- Learning Objectives
- A Call to Action: Exercise Is Medicine™
- Who Should Implement the Exercise Prescription?
- Key Concepts for Successfully Partnering with Physicians
- Professional Qualifications
- Scope of Practice
- Communicating with Physicians
- Outcome Track Record
- Behavior Change: A Key to Maximizing Outcomes
- Referrals: A Two-Way Street (When to Refer to a Physician)
- Organizational Skills
- Marketing Services
- Facilities that Use Exercise Is Medicine Programming
- ACAC PREP
- Dedham Health and Athletic Complex Program
- The Summit Medical Fitness Center
- The Summit Medical Fitness Center
Upon completion of this course, the student should be able to
- State three primary objectives of the Exercise Is Medicine initiative.
- Identify key characteristics that physicians will look for in fitness professionals when considering patient referrals.
- Identify key components toward successfully partnering with referring physicians and the medical community.
Partnering with the Medical Community
Championed by Robert E. Sallis, MD, and the American College of Sports Medicine (ACSM), the phrase "Exercise Is Medicine™" (EIM) has become a hot topic in the fitness industry.1 A wide variety of health and fitness organizations have joined the effort to medicalize physical inactivity and to lobby for a stronger emphasis on the inclusion of physical activity assessment and prescription in legitimate and reimbursable healthcare procedures. The exponential rise of chronic disease in the United States, especially diabetes and conditions related to obesity, along with an aging population has brought us to a critical juncture in our approach to healthcare. Healthcare reform will work only with a strong preventive approach that includes physical activity prescription as an essential component.
The underlying concept of EIM is not new. In fact, it dates back to the fourth century BCE when Hippocrates argued that without physical movement living organisms deteriorate. He stated that "Eating alone will not keep a man well; he must also take exercise. For food and exercise…work together to produce health"; and "That which is used develops; that which is not used wastes away."2 Hippocrates is often credited as being the father of preventive medicine; however, many historians credit Herodicus as being the person behind Hippocrates' interest in physical fitness. In fact, the first study on therapeutic medicine (gymnastics) was conducted by Herodicus, a Greek physician and former exercise instructor, sometime around 480 BCE.3 Hippocrates greatly influenced Claudius Galenus (Galen), a Greek physician who provided numerous medical writings of significance in the second century BCE Galen stated in his work On Hygiene that "The uses of exercise, I think are twofold, one for the evacuation of the excrements, the other for the production of good condition of the firm parts of the body. For since vigorous motion is exercise, it must need be that only these three things result from it in the exercising body – hardness of the organs from mutual attrition, increase of the intrinsic warmth, and accelerated movement of respiration."4
Epidemiologic and exercise training studies over the past 60 years have substantiated the importance of physical activity for good health. Dr. Jeremy Morris, in his study of 31,000 male workers on the double deck buses in London, England, showed a relationship between a lack of physical activity and the development of coronary heart disease.5 In his study, Dr. Morris noticed that the relatively sedentary bus drivers had a significantly higher incidence of coronary heart disease than the more active ticket takers who walked up and down the bus aisles and stairs. A follow-up study published in 1966 further supported this finding, and in 1973 and 1980 Dr. Morris published research on British male executive workers that showed an inverse relationship between leisure time physical activity and initial heart attack.6,7,8 Dr. Ralph Paffenbarger's landmark study "Work Activity and Coronary Heart Mortality," 9 published in 1975, followed for 22 years 6,351 male longshoremen and found that those who were less active had significantly greater death rates from coronary heart disease than their more active counterparts. In 1978, Paffenbarger published his landmark Harvard male alumni study that showed that those who expended 2,000 or more kcal/week had a lower incidence of initial fatal heart attack than those who did not.10 Dr. Steven Blair further explored the importance of physical activity with a number of peer-reviewed publications that showed an inverse relationship between fit and unfit men and women and death due to cardiovascular disease.11,12 Studies like these eventually led to the 1996 Surgeon General's "Report on Physical Activity and Health" that recommended all Americans accumulate 30 minutes of moderate physical activity on most, if not all, days of the week.13 The Surgeon General's Report provides an excellent history of physical activity research, along with other helpful information.
The U.S. Department of Health and Human Services released new physical activity guidelines for Americans in 2008.14 The following key guidelines were recommended for adults (some key phrases are in italic):
- All adults should avoid inactivity. Some physical activity is better than none and adults who participate in any amount of physical activity gain some health benefits.
