Spotlight on the Obesity Treatment Center at Catholic Medical Center Manchester, New Hampshire

Spotlight on the Obesity Treatment Center at Catholic Medical Center
Manchester, New Hampshire

by Alison Olsen, MS, PA-C

Ms. Olsen is Physician Assistant, Catholic Medical Center, Obesity Treatment Center/NH Surgical Specialists, Manchester, New Hampshire.

Bariatric Times. 2011;8(1)22–25

Welcome to the Obesity Treatment Center and New Hampshire Surgical Specialists at Catholic Medical Center
The Obesity Treatment Center (OTC) at Catholic Medical Center (CMC) has seen tremendous growth since its start in 2003. From expanded, newly renovated space to a growing staff, the OTC strives to meet and exceed expectations, as well as the demands of a population in need of our services. The OTC and CMC are very proud of the hard work that went into becoming one of the only American Society of Metabolic and Bariatric Surgery (ASMBS) Centers Of Excellence (COE) in New Hampshire.

Our staff
Dr. Connie Campbell is the Surgical Director for for the OTC and has her own practice, New Hampshire Surgical Specialists. She started the program in 2003 and has performed nearly 1,000 surgeries since the program’s inception. Operative procedures include da Vinci® robotic (Intuitive Surgical, Inc., Sunnyvale, California) and laparoscopic gastric bypass, Lap-Band® (Allergan, Inc., Irvine, California) and laparoscopic sleeve gastrectomy. Dr. Robert Catania of the Surgical Care Group joined the program in 2009. He performs Realize® (Ethicon EndoSurgery, Inc., Cincinnati, Ohio) gastric band, laparoscopic gastric bypass, and laparoscopic sleeve gastrectomy procedures.

Drs. Campbell and Catania practice in separate offices, but both operate at Catholic Medical Center (CMC). The Obesity Treatment Center (OTC) is part of CMC hospital.

Jacquie Cuddihy, RD, is the Program Director for the Obesity Treatment Center program. Among her many duties as director, she also runs pre- and postoperative support groups and new patient information sessions bimonthly about the program.

Primary Care Physician and newly appointed medical director, Diane Snow, MD, has taken a very active role in ongoing program development. Dr. Snow evaluates all patients preoperatively for medical optimization and follows high-risk patients postoperatively for medication and disease management.

We have three physician assistants and one ARNP. Alison Olsen, PA-C, was previously employed at Tufts/New England Medical Center and Cornell Weight Loss Center. She works full time between OTC and NH Surgical Specialists. Monica Ball, PA-C, works in primary care full time and with the OTC and NH Surgical Specialists part-time. Carrie Fontaine, PA-C, works full time with NH Surgical Specialists, and is the first assistant in the operating room. Jessica Dumais, ARNP, works in primary care full time and in the OTC part time. All mid-level providers assist in pre- and postoperative evaluation and care, including Lap-Band adjustments, wound care, and lab monitoring.

Registered Dieticians, Deb Freeman, Valerie Chames, and Chris Lauer, provide pre- and postoperative nutritional counseling and education in group and individual settings.
Our administrative staff members multitask the various administrative duties of scheduling, billing, charts, and insurance. Lisa Lemay, Sharon DeSantis and Jenna Mara are administrative assistants at the OTC. Nancy Shultz and Cheryl Avila are administrative assistants at NH Surgical Specialists.

We have two medical assistants, Laura Stevens (at the OTC) and Carolanne Skerry (at NH Surgical Specialists), who support the various providers in the office and help the offices run smoothly. We also have two exercise physiologists, Denise Houseman, MS and Michelle Keenan, MS who do exercise evaluations in order to develop individualized exercise plans for all preoperative patients.

Our Bariatric Facility
The OTC at CMC is newly renovated. We continue to grow and expand. We have two new exam rooms, equipped with bariatric scales, exam tables, gowns, and cuffs and six office rooms for the doctors, physician assistants, and registered dietitians. We also have a new group room to hold nutrition classes, support groups, and other meetings. We have a new waiting area with bariatric chairs, educational materials, and a billboard for success stories along with pictures. We are already planning to expand and create 1 to 2 more exam rooms and additional office space.

