Bariatric surgery patients need long-term support

Case managers follow them before and after surgery

Bariatric surgery works wonders, but it's not a miracle cure. That's why insurers and hospitals alike take pains to make sure their patients are prepared for the surgery and the lifestyle changes it requires.

"I make it clear to the surgical patients that they're not going to get out of diet and exercise. The surgery is a tool to allow diet and exercise to work for them," says Pamela Davis, RN, CCM, clinical coordinator for bariatric surgery at Baptist Metabolic Surgery Center of Baptist Hospital in Nashville, TN.

Davis, who underwent laparoscopic gastric bypass surgery in 2001, understands firsthand the challenges that her patients face.

Weight loss surgery can have a positive effect on the disease process, Davis points out. "We see patients who come in taking 60 to 100 units of insulin and they go home on a low amount or no insulin," she says.

Case managers working together on the payer and facility side help the patient ensure the long-term success of weight loss surgery, she says.

There are three types of metabolic surgery:

Laparoscopic adjustable band

This laparoscopic procedure is the least invasive form of surgery and involves placing a band around the upper part of the stomach. The patient receives an access port that is used to periodically inject saline into the inner portion of the band to restrict the amount of food the patient can take in. It typically takes three to four saline injections to achieve optimal results.

Gastric bypass

This surgical procedure, typically done laparoscopically, creates a small stomach pouch and bypasses part of the small intestine. This results in restriction and a mild degree of malabsorption of food.

Duodenal switch

This surgery, usually done by open incision, removes a portion of the stomach, leaving room for about eight ounces of food at a time and provides a higher degree of malabsorption of food.

"In the health care field, we tend to think that once we've fixed the problem, the patient doesn't need us. Patients with morbid obesity can flip into their old habits at any time. We need to support the patients for a lifetime to make sure they maintain the weight loss and prolong the health benefits," she says.

Davis works with bariatric surgery patients through the entire process, beginning with the new patient seminars the surgery center presents for patients considering weight loss surgery.

The session typically takes one to three hours and includes details from a surgeon on the various types of surgical procedures. Davis talks to participants about the steps they must go through, dietary and other lifestyle changes that will be necessary after surgery, and what is expected of them as patients to make the surgery successful.

For instance, patients who have weight loss surgery must give up carbonated beverages and must make changes in their eating behavior such as not drinking with meals and eating carbohydrates last.

Depending on the type of surgery they have, patients have to take vitamin and mineral supplements to compensate for what their body will no longer absorb.

Patients leave the seminar with packets of information about the criteria for eligibility and the process leading up to surgery, which can be lengthy depending on their insurance company's approval process.

At Baptist Metabolic Surgery, like other bariatric centers of excellence, patients are required to have a psychological evaluation before surgery.

"We need to make sure they are capable of understanding the lifestyle changes they must make and the long-term effects of surgery. If food is how they handle emotional issues, they may need help in developing other coping mechanisms," she says.

When the patient makes the decision to have surgery, Davis starts the educational process of case management and makes sure patients attend support groups and educational sessions before the surgery.

"It's important to take things slowly. It takes time for the patients to make the mental preparation and time for them to get used to the dietary changes," she says.

The insurance coordinator in the metabolic surgery program works with the insurance company to make sure the documentation is in place.

"Once we know the insurance company will cover the surgery, we help the patient collect the information to submit to the insurer," she says.

Typical requirements include a letter of referral from the primary care physician, documentation of weight loss attempts in the past few years, and a five year history of morbid obesity.

Davis meets with the patients to educate them on the lifestyle changes required for an optimal outcome from surgery. She is available by telephone to answer their questions in between visits.

"We see our patients multiple times for the first two years after surgery and at least once a year after that," she says.

When patients move out of state, Davis continues to follow them by telephone. She gets the results of their annual check-up and discusses it with them.

"We help support the patients in maintaining their weight and other long-term outcomes. I work with them to make sure they're not struggling with weight gain," she says.

Davis encourages the patients to continue taking their vitamins and follow their treatment regimen to avoid side effects such as fatigue and itchy skin.

"Once they start feeling good, they may think they don't need their vitamins. These patients need long-term support," she says.

Case managers in the insurance field whose clients include bariatric surgery patients, should make their own resources book, Davis recommends. She suggests asking the centers of excellence within your state for educational materials to keep on file.

"If insurance case managers have all the educational materials from the hospital where the surgery was performed, they can better help patients follow the recommended treatment regimen," she says.

For instance, if a patient isn't taking iron, the case managers can point out where the requirement is listed in the educational material and find out if the patient isn't taking the iron because he or she can't afford it.

When members of BlueCross Blue Shield of Tennessee are referred for bariatric surgery, their care is coordinated by an insurance case manager certified in bariatric surgery, who reinforces the education the member is receiving from the surgical team, says Jackie Flowers, RN, CCM, manager in total health management.

The case managers spend a lot of time on the telephone with members before the surgery to make sure they understand the process and to help them prepare for the surgery and the lifestyle changes that must occur, she adds.

"We emphasize that bariatric surgery is not an easy fix. Members need a lot of education to make sure they are committed to being compliant with the diet and exercise program they must follow," Flowers says.

The health plan conducts extensive evaluations of the member to make sure that he or she is a good candidate for surgery, adds Nancy Alsgard, RN, managing director of medical clinical strategy.

"Bariatric surgery is a major procedure and we take it very seriously. We are absolutely committed to assuring safety and success. We look at the members very critically to determine if they are prepared to make lifestyle changes in order to retain the long-term health benefit," Alsgard says.

The health plan's case managers follow the members by telephone for at least six months after surgery to make sure they understand their post-operative instructions and that they are complying with the exercise and dietary regimen.