Northern Minnesota Weight Management Clinic at Deer River Health Care Center

| March 22, 2012

by Carol Church, RN, MS, MA, CNS-BC

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

AUTHOR AFFILIATION: Carol Church is the Clinical Nurse Specialist at Deer River Health Care Center, Deer River, Minnesota and  Director of Practical Nursing Program at Itasca Community College in Grand Rapids, Minnesota.

Bariatric Times. 2012;9(3):22–26

Welcome to the Northern Minnesota Weight Management Clinic at Deer River Health Care Center
The Northern Minnesota Weight Management Clinic is located within Deer River Health Care Center, Inc. (DRHC), a nonprofit, community-owned and operated, comprehensive healthcare campus. Located in Deer River, Minnesota, our service area consists of a 50-mile radius and a staff of over 200 healthcare workers. We offer patients a wide range of excellent healthcare services. DRHC is committed to providing quality, compassionate healthcare for life.

Our Staff
Clinical nurse specialist. Carol Church, RN, MS, MA, CNS-BC, is the clinical nurse specialist for the bariatric program. Her duties include working with patients during clinical consultation, educating patients on the intraoperative experience, outlining preoperative resourcing and tests, and developing individual medical and educational plans for patients. As a midlevel provider, Church sees patients for evaluation and adjustment of adjustable gastric bands and problem solving related to patients’ weight loss journeys. She works closely with the surgeon and other team members to manage care of patients who are undergoing or who have undergone laparoscopic adjustable gastric bandng (LAGB).

Bariatric program coordinator. Dawn Evans, RN, the bariatric program coordinator, handles scheduling of resources for patients; meets with patients to educate them on the program, eligibility requirements, and insurance information; and sees uncomplicated patients for adjustments and tracking. Evans also keeps current on the latest news and trends in bariatric surgery, practice, and patient management.

Bariatric assistant. Sheila Maki, the bariatric assistant, is involved in telephone communication with present and potential patients; scheduling patients for appropriate follow up; and patient interventions after nursing consults. Maki and Evans maintain and update patient records and communicate with patients. Maki provides the stabilization of the program and is the go-to person who keeps the patients engaged with the program and providers.

Registered dietitian. Kim Diehl, the program’s registered dietitian, meets with patients to assess, teach, and promote behavior changes related to nutrition.
Occupational therapist. Tracey Bartholomew, the program’s occupational therapist, meets with patients to assess, teach, and promote physical activity interventions related to the weight loss journey.

Our Facility
Our waiting, operating, and exam rooms are outfitted with bariatric-sized equipment, such as chairs and stretchers. In our newly remodeled rural hospital, the rooms and equipment are all designed with the diverse patient in mind. Rooms throughout the facility are single bed and spacious.
From 2004 until present, we have performed 400 laparoscopic adjustable gastric banding (LAGB) surgeries. The demographic breakdown of these procedures is as follows: 350 women, 50 men, average age of 40 to 50 years.

A Center of Excellence
We are a Certified LapBand Total Care Program with Allergan (Irvine, California). In 2008, we received accreditation as an American College of Surgeons  Bariatric Surgical Center Network (ACS BSCN) Center of Excellence (COE).

At our information sessions, we annouce this to all of our potential patients, and it is posted at the entrance of our bariatric procedure room.

The process of attaining the certification was a nice learning experience for all involved. Our department wrote policies and procedures and thought through the care we provided to our patients, following a continuing quality assessment process.

Patient Adherence and Long-term Follow Up
There are a few ways that we directly and indirectly handle patient adherence and commitments. The bariatric department sends out a winter newsletter to all patients with information about the facility happenings. We invite them to come back to see us, chat, and have their weight checked. We also make our phone number, e-mail address, and Facebook page available to them. The staff within the department mans and manages the Facebook page at least twice per week. This is a perfect place for our patients to connect via a cyber support group, sharing their successes, failures, recipes, family stories, and more. We can be found on Facebook at www.facebook.com/smaki@drhc.org. Because many of our patients are spread across northern Minnesota, this is a perfect way to connect patients and promote patient adherence and positive outcomes.

