The Center for Surgical Weight Management at Gwinnett Medical Center Duluth
by Debra Proulx, RN, BHS, MBA, CBN
Debra Proulx, RN, BHS, MBA, CBN, is the Director of Bariatric Services for Gwinnett Medical Center. She currently serves on the ASMBS Integrated Health Clinical Issues Committee.
Bariatric Times. 2013;10(10):26–29.
Welcome to the Center for Surgical Weight Management at Gwinnett Medical Center Duluth
The Center for Surgical Weight Management (CSWM) is a comprehensive, hospital-based program of Gwinnett Medical Center-Duluth (GMC-Duluth). The program provides patients with an exit strategy from obesity through laparoscopic adjustable gastric banding (AGB), sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Conveniently located in metro Atlanta, the program serves the residents of Gwinnett county and surrounding areas. CSWM’s humble beginning started in the summer of 2009 with the partnership of the hospital and bariatric surgeon, Robert Richard, MD, FACS. The Director of Bariatrics, Debra Proulx, RN, BHS, MBA, CBN, joined the program in January of 2010, which was also when the very first patient was seen in the clinic. The first surgical cases were performed in March 2010. Since that time, CSWM has grown into a highly respected program in the patient and medical community, housing most services under one roof. GMC-Duluth, along with a generous community donor, committed to a one-million dollar facility renovation to house the CSWM team and many of its collaborative providers. The renovation was completed in August of 2012 and additionally houses the sleep center, behavioral health services, nutrition services, and massage therapy.
While CSWM enjoys all the support services from the entire hospital system, all surgeries are performed at Gwinnett Medical Center–Duluth. The bariatric team chose this facility because it combines a quiet, healing environment with the latest in medical technology. The 31-bed surgical floor features private, spacious patient rooms and comfortable family suites. Currently, there are five rooms dedicated to the bariatric program.
Our Staff
The leadership of CSWM is shared by Dr. Robert Richard, Medical Director, and Debra Proulx, Director of Bariatric Services. Both have extensive experience in program management and design. The program uses the expert services of an engaged multidisciplinary team. Three registered dietitians, who specialize in diabetes management and medical and surgical weight loss, meet with patients individually pre- and postoperatively in the clinic during the surgeon visit. There are four behavioral health specialists associated with the program. One is a licensed clinical psychologist who is employed full time by CSWM. She oversees the entire support program in addition to counseling patients individually. Two of the behavioral specialists are independent psychologists who share an office in the center and perform all preoperative psychological assessments. The fourth is a cognitive behavioral health therapist who teaches some of our life coaching classes and sees patients for individual counseling in the center as well as in his private practice.
Our exercise specialist evaluates all patients preoperatively and designs individual exercise plans to meet patients’ needs along the journey to better fitness and health. The program employs a full-time financial counselor who is responsible for the entire insurance approval process. He also meets with each patient before surgery to review insurance requirements and payment responsibilities. Two certified bariatric nurses comprise the clinical team. One registered nurse (RN) is a nurse clinician who helps with clinic patients, is responsible for all hospital staff education, and sees all patients in the preoperative area on the day of surgery. This nurse also serves as the hospital staff resource for clinical questions relating to our patients or other bariatric patient-related clinical concerns. Our second RN facilitates the majority of the clinic responsibilities. She helps process new patient applications and verifies each patient’s medical history. She is also cross-trained to cover for our nurse clinician at the hospital when needed. Both nurses are involved with process improvements for clinical care and research. They also perform gastric band adjustments and lab draws in our clinic.
Two front office coordinators complete the team. The front desk coordinator is our front line face for the program. Her strong customer service skills and welcoming attitude help patients feel comfortable when they arrive at our clinic. She is the main contact for potential new patient e-mail and phone inquiries. Additionally, she registers all patients, collects patient fees, and schedules most new patient appointments. Our business coordinator assists with the front desk responsibilities, schedules most postoperative appointments, assists with financial counseling, insurance preauthorizations, and is the patients’ resource for hospital billing questions. Both are cross-trained to perform insurance verifications. All front office team members undergo sales and marketing training to better understand a potential patient’s motivation for contacting our program and to help focus answers to meet the patient’s need.
