Cover Story: A New Way of Life

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July 2004

By Rich Smith

Steve Forbush, PT, MS, bariatric rehab program manager (standing), helps motivate a client.

Weight-loss surgeries offered at Northeast Georgia Medical Center and Health System in Gainesville, Ga, routinely delivered good results for the severely obese who underwent them. Now, outcomes are expected to be even better, thanks to the recent addition of a rehab component.

“This is rehab specifically tailored to the bariatric patient, but it is really no different from what we provide to everybody else,” insists Steve Forbush, PT, MS, bariatric rehab program manager. “For example, the bariatric patient can present with cardiopulmonary issues and degenerative arthritic changes, the same as a person of appropriate weight. In both instances, the goal is to get them out of pain and help them regain function.

“The only difference, then, is in how these patients are managed. Just to illustrate this, we can’t put an extremely obese patient on equipment intended for use by someone of half that weight. And the care can’t be cookie-cuttered; we often must radically tailor the therapy to fit the patients’ needs: some of them are not able to walk very far because of a greatly compromised cardiorespiratory system, while others can’t walk far because they’re unable to support their extraordinary weight.

“Still others don’t need to develop strength—they already possess it because the weight they carry around is so significant that their muscles are working at a very high level all the time; what they need instead is strength maintenance so that as they postoperatively lose the weight, they don’t also lose the functional ability of those muscles.”

Mary Martin, RN, MBA, director of operations in bariatric services, praises the rehab component as something that goes well beyond helping patients look and feel their best after an operation to induce the shedding of a massive amount of weight. In her eyes, it is a path to life change.

“The thing that’s most rewarding about bariatric services in general is that you often see people who come in feeling hopeless but then end up with lives dramatically changed for the better,” she says. “With rehab now part of this mix, we expect to see this kind of thing much more frequently.”

THE NEW PROGRAM
The bariatric rehab program was rolled out at the hospital this past April, even though weight-loss surgeries have been performed since the 1970s at the 50-year-old, not-for-profit, 418-bed inpatient hospital and 285-bed skilled nursing system. (In actuality, bariatric services as a formal unit of Northeast Georgia Medical Center and Health System is only a little older than the rehab component—up until 2003, bariatric patients underwent surgery in a general operating room without benefit of bariatric-trained nurses and girth-accommodating equipment, as is the case today.)

That is not to suggest bariatric patients received no rehab interventions prior to April. In fact, they did, but not in the form of therapy tied to their primary problem of morbid obesity.

“A sense had emerged that there needed to be rehab support specific to bariatric services” in order to maximize the effectiveness of the functional therapies being provided, says Forbush, a veteran therapist who had worked with bariatric patients throughout his nearly three-decade-long career. “We saw this as an opportunity to better serve not only our hospital, but also the community.”

In some hospitals, securing administrative approval to develop a new product like bariatric rehab can be a daunting challenge. Money to pay for it is one issue. The expectation of turf battles is another. However, in this instance, obtaining a green light for the rehab component proved relatively easy.

“We happen to have an administration that’s very supportive of starting new programs where there’s a demonstrated need,” Forbush conveys. “This was no exception.”

As a first step in pulling together the bariatric rehab component, Forbush recruited an exercise physiologist with experience helping the obese. He also tapped a therapist to serve as case manager. Together, these two plus Forbush constitute the bariatric rehab team. However, therapists across the enterprise—52 in all—have been undergoing in-service training to develop sufficient expertise to themselves handle bariatric patients when called upon to do so in support of the team.

Next came selection of equipment. Rather than go to the expense of purchasing pieces solely for use in the bariatric program, Forbush and his team toured the institution’s two Gainesville hospitals as well as its outpatient satellites in the locales of Buford, Cleveland, Coal Mountain, Dahlonega, and Oakwood to identify existing equipment that could be utilized by bariatric patients.

“We saved a lot of money by taking this approach,” says Forbush, “because all the equipment we expected to need was already present in our inventory. There was no need to go out and acquire extra gear.”

The trick, however, was to designate for the bariatric program only that equipment sturdy enough to withstand use by severely overweight patients.

“We went through the manufacturer details on each piece of equipment we wanted to use in the program and determined how much weight each could handle,” says Forbush. “When we completed that process, we had a list of equipment matched to specific weight ranges. If a patient weighs more than a particular machine can accept, then obviously that piece of equipment can’t be used for that patient. But that’s not the end of it. The therapist simply modifies the patient’s rehab plan by providing an exercise alternative that can deliver comparable therapeutic benefit. The alternative is left to the discretion of the therapist—she’s got plenty of decision-making autonomy to do what’s best for the patient.”

Although equipment is earmarked for use by bariatric patients, that does not give the bariatric rehab program exclusive use of those items. “It’s equipment shared among our other rehab programs,” Forbush clarifies.

Bariatric-designated equipment at the institution includes a quantity of exercise ergometers, seated and upper-extremity stationary bikes, weight machines, and a therapy pool (the pool is outfitted with a 450-pound-capacity lift for use by patients too heavy or functionally impaired to enter the water by walking in).

REHAB AND WELLNESS
Northeast Georgia Medical Center and Health System’s bariatric rehab program offers patients a choice of products. The first is wellness-oriented and intended for those who want straightforwardly to improve their general health following a bariatric procedure. It is a 100% outpatient-delivered service.