One of the indirect ways that we impact our patient commitment to their weight loss journey is by positioning our bariatric program in a small, rural community (Deer River has a population of 1,000). We see our patients in the grocery store, the post office, the dentist, the clinic, the school, and in the next town. Our patients frequently stop to talk to us and ask for advice. They ask when the next support group meets or when can they just stop by and have their weight checked.

The biggest complication in terms of patient adherence is just plain “falling off the train” and experiencing weight gain and the psychological stress that accompanies that situation. It seems that some patients vaguely remember all the resources they were given to help them be successful on their weightloss journey. When they do not come back for their appointments with us and the weight starts to build, they can become embarrassed and unfocused on anything else but their failures. This is the common thread we hear from some patients who have experienced weight regain.

We keep all patient information private. When our patients enter our building, they come through a lessor-traveled entrance. They walk down a very short hallway and through a closed door that leads them to a small outpatient area that we share with two ultrasound technicians. We have an office, a procedure room, a consultation room, and a small waiting area all in this small outpatient setting. So, when our patients enter the building, they know that they are coming to a very safe environment where we protect their privacy so they may be stress free in their learning and experiences with the center.

Procedure Scheduling and Inventory Management
Our department scheduling is usually done by the bariatric program coordinator or assistant. We do not have a dedicated software package, rather we use the table function in Microsoft Word to complete scheduling and patient tracking software (Exemplo Medical, Oldsmar, Florida) for record keeping and data entry, such as demographic and appointment information.

Central Ordering Department is our purchasing department. If there is something special to order, generally we do the research and provide the information to them.

Managing Patient Care
Initially, patients call our program to inquire about LAGB. At that time, we make an appointment for them to meet with the clinical nurse specialist for a consultation. At this meeting, the medical and surgical history of the patient is reviewed and data about his or her prior weight loss attempts are gathered. The patient’s weight, height, and body mass index (BMI) are calculated. Education is provided for the patient about anatomy and physiology of the digestive system and the LAGB procedure, including how it is performed; potential risks, benefits, complications; preoperative course; intra-operative course; and postoperative course. During this consultation, all of the indications for LAGB are reviewed with the patient. Determination is made about the patient’s eligibility at this time as well. If the patient meets the indications, a preoperative course is designed to guide the patient through the rest of the screen procedures. Additional procedures include the following:
•    Nutrition/dietary therapy. The registered dietitian meets with the patient to assess his or her knowledge base about foods, composition, reading labels, supplements, pre- and postoperative diet progression plans, protein sources, and importance of adherence to diet. Most insurance policies require six months of this education and assessment of the patient, and promotion of behavior changes.
•    Psychological assessment. The patient is assessed by a professional to help him or her understand eating “triggers” and how he or she can change these behaviors. The patient is evaluated for any underlying depression and unchecked chemical issues. The patient is also evaluated about commitment to goal and motivation for weight loss.
•    Respiratory therapy. A pulmonary function test is performed to assess if the patient has some underlying respiratory condition that may be treated effectively before surgery or if he or she would be an appropriate candidate for ambulatory surgery within our facility.
•    Physical therapy/occupational therapy. A screen process is performed to assist the patient in choosing a method of physical activity he or she may pursue prior to and after surgery. With this screening, education is provided to the patient about the importance of exercise in his or her weight loss journey. A life coach, whom is also the staff physical therapist, assists the patient in exploring life and behavior changes.
•    Abdominal ultrasound. An abdominal unltrasound is performed to determine whether the patient has existing gallbladder disease. During this preoperative time, patients with newly diagnosed gallbladder disease may choose to have a surgical intervention to treat it.
•   Esophogeal manometry. Esophageal manometry is a test used to measure the function of the lower esophageal sphincter. This test is performed if the patient has experienced a long history of heartburn or gastroesophageal reflux disease (GERD) or swallowing issues.
•    Anesthetic consultation. Anesthesia meets with the patient to determine if he or she has any contraindications to undergoing LAGB in an ambulatory surgical setting. If a patient is compromised in respiratory function, he or she may need to have a pulmonologist or ventilator available. In this case, we work with the patient to connect him or her to an inpatient surgical site to place their band.
•    Support groups. Patients are encouraged to attend at least one support group in our area or their area.
•    Esophagogastroduodenoscopy. An esophagogastroduodenoscopy (EGD) is performed by the surgeon who will do the surgery and place the band. During this procedure, biopsies may be taken of the gastric lining to evaluate for any infection or abnormal tissue as well as visualization of the gastric anatomy and any potential problems to anticipate with the band placement.

