Welcome to a Boutique Bariatric Facility

This column is dedicated to featuring accredited bariatric centers around the world, with a focus on their facilities, staff, statistics, processes, technology, and patient care.

The Bariatric Center of Kansas City & Shawnee Mission Health
Lenexa, Kansas

by Christine Bovos, BSN, RN, CBN

Christine Bovos, BSN, RN, CBN, is Bariatric Program Coordinator Shawnee Mission Health– Prairie Star, Lenexa, Kansas.

Bariatric Times. 2015;12(3):28–31.

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Welcome to the Bariatric Center of Kansas City & Shawnee Mission Health
The Bariatric Center of Kansas City is a private bariatric surgery practice in Lenexa, Kansas, a suburb of Kansas City. By partnering with Shawnee Mission Health (SMH), we are able to provide everything our patients need for bariatric surgery and follow up in a single building. This provides convenience for our patients and staff, helps maintain consistency, and allows for tremendous efficiency within the program. We have been able to improve our outcomes, volumes, and patient satisfaction through creating an environment that is focused specifically on the needs of our bariatric population.

Our Facility
In 2007, Shawnee Mission Medical Center, now Shawnee Mission Health (SMH), is a 504-bed community hospital that is part of the not-for-profit Adventist Health System, received its designation as a Center of Excellence (COE) through the American Society for Metabolic and Bariatric Surgery (ASMBS) at the main hospital campus located at I-35 & 75th Street in Merriam, Kansas, and was recertified in 2010. During the first year, 261 surgeries were performed, and the program has continued to grow. In 2008, SMH built an outpatient facility (now SMH Prairie Star), about 15 miles west of the SMMC campus, to accommodate a growing suburban population. A full-service emergency department is located on the first floor along with a laboratory, radiology department, wound care center, and an outpatient physical therapy center. On the second floor, an ambulatory surgery center was built along with physician office space. While not part of the COE, ajustable gastric band surgeries were performed there along with minimally invasive surgeries, such as arthroscopies, cholecystectomies, and other outpatient laparoscopic procedures. The ambulatory surgery center is a joint partnership with ownership split 50/50 by a group of surgeons and SMH.

Stanley Hoehn, MD, Medical Director of the Bariatric Surgery Program since 2004, saw the potential to expand the bariatric surgery program to a single facility by moving it to SMH Prairie Star. In 2011, Hoehn moved his practice to the third floor of Building B at SMH Prairie Star, while the COE remained at the SMMC campus. In 2012, a new inpatient unit was built out on the remainder of the third floor with two inpatient operating rooms, four peri-anesthesia bays, and eight private rooms. It is 100-percent owned and operated by SMH. The result is a three-story facility that contains three separate entities—The Bariatric Center of Kansas City private surgical practice, ambulatory surgery center, and the SMH Prairie Star inpatient unit. The facility contains the following:
•    Surgeons’ offices, which also house case managers, a registered dietitian, physician assistants (PAs), a clinical psychologist, medical assistants, and office staff
•    Seminar room that holds 100 people and is used for pre-operative education classes. It also has a complete kitchen for postoperative support groups.
•    Inpatient unit with two inpatient operating rooms, four post-anesthesia care units (PACU) bays, eight private rooms, and a large family room.
•    Ambulatory surgery center with three ORs, six pre-operative bays, and 12 postoperative bays, plus six private rooms for patients to remain overnight as 23-hour observation patients
•    Laboratory, diagnostic radiology, full emergency department, and wound care center
•    The ability to transfer a patient to the SMMC campus within 10 minutes for any service not provided at SMH Prairie Star, (e.g., interventional radiology)
Our total facility capacity is 14 private rooms for bariatric surgery patients. The entire facility runs smoothly with staff in each department working together as a team.

Our Practice Staff
The Bariatric Center of Kansas City is a private practice comprised of three Board-certified surgeons, all trained in bariatric and advanced laparoscopic techniques; two PAs, three medical assistants, five case managers, a practice manager, a scheduler, a registered dietitian, a clinical psychologist, three billing staff, and front office staff. The Bariatric Program Coordinator and Bariatric Clinical Reviewer, both of whom are employed by SMH, are housed in an office next door in the patient care unit for easy access and data collection. They work closely with the Bariatric Center of Kansas City staff, the inpatient unit, and the ambulatory surgery center.

The inpatient care unit on the third floor is staffed by SMH with bariatric-trained registered nurses (RNs) at a three-to-one ratio, assisted by a respiratory therapist, pharmacist, and ancillary staff as needed. There is a radiology department and laboratory in the same building. Surgery is performed Monday through Friday, and anesthesia is present throughout surgery days until the last patient is discharged from PACU to the floor. All staff receive bariatric-sensitivity training annually throughout all facilities. The Bariatric Coordinator provides our nursing staff with specialized training at hire and annually about obesity, the surgical procedures performed, postoperative care and complications, safe patient handling/transfer, and the latest research in the field.