- For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, and, preferably, it should be spread throughout the week.
- For additional and more extensive health benefits, adults should increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate-intensity, or 150 minutes a week of vigorous-intensity, aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity activity. Additional health benefits are gained by engaging in physical activity beyond this amount.
- Adults should also do muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week, as these activities provide additional health benefits.
Since the 1996 Surgeon General's Report, people have been inundated with media messages regarding the importance of living a physically active lifestyle. Unfortunately, little progress has been realized, and Americans seem to be getting heavier and more out of shape by the hour. This is paralleled by a rapid rise in chronic health conditions and associated healthcare costs. Part of the challenge is related to advancing labor technology, changes in school physical activity opportunities, a public that is resistant to change, and communities that have not been designed to foster a physically active lifestyle. However, fitness professionals also shoulder part of the blame. In our exuberance to apply exercise recommendations, fitness professionals have, at times, made physical activity too difficult for people and have tended to direct rather than coach and support. In addition, many fitness professionals have had little training in or understanding of the behavior change process and we have not established ourselves as part of the healthcare continuum. While the key physical activity word for health benefits is regular, fitness professionals have often focused more on getting people rapidly to the recommended intensity and duration, leading to high dropout rates.
Healthcare professionals have also contributed to the physical activity challenge. Currently, only 40% of physicians talk to their patients about physical activity, and many do not model appropriate physical activity behavior themselves. Of physicians who do provide physical activity recommendations, many are frustrated by the lack of patient follow-through – even to the extent of feeling "why bother, no one will do it anyway!" Many physician specialists do not feel that it is their role to make physical activity recommendations and that it is the sole responsibility of the primary care provider to assess and recommend physical activity. Some people do not see a physician, but instead receive primary care services from a physician extender such as a physician assistant or a nurse practitioner. In some states, nurse practitioners are not required to work under the direct supervision of a physician and may have their own office or clinic. Additionally, the large and growing population of uninsured do not have nor seek a primary care physician. Such individuals frequently engage with the medical community through urgent care and/or hospital emergency departments where the focus is on treating the acute situation. Preventive recommendations, such as physical activity, are rarely part of such a visit. Finally, people who seek primary care service from chiropractors and naturopathic providers may only interact with traditional medical professionals for specialty care. Thus, it is important that all physicians, specialists included, be active in assessing and recommending physical activity to patients and that training efforts be extended beyond physicians to other healthcare professionals.
A Call to Action: Exercise Is Medicine™
In order to address the nation's physical activity challenge, the ACSM, under the guidance of Dr. Robert Sallis, has launched a universal healthcare Call to Action. Exercise Is Medicine is a nationwide initiative to encourage physicians and other healthcare professionals to include exercise assessment and prescription as part of the evaluation and treatment of all patients. A key component of the EIM initiative is for physical activity to be considered a vital sign that is assessed by every physician/healthcare provider at each patient visit and for it to be appropriately treated. Ideally, patients will leave a healthcare provider's office with exercise clearance and a prescription or referral to a certified health or fitness professional. In support of this initiative, some organizations, such as Kaiser Permanente in California and other physician practices around the country, have integrated physical activity into their Electronic Medical Record (EMR) as a vital sign. This strategy requires physicians to assess and address physical activity at each patient visit.
Who Should Implement the Exercise Prescription?
In addition to time constraints, lack of reimbursement, and personal habits, physicians have been reluctant to provide activity counseling to patients due to their own limited understanding of the science of physical activity. Currently, only 6% of medical school programs include any curriculum on physical activity, and many seasoned physicians have never received any formal training. To counter this challenge, Edward M. Phillips, MD, co-author of ACSM's Exercise Is Medicine: A Clinician's Guide to Exercise Prescription,15 and Harvard Medical School are providing Continuing Medical Education (CME) workshops to train physicians how to assess and counsel patients on physical activity. The Harvard Medical School CME course "Active Doctors Active Patients" focuses on the science and experience of exercise.16 The Institute of Lifestyle Medicine (ILM) at Spaulding Rehabilitation Hospital offers CME online programs through Harvard Medical School that focus on exercise prescription.17 ILM is also working on writing and assessing a core curriculum for undergraduate medical education programs. As more physicians are trained and the EIM initiative moves forward, there will be an increasing opportunity for exercise professionals to partner with physicians to provide referred individuals with appropriate coaching and guidance and to communicate effectively individual progress and challenges back to the physician to enhance follow-up efforts. Physician follow-up will be a key component toward improving physical activity adherence and retention rates.