Our Facility
The CSWM is located in a newly renovated, 12,000-square-foot space on the Glancy Campus of Gwinnett Medical Center-Duluth in Duluth, Georgia. This new space was designed specifically to meet the needs of bariatric patients up to 700 pounds. The design of the new clinic incorporates warm colors and comfortable furniture in a spa-like environment. Our independent massage therapist helps patients treat themselves to a therapeutic or relaxing massage right before or after their appointment with the surgeon. A very popular area of our center is the clothing closet. It was developed by and is maintained by our patients. It helps patients minimize clothing costs during the period of rapid weight loss. Men and women fashions are always stocked appropriately for the season. Associates of Gwinnett Medical Center as well as patients donate clothing of all sizes to meet everyone’s needs. Our center has four classrooms, each with different space capacities, to accommodate the expansive educational classes we offer at no charge to our patients. An exercise room with a special flooring and cooling system also gets plenty of use for our belly dancing and line dancing classes. A state-of-the-art “Eating Well Kitchen” was also included in the construction project. Visiting chefs present quarterly cooking classes to our patients. Our dietitians use the space to record their video series on how to prepare mouthwatering, healthy recipes.
Gwinnett Medical Center-Duluth can accommodate patients up to 1,000 pounds with the use of portable and overhead lifts, wider wheelchairs, bariatric beds, recliners, walkers, toilets, gowns, and other items specifically available to safely meet the needs of our associates and patients. All waiting rooms and other clinical areas of the hospital are also equipped with bariatric chairs and recliners needed to accommodate bariatric patients.
An Accredited Center
In just two short years after our first surgical case, we qualified for the American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence (COE) accreditation. At that time, we also elected to pursue the American College of Surgeons (ACS) Level 1 Accredited Center deignation. Our site inspection occurred in November of 2012 at which time we succeeded in achieving this prestigious accredited status. Since the merging of the ASMBS and ACS programs, we will renew our accreditation under the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) when appropriate.
This has opened the door for us to significantly help more people in our community meet their weight loss goals.
Patient Adherence and Long-term Follow Up
We share the same belief and determination of our bariatric colleagues that adherence to program guidelines and long-term follow-up are essential to the health and well-being of our patients. If a patient misses an appointment, we call him or her in an attempt to reschedule. If we do not hear back from the patient, we send a letter from our surgeon requesting that they please follow-up with us. If there is still no response, our nurses attempt to call and obtain a health information update and try to explain the importance of regular follow-up visits. These nurse calls do not take the place of an office visit, but serve as an opportunity for our nurses to triage the patient, looking for any clinical issues that may be occurring. We also track a patient’s attendance at all of our educational classes or patient celebration events and ask him or her to complete a questionnaire on his or her health. We also use this opportunity to educate, support, and re-motivate the patient into returning for follow-up.
Comprehensive Support Program
Since our CSWM leadership has been working in the bariatric surgery field for more than two decades combined, the importance of support both before and after surgery has been a focus of this program. It is essential that we keep our patients engaged and supported throughout their journey. We provide most of our support services at no cost to our patients. This helps to remove the financial barrier, which can be an obstacle for many patients. We provide patients with unlimited access to ongoing care and support.
Services we offer include the following:
• Support groups to meet the diverse needs of the patients in our program. Support groups include a main group for all stages of weight loss, a support person’s group, an adjustable gastric band group, a men’s group, an alumni group, and a lunch and learn group for associates of Gwinnett Medical Center.
• Life coaching classes. Classes are led twice monthly by one of our behavioral health specialists. Some of the class topics include the following: “When Hunger Returns,” “Coping with Food Loss,” “Freedom from Emotional Eating,” “Self Compassion,” “Communication,” “Managing Expectations,” and “Stress Management.” We continuously evaluate the needs of our patients through surveys and personal interactions then develop programs around those needs.
