The Rise of Integrated Health

Numbers, Prominence, Authority All Moving in the Right Direction --- UP!

Published in June 2013 Issue             

Between 2000 and 2012, the Integrated Health Section within the American Society for Metabolic & Bariatric Surgery (ASMBS) has experienced explosive growth. During this time, the number of Integrated Health members has grown from 113 to 1,683 -- a nearly 15-fold increase. But the numbers alone do not tell the story of the rise of Integrated Health in terms of its significance to bariatric and metabolic surgery and patient care.

While Integrated Health, formerly Allied Health, has been a part of the ASMBS since its inception in 1983 (only three members then), it wasn't until 1987 that the first allied health program was introduced at the annual meeting. There were few attendees and little interest in organizing another program until 1991, when an official "Allied Health" committee was formed. The program was a simple roundtable discussion that included nurses, a psychologist, a program director, dietitians and an operating room technician.

 "We were hungry for information about best practices and ways to improve patient care, and the only place we were going to get it in those days was from each other," recalled ASMBS Executive Director Georgeann Mallory, RD, who at the time was the first appointed chair of the Allied Health Committee and one of the registered dietitians sitting around that table."While even then there was friendly competition between practices, it was more than outweighed by a collegial spirit and the passion we shared for our patients."

That collegiality and passion for patients has been a driving force for Integrated Health through the years, but it has been more than that spirit that has established the interdisciplinary approach as standard practice in the surgical and medical treatment of the disease of obesity. What started out as simple, but important exchanges of information, have turned into data presentations, best practice guidelines for gastric band adjustments and peer-reviewed articles on pre- and post-operative care that have been published in top journals including Journal of the American Medical Association, New England Journal of Medicine, SOARD, Critical Care Nursing and Archives of Surgery.

"When we started there was no science of integrated health. We were just doing what we thought was right for the patient and paving the road as we went along," said Tracy Martinez, RN, BSN, who joined the society in 1996 and became the first-elected Chair of the Allied Health Committee in 2000. "Now we have data on nutrition, exercise, behavioral health, specialized nurse training and many other topics that support our role. We have and we continue to raise the bar on pre- and post-operative care and our voices are being heard both inside and outside the society."

Martinez points to the ASMBS Certified Bariatric Nurse (CBN) program, the first certification program for bariatric nurses, as one of the biggest achievements in the last 10 years. CBN was established in 2007 and since then more than 1,200 nurses have been certified for their skills in clinical management, multidisciplinary team collaboration, communication, outreach and leadership in program administration.

"I wear my CBN pin on my lab coat every day with great pride," said Martinez, Program Director of the Wittgrove Bariatric Center in La Jolla, California and the 2007 recipient of the IH Circle of Excellence Award.

A 2007 IH Circle of Excellence Award recipient himself, Bill Gourash, MSN, CRNP, Integrated  Health Senior Past President and Chair of the CBN Certification Committee, was a driving force behind CBN. He helped the ASMBS navigate the road to certification, a complex process that involved organization, research, funding and coming to a full understanding of its professional and legal implications of the program. Perhaps even more importantly, according to Gourash, was the need to develop an exam that accurately assessed the knowledge and skills required to be a bariatric nurse.

"Everybody stepped up," said Gourash, Senior Research Coordinator and Nurse Practitioner with Minimally Invasive Bariatric and General Surgery Division at University of Pittsburgh Medical Center. "The nurses, the surgeons, the ASMBS Foundation and the entire Integrated Health section did everything they were asked to do and more. I think everyone would agree that all the effort we put into CBN was worth it. It was incredibly important for us and to
our specialty."

Another proud CBN pin-wearing member is ASMBS Integrated Health President Karen Schulz, RN, MSN, CBN, who says the ASMBS accreditation program established in 2004 was another milestone for integrated health in that it made interdisciplinary care a requirement, not an option.

"Accreditation not only mandated interdisciplinary care, it validated what the best programs were doing," said Schulz, Clinical Nurse Specialist, University Hospitals of Cleveland in Ohio. "It redefined a standard of care and that standard recognized the importance of a continuum of care that starts before a patient goes to the operating room and continues well after surgery."

Beyond accreditation programs, updated joint clinical practice guidelines issued this year by the ASMBS, The Obesity Society (TOS) and the American Association of Clinical Endocrinologists (AACE), stated perioperative care "is mandatory with special attention to nutritional and metabolic issues." This was among 74 evidence-based recommendations for the perioperative nutritional, metabolic and nonsurgical support of the bariatric surgery patient.

Robin Blackstone, MD, FACS, Immediate Past President of the ASMBS and Medical Director of the Scottsdale Healthcare Bariatric Center, is a firm believer in the power of integrated health based on both science and clinical experience. Dr. Blackstone's team includes a practice coordinator, exercise physiologists, bariatrician, nurse practitioners, physician assistant, registered dietitians, psychologists and research director.