On the second floor, surgeons perform a number of outpatient procedures in addition to bariatric surgery, as well as the diagnostic EGDs required beforehand. The staff working with bariatric patients are all trained to care for those who have had either an adjustable gastric band placement or sleeve gastrectomy. Those patients having sleeve gastrectomy are registered as 23-hour observation and spend the night in one of the six private rooms on the second floor. The RN to patient ratio is three to one, and staff receive the same training as on the inpatient unit.

Hoehn has been the Medical Director of the program at SMH since 2004 and has performed more than 4,000 bariatric surgeries since 2000. Brice Hamilton, MD, joined the practice in 2012 from a general surgery practice where he performed band placements. He has performed over 1,000 bariatric surgeries to date. Robert Aragon, MD, is the newest member of the team, joining the practice in July of 2014 after completing a bariatric fellowship at University of California, Davis (UC Davis), Davis, California. All three surgeons have extensive training in advanced laparoscopic techniques. Between the three surgeons, a total of over 1,100 bariatric procedures were performed in 2014, almost doubling their outcomes since opening our new facility.

We are able to maintain such a high volume of surgeries with outcomes that meet or exceed benchmarks from the The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) due to the techniques that Dr. Hoehn has developed that allow him to perform a sleeve in 20 to 30 minutes and a gastric bypass in 30 to 45 minutes. The patients are under anesthesia so briefly that their recovery time is dramatically reduced, with the majority of our patients being discharged home approximately 24 hours after surgery. With lengths of stay around 1.2 days for all patients, and operative times that are half of the MBSAQIP benchmarks, we have been able to see tremendous savings in time and costs. Having the surgeons in the same building on the same floor not only allows for tremendous efficiency, but is also safer. In the event that one of the surgeons runs into difficulty in surgery, it is easy to have one of the other surgeons immediately available to assist.

Dr. Hoehn has mentored both of his partners to ensure that all three surgeons use the same techniques, resulting in the same outcomes. As a result, The Bariatric Center of Kansas City has become the provider of choice for most insurance companies in the Midwest. They also receive many referrals from other centers whose patients need revisions that other surgeons may feel uncomfortable performing. This has doubled the number of revisions done annually. Dr. Hoehn has served as a mentor surgeon for Ethicon (Cincinnati, Ohio) for the last five years, continuing to share how to improve their techniques and outcomes. Using a Steris audio/visual feed between the operating room and seminar room, we have the ability for staff and other surgeons to watch him perform surgery live and ask questions in real time.

Patient Care
Most of our patients begin their journey to surgery by attending a seminar presented by the surgeons twice a month. The seminar room holds 100 people and is consistently full with potential patients and families. We retain over 85 percent of the patients who attend. If they meet criteria for surgery, they are assigned to a case manager who will verify benefits and schedule the patient’s first one-on-one appointment with the surgeon. The case manager will also meet with them at that time to review the criteria they need to complete for surgery and provide them with a detailed educational binder written by our clinical experts that contains all pre- and postoperative information, nutritional guidelines, and activity expectations. The program criteria includes a psych evaluation, nutritional assessment, Esophagogastroduodenoscopy (EGD) with biopsy for H. pylori, relevant medical clearances, and pre-operative education class. Once criteria has been met for surgery and approval is received, the case is handed off to the scheduler who will schedule surgery and first follow-up appointment. All Roux-en-Y gastric bypass surgeries and revisions, including eroded band removals, are done on the third floor inpatient unit. Sleeves, bands, and most band removals are done either on the inpatient unit or in the ambulatory surgery center on the second floor, depending on where the insurance company authorizes payment for the surgery.

If a patient does not have benefits and wishes to self-pay, he or she will meet with the financial specialist who will review the all-inclusive cost. The financial specialist also provides them with information on Blis™ Insurance (Lake Oswego, Oregon), which is available to our patients due to our low complication rate. While we do not offer financing through the office, we do refer patients to other resources. After surgery, we are able to stay in touch with many of our patients through our Facebook page where they can find information about the date and time for the next support group, read stories from other patients, and watch videos of the licensed speakers who present for the first 30 minutes of the group.

Demographics
As one of the largest bariatric centers in the country, our demographics cover a wide geographical reach. With Kansas City located on the eastern edge of Kansas and the western edge of Missouri, many of our patients come from far outside the Kansas City area and may travel up to eight hours or more to reach us. Patients have even traveled from as far as Delaware, Wisconsin, Ohio, and all surrounding states. In order to accommodate those patients, we try to schedule as many of their appointments as possible within a day or two and allow them to complete as much of the medically supervised dieting and clearances with physicians in their hometown. They must come to our facility for their appointments with the surgeon, nutritional assessment with our registered dietitian, psychological evaluation with our psychologist, and participate in the 2.5 hour pre-operative education class.

