the Moorehead-Ardelt Quality of Life Questionnaire II (MAII) is administered.[4]

During the initial psych interview, psychological informed consent issues are identified, addressed, discussed, and documented. Patients read aloud to me the following passages found on their worksheet:
It is very important that you have ‘Psychological Informed Consent’ as you are preparing for bariatric surgery. There is a potential for postoperative problems that may impact your emotional well-being including, but not limited to the following:
•    Spiking of depression or anxiety, (some studies have stated increased risk for suicide following bariatric surgery)
•    Changing dynamics of relationships, including divorce/separation
•    What has become known as the concept of: ‘Transfer of addiction.’ Some people have reported that following bariatric surgery they turned to excessive and destructive behaviors such as, but not limited to excessive alcohol use, smoking, gambling, shopping, and exercise. If you notice any of these behaviors in yourself after your surgery remember to call your doctors immediately to secure help
•    Excess skin folds.

When closing out the initial psychological interview, the value of cooperation and teamwork is stressed to the patient. Modeling cooperation, I may consult the patient regarding any possible need or potential benefit that might be gained by recommending additional psychiatric/psychotherapeutic referrals while preparing for surgery. Certainly, recommendations prove useful and help me feel more comfortable, at times, with the responsibilities I have, both to my patient and their program. We also provide to each patient a two-disc audio CD that I developed titled, The Gift and The Tool: A Personal Guide for a Lifelong Journey.

KS: What are your thoughts on access to care?

MM: More patients on Medicare/Medicaid are presenting for surgery. Many people on Social Security disability are on such for psychiatric reasons. Unfortunately, some individuals on Social Security disability for psychiatric reasons have not been properly treated or managed for years. Psychiatric disorders can be challenging enough to an individual or family, particularly when not properly diagnosed or treated. Still, when such a person presents for treatment at JFK, we recognize the extra burden that weight, loss of quality of life, and other significant stressors can also have on a person’s life. We strive to secure cooperation from the patient and/or family and tap the spirit within their desire for health that brought them to us. We establish a plan of action, securing appropriate referrals to safely prepare for surgery and its aftermath. There are wonderful opportunities for increased health and well being for such patients beyond what surgery alone can afford.

KS: What other aspects of the JFK program would you like to address that elucidates the integrated healthcare approach?

MM: The surgeons, of course, are the head of the team, and the surgery is the central event. Our nurses are the keystone of the entire program. Working collaboratively with our nutritionist has proven critically valuable to me. She has provided numerous consults that have given me a heads up regarding a patient’s alcohol use or family dynamics, as they may evidence during a nutritional consult. Our front office staff presents the very first impression in this integrated healthcare approach, thus requiring consistent, even mannered, delivery of service that produces a sense of confidence and safety for our patients.

The weekly interdisciplinary team meeting is a hallmark of integrated health at JFK. All patients are conferenced (i.e., every patient on the surgical schedule is individually discussed by each discipline), providing each member of the team specific information to help them better know the patient as a whole person. There may be times when the dietitian or I, respectively, may simply say, “Patient cleared for surgery from a nutritional point of view,” or “I anticipate cooperation from this person.” When the surgeon decides surgery is indicated, even when psychological recommendations have not been put in place, I might say, “wavier of psych recommendations is required” and I will have elucidated the specifics of the case so that the entire team understands my concerns and also has informed consent. When psychological waivers occur, I request closer follow up. I work hard at keeping the power in the hands of the surgeon who decides when surgery will occur (rather than insurance companies). Each patient is case conferenced two weeks and one week prior to their surgery. Every member of the team is present, including key hospital personnel. Surgeons and psychologists may approach the patient with different perspectives on healthcare and this factor can prove challenging regarding communication. Integrated care teams must encourage both disciplines to learn how to communicate effectively together thus having all staff members on the same page, greatly enhancing patient care.[5]

At times and very unexpectedly, spontaneous communication can occur among the nonsurgical team members around the water cooler. This type of communication can be very valuable regarding patient care and an immediate way to pass on relevant patient information.