The second product is rehab, pure and simple. Provided to those who need therapy for treatment of a disability related to their weight problem, rehab is available chiefly on an outpatient basis, although it can be used in support of inpatients as needed.

“Bariatric patients typically leave the hospital within two and a half days after surgery, which doesn’t give us much time to address their rehab and exercise needs as inpatients,” says Forbush. Besides, he notes, patients are not in any shape to begin bariatric rehab so soon following the operation. “We have to wait for them to become medically stable, a status they usually don’t attain until a week or more later.”

Patients can begin accessing either of the program’s products at any point up to 6 months after surgery. And it is only the bariatric surgery patient who may partake of them. “Someone who has no intention of undergoing bariatric surgery would not be accepted into the bariatric rehab program,” says Forbush. “It’s not a stand-alone service.” Patients qualify as candidates for bariatric surgery at Northeast Georgia Medical Center and Health System if they have a body-mass index of at least 40 (35 when comorbidities exist) and are 100 or more pounds heavier than the ideal weight for their age, sex, and height.

“The majority of our patients are middle-aged and female,” says Martin in sketching the demographic outlines of the overall program. “We have some adolescents. Increasingly, we’re seeing more men.”

Whether bariatric surgery is indicated for a prospective patient is determined by means of a process that begins with an interdisciplinary assessment. Here, the prospective patient submits a detailed medical history and other relevant information, which then is reviewed by representatives from the fields of nutrition and psychology as well as rehab. This interdisciplinary assemblage subsequently makes a recommendation to the surgeons as to the advisability of a bariatric procedure. If surgery is indicated, the doctors who will perform it then meet with the patient for an at-length consultation. From there, if all goes well, a surgery date will be scheduled.

REIMBURSEMENT ISSUES
Happily, reimbursement is readily available to bariatric clients.

“It reimburses as well as any other rehab service for which we bill,” says Forbush. “So far, we’ve found no third-party payor unwilling to reimburse for bariatric rehab. The reason is that the rehab is a medically necessary service for those patients coming into the program.”

It is a different story for the patient participating in the wellness-oriented rehab product.

“In this situation, there is no insurance reimbursement; it’s entirely self-pay,” Forbush tells. “However, it’s reasonably priced. The fee we charge is $50 a month.”

Northeast Georgia Medical Center and Health System markets its bariatric service to referring physicians and consumers within a 20-county radius of Gainesville. Even so, because the surgeons who perform the procedures are nationally known, the bariatric program draws patients from across the South and, occasionally, even as far west as California.

About 500 patients underwent bariatric surgery at the hospital in 2003, and at least that many are expected again this year. Of those who since April have undergone the procedure, only a relative handful have requested admission to the fledgling rehab program. Forbush is nonetheless optimistic that the number will rise dramatically as the months pass and word of what is offered spreads.

“Based on national trends, our expectation is that somewhere between 10% and 30% of our bariatric surgery patients will avail themselves of our rehab products,” says Forbush. “So, we’re looking for anywhere from 50 to 150 patients a year once we hit our stride. Our facility capacities at the two hospitals and all the satellites are such that we can accommodate as many as 300 patients a year.”

No matter how it ultimately shakes out, Forbush expresses confidence the program will be well utilized and prove to be popular.

“The purpose of this program is to help our bariatric patients get out of pain and make the necessary changes—lifestyle and mental—that could otherwise discourage them from continuing down the weight-loss path they’ve chosen,” he says. “Our view is that, if we can get these patients to be more functional, they’ll do much better with activities of daily living and, importantly, with maintaining the weight loss.

“I don’t have a grand vision for how big this program will become; I have no big goals for it. I want simply to meet the needs of this patient community within the context of the service industry we’re in. It’s a need that deserves to be met.”

Mary Martin, RN, MBA

A PERSONAL STORY: A PATIENT-TURNED-DIRECTOR PUTS THE PROGRAM IN MOTION
Talk about a challenge: in setting up the bariatric rehab program at Northeast Georgia Medical Center and Health System, communication proved the biggest one.

“With a hospital this size, it’s hard to get the right people interacting correctly and fluently to make sure the program is developed in the right way,” says Steve Forbush, PT, MS, bariatric rehab program manager.

That is where Mary Martin, RN, MBA, came in. Martin is director of operations for bariatric services. At her level of authority in the system, she was able to serve as an effective champion of the program, someone who could easily bridge the divide among all the players and get them on board.

Of course, it helped immeasurably that Martin was herself once a bariatric patient at Northeast Georgia Medical Center and Health System: she underwent surgery in May 2003, shortly before the designated bariatric unit and its supporting program components were established.

“I had no idea then that I’d end up being the director of the program,” says Martin, at that juncture the head of the institution’s education department. “Having been a patient though, I’ve been able to apply my own personal experience and come up with a good understanding of what the population we’re serving really needs in a bariatric program. The rehab component was one that I felt, from the patient perspective, we were lacking. That’s why I was so adamant we get it going.”

Presurgery, Martin had a body mass index of more than 50, plus severe hypertension along with other cardiac problems related to severe obesity. She is now off the medications for those comorbidities. By the 1-year anniversary of her surgery, she had shed 132 pounds, and thanks in part to her utilization of the rehab component she helped create, the weight is continuing to vanish.

Rich Smith is a contributing writer for Rehab Management.

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July 2004