"I never believed that surgery stood alone. At the beginning of our practice, it took a tremendous effort to build an integrated team who understood bariatric surgery and how to specifically care for this patient," said Dr. Blackstone, who began doing bariatric and metabolic surgery in 2001 and is the ASMBS Executive Council Liaison to Integrated Health. "Back then there were fewer integrated health professionals dedicated to the specialty and the knowledge and experience base wasn't as informed by peer-reviewed data as it is today. Now we know more about the physiology of the surgical procedures, more about the science of obesity and more about the impact interdisciplinary care can have on patient outcomes."

Christopher D. Still, DO, FACN, FACP, Director of the Center for Nutrition and Weight Management Clinic at Geisinger Health Care System in Danville, Pennsylvania has been involved in the medical management of obesity since 1994, seven years before Geisinger had a bariatric surgery program.

"In effect we went the other way. We had our comprehensive care program for obesity before we had our bariatric program," said Dr. Still, who has been a member since 2006 and received the IH Circle of Excellence Award in 2011. "We knew from the outset patients needed a team of health professionals to treat obesity. The surgery added a powerful dimension to our treatment and the surgeon added another important member to the team."

At Geisinger, patients with obesity must first be seen by an obesity medicine specialist and other members of the integrated health team before consulting with a bariatric surgeon. About 25 percent of patients seeking surgery are not referred and remain in medical management. Dr. Still points out, however, that about 30 percent of patients initially seeking medical management only, ultimately have bariatric surgery. "There's an ebb and flow between medical management and surgery,"
Dr. Still explained.

Those who are accepted for surgery are encouraged to lose five to 10 percent of their current weight, stop smoking, complete behavior modification modules, attend three educational classes and two patient support groups, and have psychological, medical, nutritional and surgical evaluations. After surgery, there are a comparable number of support measures.

"We have identified 36 best practice elements and about half of them occur before surgery and most of the remaining elements occur after surgery," said Anthony Thomas Petrick, FACS, FSSO, MD, Director of Bariatric Surgery at Geisinger. "By adhering to this best practices pathway, we have significantly reduced length of stay, hospital readmissions, ICU admissions and reoperations while cutting costs and improving
patient outcomes."

Dr. Petrick says the integrated team constantly follows and documents each of the benchmarks of care before, during and after each procedure in an attempt to continually improve quality and outcomes.

"The goal is to provide the best care, at the best time, to the right patient, at the right cost," added Dr. Still. "This is what comprehensive and integrated care is all about and bariatric programs all across the country are innovating in this area. Only together can we produce the best clinical and economic outcomes."

The Integrated Health section of the ASMBS is helping to drive some of this innovation and further define and solidify its role in the management of obesity and has organized itself around both the opportunities and challenges facing the specialty. It has its own IH Executive Council and eight committees focused on areas including professional education, clinical issues, membership, support groups, credentialing and multidisciplinary care. There are two Integrated Health voting members on the ASMBS Executive Council.

The IH Clinical Issues Committee is currently working on the development of sensitivity training guidelines and exercise recommendations for the bariatric patient and a revision to both its guidelines on nutrition and psychological assessment. The IH Multidisciplinary Care Committee recently completed a member survey that explored the roles and responsibilities fulfilled by nursing, exercise, nutrition, obesity medicine, surgery and behavioral health professionals. Survey results and analysis will be published soon.

The Future of Integrated Health

Psychologist David Sarwer, PhD, Professor of Psychology in Psychiatry and Surgery at the Perelman School of Medicine at the University of Pennsylvania, has been an Integrated Health member since 2006. He is principal or co-principal investigator on three NIH funded grants investigating the psychological aspects of bariatric surgery. He received the IH Circle of Excellence Award last year.

"We have entered a new generation of surgical care for patients with obesity that recognizes the disease goes beyond the physical," said Dr. Sarwer, Director of the Stunkard Weight Management Program at Penn. "Surgery is the most powerful tool to treat obesity, but it's still just a tool. If a patient is struggling with behavioral, emotional or other issues they can compromise his or her long-term outcomes. Everyone on the integrated health team is getting better at recognizing these issues and addressing them before and after surgery. We need to work hard to get others, particularly insurers, to do the same. The benefits to patients and to health care systems far exceed the costs."

Martinez, Co-Chair of the Integrated Health Multidisciplinary Care committee, which was formed in 2011, agrees. The committee is working to provide evidence-based support for the role of all the team members in the long-term success of the bariatric surgical patient. "We've all seen the impact of the team approach on patients with obesity and we continue to develop the data that defines its value to the patient, the insurer, health care system
and society."

Expect some of that data to be presented and discussed during Obesity Week in Atlanta during the Integrated Health Plenary Session. In addition, Integrated Health will host two roundtable discussions, a format reminiscent of the first official IH meeting back in 1991.

"We have come a long way. In 1991, we held one roundtable and that was the extent of the program," said Mallory, who received her IH Circle of Excellence Award in 2008. "Now we have a week of plenary sessions, symposia and courses and surgeon and integrated health members are more connected than ever before. It's the only meeting of its kind. Every discipline comes together and converges on the disease of obesity. It takes a team to be successful. The patient can't do it alone and neither can any single intervention."