NH Surgical Specialists moved into its new medical office building at CMC (Notre Dame Pavilion) in December 2008 and has five fully equipped bariatric exams rooms, a minor procedure room, and a waiting room with bariatric chairs and benches.

CMC has bariatric chairs in appropriate departments, including radiology, endoscopy, sleep center, and admissions. All “expanded-capacity” seating is labeled “EC” throughout the hospital. Bariatric beds, gowns, and extra-wide wheelchairs are available throughout the hospital and specifically on the inpatient floor where all bariatric patients are admitted. All bariatric patients go to the cardiac unit and are monitored closely by nurses trained and educated to routinely care for our patients.

The new operating rooms at CMC were completed in 2007. They offer state-of-the-art laparoscopic equipment and two DaVinci robots. The surgeons work with designated anesthesia and operating room nursing staff who are familiar with the bariatric surgeries, equipment, and patient considerations.

Patient Demographics
For the last two years we have averaged approximately 250 cases between the two surgeons annually.

We are seeing a shifting trend between laparoscopic adjustable gastric banding and gastric bypass. In 2009, 73 percent of surgeries performed were gastric bands and 27 percent were gastric bypass. So far, for 2010, 65 percent of surgeries were bands and 35 percent were gastric bypass. Our patient population is about 80 percent women and 20 percent men. Our patients come from all around southern New Hampshire and the greater Manchester area. We also have many patients who travel from the Concord and Laconia areas, and some as far as three hours north.

An American Society of Metabolic and Bariatric Surgery Surgical Review Corporation Center of Excellence
The process of submitting our center to be considered as an ASMBS Surgical Review Corporation (SRC) Center of Excellence (COE) was long and challenging at times, but overall it enhanced our program, center, and hospital environment. The training involved for all hospital staff was necessary and long overdue since bariatric patients are seen in all specialties throughout the hospital— not just through our service at the OTC. The Bariatric Outcomes Longitudinal DatabaseSM (BOLD) process has been challenging as well, but it is getting easier as we troubleshoot some of the hurdles within the program. The clinical pathways involved the most work and coordination among staff and departments. We did several mock “walk-through” tours of the hospital to be sure staff and equipment were appropriate to meet the SRC standards. CMC Hospital was committed to the process and has been supportive of the program growth and commitment to achieving the COE designation.

Some potential patients do ask about our designation as a COE. We have also been marketing the program and our COE designation to make the public more aware. We have had many patients referred by their insurance carriers or other programs that are not a COE.

Adherence/Long-Term Follow up
Patient adherence is something to which we are very committed and about which we feel strongly in order to help optimize our patients’ success. All staff emphasize and educate patients on the need to commit to lifetime follow up with the OTC. All patients are required to schedule a follow-up appointment before they leave either office at OTC and NH Surgical Specialists after every visit.

Preoperatively, staff members explain to patients at their initial appointment that follow up is expected every 4 to 6 weeks with one of the OTC providers (PA, NP, MD, or RD) until they are ready to have a consultation with the surgeon. Patients are called to reschedule if they miss an appointment. Patients are also required to sign a “Patient Right and Responsibilities” contract entering the program. The listed items on the contract include commitment and adherence with pre- and postoperative follow-up appointments. It also states that if a patient has three or more “no-shows,” he or she will be required to start over in the program.

Postoperatively, all patients are called to reschedule if they miss an appointment. If they are not heard from after the initial phone call, an additional call is made two weeks later. If the patient still has not called the office, a letter is sent to remind them to reschedule their appointment. An audit is run every six months to track patients who have not been seen in the last six months. If they have not been seen in either office, then a certified letter is sent to them. We also try to keep the primary care physicians (PCPs) informed of patient progress and the need for continued follow up with both the OTC and NH Surgical Specialists. Hopefully, the PCPs will also remind long-term patients to return to us for ongoing follow-up care.