Not every person requires the expertise of a fitness professional to begin a physical activity program. Those who are younger and/or those without significant risk factors may choose to use tools such as pedometers and environments such as walking trails, community centers, and faith-based facilities to initiate an exercise program. However, a significant number of these individuals could benefit from coaching sessions, especially sessions that focus on behavior change strategies. Similarly, people who are at low risk and who may benefit from coaching will not necessarily require the services of a highly trained clinical exercise specialist. However, such expertise is important when working with people at higher risk and with those with known chronic health conditions.
Key Concepts for Successfully Partnering with Physicians
A comprehensive Exercise Is Medicine plan will provide significant opportunities for fitness professionals to partner with the medical community. Referrals to exercise specialists will become an inherent aspect of the health care continuum due to constraints placed on time physicians spend with patients, physician specialization, and the growth of chronic disease directly related to lifestyle. Key aspects of successfully partnering with physicians include appropriate professional qualifications, defined scope of practice, effective communication with physicians, an understanding of the referral system, and knowledge of behavior change strategies.
In a recent interview with Dr. Eddie Phillips, MD, I asked him what qualities a physician will look for in an exercise professional when referring a patient for physical activity counseling. Dr. Phillips responded, "A physician referring their patients to an exercise professional will feel more confident if the individual has qualifications such as appropriate educational training and a professional certification that has been accredited by the National Commission for Certifying Agencies (NCCA)." Thus, it is imperative that fitness professionals desiring to partner with physicians garner the following:
- Formal education – Earning a degree in a wellness/exercise science field will improve the fitness professional's chances of being noticed and respected by the medical community. Basic course work in anatomy and physiology, exercise physiology, kinesiology, biochemistry, and fitness assessment are generally required for a bachelor's degree and provide an excellent understanding of the basic science behind exercise. Many community colleges offer this basic course work at the undergraduate level, and some have specialized certificate programs that focus on the science behind exercise assessment and training. Formal training is essential in developing the skill sets necessary to work with people who present with a variety of health challenges and with clients who have chronic disease. Fitness professionals who want to work with clinical patients should have additional course work that includes exercise testing and training in special populations and exercise cardiology and pathology. Because a wide variety of courses have been offered as part of exercise science degrees, the Committee on Accreditation for the Exercise Sciences (CoAES), under the Commission on Accreditation of Allied Health Education Programs (CAAHEP), has developed academic standardization for exercise science programs. Established in 2004, CoAES sets the standards and guidelines for academic programs that focus on preparing students to work in the fields of health, fitness, and exercise. Information regarding accredited programs is available on the CoAES website (www.coaes.org).
Regardless of the population the fitness professional decides to work with, special consideration should be placed on obtaining education and associated skills in behavior change methods. This is an area of weakness for many fitness professionals and clinicians, and a strong foundation is critical to optimizing outcomes of referred clients. Without appropriate counseling in behavior change strategies, many people will not continue their physical activity program. Once again, because this is not a strong point for most physicians, they will look to other professionals for assistance. Academic preparation and experience in behavior change will increase the fitness professional's opportunity to partner with the medical community.
- Credentials – Licensing and/or certification from an accredited fitness organization is an important frame of reference for physicians. Currently, the National Commission for Certifying Agencies (NCCA), a division of the National Organization for Competency Assurance (NOCA), provides fitness organizations accreditation. Accredited organizations can be found by visiting the NCCA website at http://www.noca.org. The thorough evaluation of the certification process by a third-party accrediting organization is essential in assisting medical and fitness professionals in differentiating between the large numbers of certification programs. A third-party accredited certification demonstrates that the fitness professional is qualified to participate as part of the healthcare continuum within the scope of his or her training. Additionally, some organizations, such as the American College of Sports Medicine (www.acsm.org) and the American Council on Exercise (www.acefitness.org), offer specialized training and certification related to specific conditions and populations. Wellcoaches provides training in the area of behavior change through their Wellness Coaching Certification (www.wellcoaches.com).