The Role of Managed Care Payors
Managed care through our insurance payers require patients to go to a Surgical Review Corporation (SRC) level COE and Blue Centers of Distinction. This requirement, epecially Blue Levels of Distinction, has greatly affected access to care for our patients. In 2009, we saw approximately 166 consults per year. Now, only about 60 patients are consulted and eligible for surgery in a non-COE. This decrease in patient consults causes an increase in cost for the patient as well as an in increase in healthcare costs. This means patients must travel quite a distance to a qualified provider with whom they may not be familiar to have surgical services. The patient then undergoes surgery and an overnight stay, which increases the costs all around. Additionally, this affects patient outcomes as transportation is an issue (geographically bound) not only for surgical interventions but also for follow up, continuation of care, and management of complications. In our opintion, insurance should look at the type of procedure, patient population, respiratory and cardiovascular issues, morbidity and mortality rates, and positive outcomes of small facilities providing ambulatory care to banding patients.

Costs and Efficiency
Initially, when we began taking care of patients, we would insist on an overnight stay to evaluate them for any potential complications. After trying this during our first year in operation, we found that the majority of patients did not experience enough complications to validate the expense of an overnight stay. We then began performing LAGB on ambulatory care patients and discharging them from the hospital’s outpatient surgical center after they had demonstrated intake and output, and were comfortable and awake.

During the first years of patient follow up for LAGB, we filled or released a patient’s band via fluoroscopy. After attending an Allergan workshop in 2008, we implemented an algorithm for use during adjustments. The algorithm addresses the band size, max volumes, and suggested fill amounts per visit. These algorithms are based on best practices performed across the United States related to gastric LapBand (Allergan) management. We found that by using this algorithm, we decreased the expense for the patient and made our patient care visits more efficient as we were able to spend more time with our patients, listening to their stories.

Patient/Caregiver Safety
We have developed a Safe Patient Handling Policy and Procedure Manual. We have color-coded equipment related to weight capacities (i.e. wheelchairs), access to an E-Z lift to assist patients in transferring safely from one hard surface to another; bariatric patient care rooms in the acute care area with ceiling mounted lifts; single patient care rooms with larger bathrooms, no-barrier showers, and floor mounted commodes; “right size” clothing; and books to educate the staff about policies and procedures and their resources.

Patient/Caregiver Education
We share our policies on caregiver education with the outpatient surgical center personnel. We have created some educational traveling storyboards that focus on some aspect of bariatric surgery (e.g., the care of the patient, sensitivity education). Caregivers can complete a short quiz. From the quiz results, we can gauge the caregiver’s attainment of new knowledge. As an incentive to complete the quiz, we enter the caregivers in a drawing where the winner receives a gift card. Our bariatric assistant keeps a checklist and schedules the move of the storyboard from one department to another, until the whole facility has participated in each educational module.

Emerging Trends
We believe that some of our potential patients are waiting for insurance companies to “walk their talk.” The patients want to participate in a cost-saving approach to this surgical intervention and medical care, yet some insurance companies will not acknowledge the cost savings that could occur by authorizing LAGB as an ambulatory surgery.