We have support groups that meet monthly, and we strongly encourage patients to get involved. Dr. Connie Campbell has also created a Facebook page to allow patients to network and provide support and encouragement to each other. Patients can post success stories and discuss their journeys before and after surgery. Patients have also organized a clothing swap through the site.

We hosted our first annual “Get Out and Move” fitness walk in September 2010. Our goal is to host the first New Hampshire “Walk From Obesity” in 2011. We had great sponsorship from vendors, and more than 80 patients participated.

Complications of Patient Adherence
The biggest complication with patient adherence is long-term follow up. Within the first two years, we have good postoperative follow up. The percentage of patients that follow up at five years drops off. Some patients stop follow up due to nonadherence, others because they have gained weight and feel embarrassed. Some patients do not understand the need for lifelong follow up, especially when they feel they are doing well. We strongly encourage more frequent follow up with the staff when patients are feeling challenged. Unfortunately, lifestyle and environment pose an added challenge to patients who struggle to control their weight long term. Temptations, hectic lifestyles, and time management are all obstacles patients continue to face. Our staff is committed to help support and guide patients through difficult times. Sometimes, this may involve mental health counseling, more intensive nutritional counseling, or a return to behavioral change class. We have recently offered a graduate behavioral change class run by the mental health providers that deals with some of the other challenges patients face, titled “Change for Good.” We have had a number of our postoperative patients participate who found it to be helpful.

Patient Care
Patients are first required to attend our program’s information session offered twice a month by our program director, Jacquie Cuddihy. At this session, patients are presented with an overview of our program, including tests, appointments, weight loss requirements for surgery; the surgery types, including risk, benefits, complications; and insurance considerations. Time is allowed for a question-and-answer session. Patients are given a comprehesive packet that must be filled out and submitted to the center, along with a recent history and physical, labs, and other pertinent testing (e.g., sleep studies, cardiac testing, pulmonary testing) from their PCP.

Patients are then scheduled for three appointments: 1) a history and physical with the PA or ARNP, 2) an initial nutrition intake appointment, and 3) an appointment with the exercise physiologist for an exercise evaluation.

At patient history and physical appointments, the preoperative requirements are clearly discussed with the patients and all pertinent testing is ordered (e.g. sleep study, labs, electrocardiogram [EKG], cardiac testing, and any radiology studies). Patients are required to lose either 5 or 8 percent of their weight preoperatively, depending on procedure type. They are also required to begin exercising at least five times per week and attend a follow-up appointment with the exercise physiologist to assess their progress. Patients must stop smoking 2 to 3 months prior to surgery and are required to pass a urine nicotine test before their surgical consultation.

Patients are required to attend a six-week behavioral change class, “Lifestyle Change,” that is run by the mental health specialists. The class focuses on mindful eating, emotional triggers, and stress reduction, among other topics.

Patients are required to attend at least two preoperative support meetings. These meeting are run by our program director and focus on various preoperative topics. Postoperative patients are always present to help answer questions as well.

Patients are also be seen by our medical director, Dr. Snow, at least once for preoperative medical optimization prior to being cleared for a surgical consultation.  Her focus is to ensure that patients’ various comorbidities are adequately controlled as they are getting closer to a potential surgery date. A member of OTC continues to see the patients every 4 to 6 weeks in preparation for surgery. At each appointment, education is ongoing. We review the procedure type, expectations, and answer any questions. We also help guide patients in selecting the most appropriate procedure based on their body mass indeces (BMI), comorbidities, and expectations. The dietitians begin educating the patients on the postoperative diet progression and necessary supplementation requirements.
Each patient chart is thoroughly reviewed for completeness prior to scheduling a consultation with one of the surgeons. It is not until all requirements are met that a patient will be cleared to schedule a consult with the surgeon.

Prior to surgery consult, patients are required to watch either the Emmi,® a 30-minute, interactive presentation about the Lap-Band System or an online video education program about gastric bypass.