• Strive program. Strive program is a six-week program for patients who are not meeting their two- or three-month postoperative weight loss targets. Our program established postoperative weight loss targets for each surgery at one, two, three, six, nine, and 12 months. Patients are monitored closely to evaluate their progress, and early intervention is suggested when the goals are not being met. We have found it more successful to intervene early in the weight loss process when patients are still highly motivated and committed. This is a six-week program that incorporates nutrition, exercise, and behavioral health interventions, along with weekly homework assignments and accountability.
• Physical activity classes. We offer a “Moving On Down” exercise class, belly dancing, and line dancing.
• Nutritional workshops. Nutritional workshops are offered each month for all postoperative patients.
• Individual behavioral health and nutritional counseling.
• Cooking classes in our Eating Well Kitchen.
• Educational and interactive webinars.
• Patient newsletter. All multidisciplinary team members contribute articles that include tips and targeted education on how to successfully navigate their journey.
• Massage therapy services. Massage therapy services are located within our clinic. Fees are significantly reduced for our patients.
• Bari Angels. Bari Angels is a group of alumni who volunteer their time to support newcomers going through the weight loss surgery process.
• Discounted meals. We offer patients discounted meals in our cafeteria and provide a special menu card.
Managed Care
Navigating the land of insurance verifications and approvals is at times challenging, especially when insurance company representatives provide conflicting requirement information. Many times, several calls and speaking to several representatives do not yield accurate answers. When this happens, our financial coordinator will file for a pre-determination to identify the exact criteria. We have been successful several times where the patient’s case was pre-authorized through the pre-determination process without submitting any additional supporting documentation. This pre-determination process helps to clarify the patient’s specific insurance requirements and prevents surgery delays due to inaccurate information. Even with early approval, patients must still meet all program requirements prior to surgery.
Our claims are filed “clean” with all the supporting documentation required. At times, despite our best efforts, a claim will be denied. When this happens, our first action is to schedule a peer-to-peer review. If that is not successful, we either appeal on the patient’s behalf or send the claim to Obesity Law for further remediation. We are noticing an increase in the number of insurance companies who require a three- or six-month supervised diet. To eliminate insurance denials for incomplete documentation of this requirement, we provide patients with the forms for their physicians or our dietitian to complete at each visit.
We are strong advocates for our patients and provide them with the commitment that we will not give up on helping them achieve their goal for better health. Having an experienced financial coordinator who is committed to the insurance approval process and who shares this mutual goal with the patient is an asset to any bariatric program.
Scheduling and Inventory
At CSWM, the clinical and nonclinical staff are responsible for managing their own inventory needs and to remain within budget targets. The operating room team at Gwinnett Medical-Duluth employs a general surgery/bariatric resource nurse to manage the surgical inventory for our cases. The CSWM RNs schedule all surgeries and alert the hospital team, through our computerized scheduling system, of the need for any special bariatric equipment, such as a bed or walker.
CSWM uses a bariatric-specific electronic medical record (EMR) software program to keep the team organized and efficient. This software program also allows for conducting specialized reports to identify efficiencies or inefficiencies in patient flow and new patient acquisition. It allows us to easily monitor our clinical outcome performance and to benchmark against national standards.
Patient Assessment
To prepare our patients thoroughly for surgery, there is a series of mandatory appointments and classes that our patients attend. All patients are asked to watch our online seminar as entry into our program. After the initial surgeon consult, a patient must then complete a psychological assessment, nutrition consultation, and a fitness evaluation. At times, other medical clearances are necessary, and our nurses assist patients with obtaining appointments. Additionally, patients must attend a support group and preoperative educational workshop. The preoperative workshop helps patients to better understand what to expect during their hospital stay, including, but not limited to, walking the evening of surgery, using the incentive spirometer, and patient-controlled analgesia (PCA) for pain control.
At the initial consultation, we schedule a tentative surgery date with the patient. To help keep our patients on track for this date, our multidisciplinary team meets weekly to track all pre-operative patients in our pipeline. We review each patient’s progress to ensure that we have or are receiving all the required clinical documentation and attestations for surgery. We also determine any specific preoperative needs a patient may have and help to develop a plan to better prepare him or her for surgery. This team meeting has proven to be essential for collaboration and communication.