Lastly, at JFK we have two monthly support groups (primary and veterans of surgery focus), both of which I facilitate. All patients and their loved ones are encouraged to attend both support groups pre- and postoperatively to help gain perspective on the process. Humbly, facilitation of support groups is one of my favorite trained skills. I have run groups monthly since the beginning of my career in bariatrics (1985). I hope one day to share what we, as professionally trained providers, might do to enhance the therapeutic value of the support group for the patient and family. In the meantime, the JFK groups are open to the entire community and are widely attended by pre/postoperative patients and family members.

KS: You have recently accepted an invitation to present on the topic “Is Psychological Clearance Really Necessary in Bariatric Surgery” at the upcoming Cleveland Clinic Florida Annual Bariatric Allied Health Professional Course, “The Bariatric Allied Health Professional’s Role in a Multidisciplinary Specialty.” What will be your focus?

MM: I am honored to have been invited to speak at this symposium and appreciate this controversial topic, which was assigned by Dr. Raul J. Rosenthal. I hope to secure and report on various perspectives. We are facing many changes in the global delivery of healthcare, and those of us involved in organizations, such as the American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), have worked hard to establish healthcare guidelines that meet the needs of the bariatric patient. I mentioned before that psychology is often misunderstood; even some highly qualified psychologists may practice in ways that prevent people from having lifesaving surgery. I have found that surgeons care deeply about safety. Fifteen or more years ago I remember giving a lecture, poorly attended, on another topic regarding psychological services during which a surgeon was presenting a parallel session down the hall. His lecture topic was how to oversew an anastamosis and his audience was overflowing into the hallway. Some might say this is how it should be. Now, I feel our society is in a critical time. When it comes to safety, everyone (including bariatric programs, educational institutions, and governments) must recognize that psychological services, provided by well-trained individuals, can help save lives, keep us safer, and provide economical solutions. Examining whether and if psychology is best to be used as gate keepers by insurance companies is another topic worth discussing. I am sure the symposium will be energizing and well attended.

KS: Dr. Moorehead, thank you for taking the time to speak with us.

Author acknowledgment: This article was prepared with great appreciation for Gina Melby, CEO, JFK Medical Center, and in honor of my mother, Joyce Williams. I am also grateful to Phyllis DeBiase of Manhattan, New York.

Editor’s note: While the title of this article states that it is a “best-practice model,” this is merely a description of one practice and Bariatric Times does not endorse it as the only standard of care.

References
1.    Higa K. An Interview with Kelvin Higa, MD, FACS. Bariatric Times. 2008. http://bariatrictimes.com/an-interview-with-kelvin-higa-md-facs/. Accessed April 16, 2013.
2.    Anderson P. Higher-than-expected suicide rate following bariatric surgery. Medscape News Today. October 23, 2007. http://www.medscape.com/viewarticle/564718 Accessed April 16, 2013.
3.    Pitombo C, Jones K, Higa K, Pareja J. Obesity Surgery Principles and Practice. McGraw Hill Medical, 2008: 75–81.
4.    Oria HE, Moorehead MK. Updated Bariatric Analysis and Reporting Outcome System (BAROS). Surg Obes Relat Dis. 2009;5:60–66.
5.    Frank RG, Baum A, Wallander JL, eds. Handbook of Clinical Health Psychology, Volume 3: Models and Perspectives in Health Psychology. Washington, DC: American Psychological Association; 2004.
Funding: No funding was provided.

Financial disclosures: Dr. Moorehead is the author of the The Gift and the Tool, and co-author of the Bariatric Analysis and Reporting Outcome System (BAROS) and the Moorehead-Ardelt Quality of Life Questionnaire II (MAII).

Category: Hot Topics in Integrated Health, Past Articles

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