The surgeon then meets with the patient to review medical history and procedure type, including risks, benefits, and complications. The surgeon may order additional tests or labs when necessary. Surgery consent is reviewed and signed. A surgery date is then scheduled if the surgeon determines that the patient is “optimized” and demonstrates readiness.

Once a surgery date is given, the patient is scheduled for several other preoperative appointments. These appointments include a preoperative weight check and medication review with one of the PAs in the surgeons office. We assess adherence with continued weight loss and give prescriptions for any postoperative medications (e.g., proton pump inhibitors [PPIs], pain medications, and other medications like ursodiol). If a patient has gained weight, he or she may have to come back to the office for an additional weight check or surgery may be postponed.

Patients also have a nutrition education appointment. This is usually a group meeting to review the 1,200 low-calorie diet patients need to follow two weeks before surgery and to review the first postoperative diet phase (i.e., full-liquid diet).

New Technologies, Equipment, Devices and Products
The da Vinci surgical robot system is the latest technology utilized in our operating rooms. Dr. Connie Campbell has performed most of her gastric bypass surgeries using the da Vinci system since January 2010. To date, she has done nearly 100 cases robotically. The da Vinci surgical system offers improved ergonomics and better visualization and instrumentation. The surgeon is able to use one less laparoscopic incision (4 total vs. 5). As a result, patients have less pain and require less of their patient-controlled analgesia (PCA) and have quicker recovery and return to daily activities and exercise.

Our dietitians are trained on a metabolic testing machine called MedGem® (Microlife Medical Home Solutions, Inc., Golden, Colorado). With this technology we are able to calculate a patient’s resting metabolic rate (RMR). This allows the RDs to then guide the patient on appropriate caloric intake to lose or maintain their weight. We offer this to both pre- and postoperative patients. It can be especially beneficial with postoperative patients who have hit a weight plateau.

The exercise physiologists are utilizing the Tanita Body Composition Analyzer (Tanita Corporation, Arlington Heights, Illinois). This device allows patients to better understand their weight relative to muscle mass, water, and body fat. The exercise physiologists calculate these values at their initial exercise assessment, which is added to patient charts. Then, they repeat the body composition analysis at patient follow up to evaluate the effect of weight loss and exercise efforts. The Tanita Body Composition Analyzer generates weight, impedance, percent body fat, BMI, fat mass, and fat-free mass. Body composition analysis is also useful postoperatively in helping patients appreciate the changes in the body aside from just the weight loss.

Procedure Scheduling and Inventory Management
Surgery scheduling and booking is handled by the administrative staff at NH Surgical Specialists for Dr. Campbell and by the medical assistant for Dr. Catania. We do not utilize any software programs. Office inventory is managed by the office/administrative staff at the respective offices.

Patient Preoperative Assessment
After patients attend one of our bimonthly information sessions, they are asked to complete a lengthy packet of information regarding medical, social, surgical, and diet history. We ask them to calculate their BMI and review the National Institutes of Health (NIH) qualifying criteria to see if they are a surgical candidate. We also ask them to contact their insurance company to be sure that bariatric surgery is a covered benefit and not excluded.

At their initial intake/history and physical with one of the mid-level providers, we determine if the patient qualifies based on NIH criteria and specific insurance criteria. We also review, in detail, the changes/steps that are required to be further considered for surgery. These include the following:
1.    Psychological assessment—determines patient’s mental health stability, medication adherence, undiagnosed psychiatric illness, and need for further therapy or treatment. The psychological assessment is also performed to uncover any eating-disordered behavior (e.g., binge eating). If eating-disordered behavior is discovered, the patient is urged to seek necessary treatment. The psychological assessment determines appropriate length of sobriety from any previous drug or alcohol abuse and appropriate length of time/stability since last psychiatric hospitalization. We initiate counseling/therapy when necessary. The mental health provider also determines the patient’s stage of change in preparation for lifestyle changes expected and necessary for preoperative readiness and postoperative success.
2.    Nutritional assessment—determines commitment to changes and adherence to dietary plan developed.
3.    Participation in a six-week behavioral change class, “Lifestyle Change.”
4.    Patients must demonstrate lifestyle changes and meet their preoperative weight loss target of either 5 or 8 percent of their weight calculated at their initial visit.
5.    Patients are required to meet with the exercise physiologists twice prior to surgery. The exercise physiologist initially develops an exercise prescription for the patient, then follows up to determine their progress and adherence. We expect patients to begin some type of exercise at least five days per week before meeting with the surgeon.
6.    Patient must complete all required testing ordered, (i.e., labs, EKG, stress test, pulmonary function testing [(PFTs)], ultrasound, sleep study). If they are diagnosed with obstructive sleep apnea, they must be adherent with continuous positive airway pressure (CPAP) or bi-level positive airway pressure(BPAP) at least 2 to 3 months prior to surgery. Patients will have a follow up with the sleep center to determine adherence based on the data reading from their CPAP/BPAP machine.