In addition, we believe that there are some patients that would qualify for LAGB with the new United States Food and Drug Administration (FDA) indications (BMI of 30–40kg/m2, with one or more obesity-related medical conditions, such as type 2 diabetes and hypertension), and when non-surgical weight loss methods (such as supervised diet, exercise, and behavior modification) have not been successful. Patients must be willing to make major changes in their eating habits and lifestyle., but insurance companies are not authorizing them at this time.

Interesting Patient Cases
Case 1. A female patient in her 30s presented to our facility after six years of trying to conceive. She had the LAGB procedure and lost weight. When she returned for follow up, she was pregnant. Since then, she has gone on to experience three successful pregnancies and deliveries.

Case 2. A male patient presented to our facility with diabetes. He was also on dialysis. He was told by his medical provider that he needed to lose weight so that could undergo a kidney transplant. The patient participated in dietary counseling sessions on a regular basis, formulated an individual exercise plan with the assistance of physical therapy, and made regular visits to the bariatric department. Ultimately, the patient was successful in weight loss and survived a kidney transplant.

Case 3. A female patient presented to our facility who appeared to have great difficulty understanding and adhering to her dietary restrictions after undergoing LAGB (e.g., she got a sausage stuck obstructing the band restriction and required surgery to relieve it). We kept the band open and created an educational pathway for this patient. When the patient displayed an understanding of managing the band in healthy eating, she was taken back to surgery. Since then, she has had continued success,

A Unique Facility

Something unique about our small facility, is that our staff is very versatile. When our department is “quiet,” employees are able to work in other capacities, performing other duties across our inpatient acute care areas and outpatient surgical center, for instance assisting with cardiac rehabilitation procedures, pain relief injections, chemotherapy infusions, and conversion to electronic medical records system.

We believe that we have many other unique features. We are a small, rural healthcare facility with an ambulatory surgical center that attracts many patients across Northern Minnesota. We provide a very comprehensive and complete preoperative, intra-operative and postoperative plan for our patients. Our patients have a huge opportunity to gain the skills and education to be successful in their weight loss journeys. We feel that patients are the “leaders of their band” and we help support them every step of the way.

After we added LAGB to our program offerings in 2008, we conducted a research project to access quality of life (QOL) in a sample of our patients who had undergone LAGB. Our hypothesis that QOL improved for the majority of patients after LAGB was proved to be correct.

In 2010, we administered the Impact Of Weight On Quality Of Life-Lite Questionnaire (IWQOL)-Lite research tool, developed by Duke University Medical Center, to a random list of 100 LAGB patients within our program. Two color-coded surveys were sent to the patients. One color survey reflected the patients’ perceptions of QOL at the beginning of their weight loss journey and the other color was related to their perceptions of QOL at the time of survey completion. Forty respondents returned their mail-in survey. As suspected, the IWQOL-Lite validated a positive increase in participant’s perceptions from the initiation of the program to the current status in their weight loss journey. This information is represented by the respondent’s decrease in “uncomfortable feelings” associated with physical function, self esteem, sexual life, public distress and work. Although this study looked only at patient perception of weight loss via a single weight loss surgical intervention, the findings were significant for the participants in this small town program.

Based on the research conducted and patient testimonials of successful weight loss, we feel that we are definitely providing a valuable service within our small, rural community.

Photos:
(From left to right) Bariatric Coordinator Dawn Evans; Bariatric Assistant Sheila Maki,
and Clinical Nurse Specialist Carol Church reviewing some of educational tools

VIEW FROM A SMALL TOWN

Dr. Margo and the operating room crew prepping for surgery

Carol Church and Dawn Evans preparing a day surgery room for the next patient

Carol Church, Sheila Maki, and Dawn Evans standing outside the DRHC entrance.

Kim Dehl, registered dietitian (left), and Tracey Bartholomew, occupational therapist (right)

Dr Margo (left), from Itasca Surgical Center in Grand Rapids, Minnesota, frequently performs LAGB procedures at Deer River Health Care Center

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Category: Bariatric Center Spotlight, Past Articles

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