Patient and Staff Safety
Associate and patient safety is of utmost importance. We require all associates to undergo sensitivity education at new employee orientation. We also educate all clinical associates on the importance of safe patient handling on the various lifting equipment and proper body mechanics. Recently, we hosted an all-day workshop with one of the industry leaders of safe patient handling of morbidly and super obese patients. Our physical therapy and nursing teams learned numerous excellent techniques to safely mobilize the patient with morbid obesity.
Staff Training
All nurses who care for our bariatric surgical patients are required to attend our presentation “Nursing Considerations for the Bariatric Surgery Patient.” This in-depth presentation includes anatomy of each surgery, potential complications along with signs and symptoms, nursing considerations specific to each surgery type, and photos of normal and abnormal radiologic findings.
Additionally, our CSWM nurse clinician presents bariatric updates and case studies at staff meetings of surgical services, surgical floor, intensive care unit (ICU), and emergency room departments. She has also developed a hospital intranet page where she posts clinical policies/protocols, available equipment and location, along with many other resources for use by the hospital team. She also maintains a bulletin board in our associate hallway highlighting the progress of many of our patients. This helps to keep the hospital team connected to our program and stay updated on the progress of the patients they cared for.
Emerging Trends
Every few months, we scan the bariatric landscape to stay informed of the latest techniques and new bariatric surgery procedures. We review and discuss the clinical research and determine if we want to add the procedure to our program offerings. We are currently performing some of our gastric bypass operations using the daVinci robot (Intuitive Surgical, Inc., Sunnyvale, California). In our competitive market, we must ensure that we stay current with the latest techniques and evaluate each for its effectiveness and value to our patients.
Our hospital-based program is known among others in the industry for our streamlined patient entry initiatives, efficiencies of patient flow, creative marketing techniques, and our high rate of insurance approvals. In November of 2011, we implemented an online seminar and have seen tremendous results in the number of patients entering our program on a steady basis. We no longer experience the ebb and flow that comes exclusively with live seminar attendance. Patients who do not have access to the internet or who are not internet savvy are scheduled time in our clinic to view the online seminar in the comfort of our private conference room equipped with a large screen TV and comfortable bariatric seating.
Offering a fast-track option of program entrance and movement to surgery is a highly popular patient request and one that we just recently implemented as an option. If a patient is self-pay or has a certain type of insurance coverage, scheduling surgery within 30 to 45 days of the initial consultation is possible. This option requires a highly motivated and medically uncomplicated patient. Patients are still required to meet all program requirements, and no short cuts in care are taken. Achieving a high level of program process efficiencies has made this option available to patients entering our program.
Our Facebook page is active. We post updates several times per week, including pictures and educational information. This site is mainly used by our current patients for peer-to-peer support. Keeping patients connected to our program is critical to maintain and sustain these important relationships.
We are in the process of developing our physician led medical weight management program. This will serve to augment the surgical services and help establish us as a full service weight management program. With the infrastructure of support already in place through the bariatric surgical program, we can modify some of the support service classes and groups to meet the needs of the nonsurgical patient.
A Unique Facility
We are a unique facility because we are a hospital-based program with significant hospital administration and board support. Our medical director is a highly skilled and dedicated surgeon providing our program with excellent clinical outcomes. In 2012, we had zero-percent occurrences for all the following: Deep vein thrombosis (DVT), reoperations, leaks, and mortality from surgical complications. These stellar outcomes have earned us the respect of the medical community, subsequently increasing our physician referrals. We are fortunate to have generous community donors who helped make our newly renovated facility a reality for our deserving patients. We embrace technology and have mastered efficiency of the patient entry into our program and the process to surgery. We serve as consultants to our bariatric program peers on how to improve patient volume and efficiencies. We have a highly engaged team who all embrace the vision for the long-term direction of our program. The CSWM program is truly committed to the success of our patients and provides one of the most comprehensive patient support programs in this industry. We strive to develop, cultivate, and maintain long-term relationships with our patients to help them achieve their goals.
Photos from the Center:
Photo 1
Category: Bariatric Center Spotlight, Past Articles
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