Managed Care
The Midwest has one of the lowest reimbursement schedules in the country, so maintaining certification as a Blue Distinction Center, an Institute of Quality, a COE, and an accredited comprehensive center with MBSAQIP remains very important. We continue to be the center of choice for the majority of managed care and are one of only two centers in the state of Kansas that also accept Medicaid. Centers for Medicare and Medicaid Services (CMS) continue to refer patients to us, despite their ruling that their patients do not need to have their surgeries in an accredited center. We are hopeful that in the coming year, that decision will be reversed based on the overwhelming evidence whether surgeries are performed at accredited bariatric centers or not continues to make a difference. Even though we accept most insurance plans, we still find that most do not offer bariatric surgery benefits, are limited to one lifetime surgery, or have a lifetime cap of $10,000. As a result, we have a large self-pay population. The majority of our insured patients are required to do 3 to 6 months of medically supervised dieting, which not only costs the patient and their insurance company more money and time, but also adds one more barrier.

Achieving Accreditation Designation
SMMC began the process to COE accreditation in 2006, and was awarded accreditation in January of 2007, and performed 261 surgeries that year. When re-accredited in 2010, 481 surgeries were performed. In 2012, a bricks and mortar survey with ASMBS was done in order to transfer the COE to SMH Prairie Star, performing 653 procedures that year. The ambulatory surgery center was not included in the survey since self-pay sleeve gastrectomy surgeries are performed. The team cross-referenced the standards from the ASMBS with the MBSAQIP standards in 2013 and applied for recertification. SMH Prairie Star received designation as an Accredited Comprehensive Center by MBSAQIP in December of 2013. (Note: We do not perform surgery on patients under 18 years of age.) With the addition of more private rooms and another surgeon, the center performed a total 1,149 bariatric surgeries in 2014, with approximately 60 percent performed on the third floor and entered into the MBSAQIP database. The remaining surgeries were performed in the ambulatory surgery center. We did 58 revisions/conversions in 2014. This does not include band removals, which are performed 6 to 12 weeks before the conversion. We have found improved outcomes with allowing the patient to heal in between the band removal and next surgery. We will apply in late 2015 for re-certification in January of 2016.

Patient Adherence and Follow Up
Routinely, patients who have a sleeve or gastric bypass follow up with the PAs at one week for staple removal, and then for lab work at two months, six months, 12 months, and then annually. For bands, they are seen at one week for staple removal, then at 5 to 6 weeks for first fill, and then monthly for the first year. The surgeons performed six laparoscopic adjustable gastric band procedures in 2014 and 105 removals for slipped or eroded bands.

Long-term follow up remains a challenge, with 75 percent following up at six months, 40 percent at one year, and 21 percent at two years. All patients receive an e-mail/phone call reminding them of their upcoming appointment. Patients who miss a follow-up appointment receive an e-mail/phone call from the Metabolic and Bariatric Surgical Clinical Reviewer (MBSCR) reminding them they are due for a follow-up appointment. They are given two weeks to schedule an appointment, and then receive a phone call from the MBSCR. The staff have been able to communicate with approximately 50 percent of those patients to ask reasons for not adhering to follow up. The reasons given are as follows in order of frequency:
•    Do not live close enough to follow up with us—going to hometown PCP
•    Cannot afford it/insurance will not pay for appointment
•    Doing fine and just following up with primary care physician
•    Embarrassed to come back in due to weight regain or plateau.

These patients are informed of support group times and encouraged to attend. They are also encouraged to contact the coordinator, dietitian, or internist, who is certified in Bariatric Medicine and works with our patients before and after surgery

Support groups are provided twice monthly for patients, and a late morning weekend support group is held bi-monthly. All speakers who address the support group monthly are licensed healthcare professionals, and those sessions are videotaped. The videos are posted on the Facebook page for The Bariatric Center of Kansas City. This is also where patients who want to share their journey can post their stories along with before and after pictures. Topics offered range from nutrition (how much protein is enough versus too much) to hypnotherapy to reduce cravings and stop smoking. The dietitian held one session where the group sampled different bariatric protein shakes and vitamins and has used a kitchen to show how to make quick and healthy meals. In 2015, the group asked us to address weight regain and stalled weight loss, so an entire series has begun this year to address that need. We also have an off-site exercise class with an exercise physiologist who works with a small group of our patients to assist with weight regain or plateaus.

Equipment and Technologies
All departments at SMH Prairie Star have state-of-the-art equipment to care for bariatric patients, including the emergency department, radiology, laboratory, the ambulatory surgery center, and the entire third floor. The surgeon’s office is completely equipped to manage patients up to 600 pounds. Wheelchairs with capacities of both 450 and 700 pounds are shared throughout the building, and all waiting rooms accommodate patients up to a minimum of 500 pounds. The operating room tables handle 1,000 pounds static.

A Unique Facility
By providing patients with one location for our entire program, our center has achieved patient satisfaction scores that are consistently high. The most common comment we hear is, “This whole experience has been excellent.” Our staff loves working at the SMH Prairie Star campus and enjoy the team atmosphere, which is reflected in their care. We are already looking to further expand our bed capacity as we continue to grow and provide more resources for our patients. To read more about our center, please visit http://www.kcbariatric.com or http://www.ShawneeMission.org.

FUNDING: No funding was provided.

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

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Category: Bariatric Center Spotlight, Past Articles