It is not until patients have met all of this criteria with satisfaction that they are “cleared” to have a consultation with one of the surgeons. The surgeon will then have the final determination of anything additional needed prior to scheduling a surgery date.

Managed Care
Keeping up to date with the various managed-care guidelines can be challenging and frustrating. The insurance companies always seem to be creating more hurdles to overcome for approval. Our staff is committed to advocating for the patient and to understanding the major insurance carriers guidelines. We also keep close track of patients who have insurances requiring mandatory six-month medically supervised diet history, to be sure we comply to the requirements and clearly document their visits. Additionally, some patients are required by their insurance carrier to lose more weight than our program guidelines, which can pose an additional challenge to the patient’s preoperative progress.

Patient and Staff Safety
All appropriate staff have completed patient transportation and safety training modules as part of our COE process. This is ongoing education that is completed and updated annually. Lift and transfer protocols are provided in the floor manuals/binders as well as online on our hospital intranet website. A comprehensive list of all bariatric equipment has been compiled in a binder that is categorized by floor. This list is also available online through the hospital intranet site, which is updated regularly.

Employee Orientation/Training for Bariatric Patients
All clinical staff participated in sensitivity training as part of the COE process. This is ongoing, and mandated to be completed annually through online training and a test. This helps to create a comfortable and accepting environment for all patients, free of weight prejudice and bias. It is important to us that patients feel welcome and comfortable throughout their hospital experience, not just in the OTC. In addition, all new employees are required to complete sensitivity training and safety/transport training when necessary. Changes to clinical pathways and protocols are updated routinely, both online and in binders located on the respective floors.

Emerging Trends
We utilize social networking sites, such as Facebook, to have more accessibility to patients and encourage support among peers. This has been helpful to enhance peer relationships and help organize program events. The ability to access information, support groups, and education online through the program is an emerging trend. Allowing patients access to videos on nutritional teaching, support meetings, and information sessions will be necessary since some patients travel two or more hours to get to our center.

We are also working on creating a satellite site at a small hospital in northern New Hampshire to serve the more rural population. We believe that satellite sites for programs will become more of a trend in order to increase adherence and improve access to care in rural settings.

In terms of surgery, we recognize that the sleeve gastrectomy is emerging as another safe and effective bariatric surgical option. Patients are becoming more aware and are interested in learning more about it. It is encouraging to see the slow trend of more insurance carriers providing coverage for the sleeve gastrectomy.

CMC is in the process of changing over all departments to electronic medical records (EMR) system. The OTC is hoping to get oriented and transition to the system in spring 2011. Utilizing EMR will improve communication among providers and provide better documentation, easier accessibility to records, and assist with tracking patient data.

A Unique Facility
CMC has been supportive and dedicated to the continued growth and excellence for the OTC. From newly renovated office space to staff training and overall improvements in the hospital to address our specific patient population needs, CMC has been behind us. As a result, we have created a dedicated team of professionals from many different backgrounds and specialties to offer our patients the best care possible. We continue to strive to improve and implement new changes as trends change. We listen to our patients in order to be sure their needs and interests are met. We are all dedicated to the process and to making sure every patient achieves long-term success.

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