- Experience – Gaining practical experience from internships, work, seminars, conferences, and networking broadens the fitness professional's skill and knowledge base and is important to the physician who is researching fitness referrals. CPR and AED training is essential in gaining the confidence of referring physicians. Fitness professionals who are interested in special medical populations should seek experience and mentoring from clinically trained health and fitness professionals. Many medical fitness centers and out-patient rehabilitation programs provide internship opportunities for students and professionals desiring to gain additional experience. The American College of Sports Medicine, the Medical Fitness Association (www.medicalfitness.org), the American Association for Cardiovascular and Pulmonary Rehabilitation (www.aacvpr.org), and IHRSA (www.ihrsa.org) offer annual educational conferences and workshops that provide excellent continuing-education opportunities along with the opportunity to network with experts in the field.
Scope of Practice
It is extremely important that fitness professionals have a strong understanding regarding scope of practice and stay within that scope while working with clients referred by physicians or other healthcare professionals. At times, in their enthusiasm to help people improve their health and well-being, trained and experienced fitness professionals are tempted to make recommendations that exceed their scope of practice or what the referring provider desires to be addressed with the client. This includes accepting clients with health conditions that are beyond the fitness professional's training and expertise, especially clients who may self-refer to the fitness professional rather than go through a healthcare provider. It is imperative that fitness professionals carefully screen each new client and make the appropriate referrals to the medical community and/or other fitness professionals as necessary. On the other hand, fitness professionals are another set of eyes for the referring provider and can spot challenges and/or complications that need to be addressed before they become major problems. The key is effective communication with the referring provider.
Communicating with Physicians
One of the greatest frustrations for referring physicians is the lack of appropriate communication from fitness professionals. In some cases, patients who have been referred to fitness professionals have not received timely follow-up due to lack of communication from the fitness professional to the referring physician or healthcare provider. Strong written and oral communication skills are essential in providing such communication and maintaining a referral base. Brief, to-the-point status reports assist the physician and other healthcare professional with follow-up strategies.
Documentation of visits, individual progress, and current health status will assist the fitness professional in appropriately adjusting the prescribed program and in preparing progress communication to the referring healthcare provider. Many health professionals use a SOAP note (Subjective, Objective, Assessment, and Plan) to document patient progress. Use of the SOAP note technique by fitness professionals is defined as follows:
The SOAP note is just one example of a documentation system. What is important is that the fitness professional maintains documentation on each referred client that can be used to adjust the program as needed and to communicate progress, challenges, and other questions and concerns to the referring healthcare provider.
- Subjective – Observations that include the client's own status report, including a description of symptoms, challenges with the program, and progress made.
- Objective – Measurements such as vital signs, height, weight, body fat, posture, fitness assessments, exercise and nutrition logs pertinent to the individual's program, and targeted outcomes.
- Assessment – A brief summary of the client's current status that is based on the subjective and objective observations.
- Plan – A description of the next steps in the program based on the assessment.
Documentation from client encounters and assessment data should be summarized in a succinct report to the referring provider. Scheduling (monthly, bi-monthly, quarterly) may vary by referring provider, client health status, and challenges that arise during the course of training that require input from the referring physician. It is important to note that physicians are frequently inundated with paperwork and rarely have the time to review lengthy reports. Thus status reports should be succinct, to the point, and present only pertinent data. Concerns, requests for further input, and other associated problems should be easily viewed while glancing at the report. Similarly, it is important that reports are neat, legible, and professional. Referring physicians are frequently interested in their patient's attendance/participation, progression through the cardiovascular and resistance exercise regime, and exercise measures, such as the 6-minute walk or other objective tests.
Outcome Track Record
Physicians work in a profession where outcomes are essential. The fitness professional should obtain skills in measuring and reporting outcomes. As pay-for-performance measures increase in healthcare, fitness professionals who can assist physicians in obtaining and reporting outcomes will be looked favorably upon. It is also important that outcomes are reported simply and concisely.
Outcome measures do not have to be exhaustive, and they may vary depending on each client's health status. Understanding the referring provider's objectives for the patient will assist the fitness professional in identifying pertinent outcome measures.
It is also a good marketing strategy for the fitness professional to summarize group outcomes on the clients he or she works with. Reporting solid outcomes will be attractive to physicians and other healthcare professionals seeking referral sources.
Behavior Change: A Key to Maximizing Outcomes
As mentioned earlier, training and experience in behavior change strategies is essential for guiding referred clients to meet the goals and objectives of their program. Far too often physicians and fitness professionals provide direction by telling the person what they should do (external motivation) rather than taking the time to understand the person's goals and what motivates him or her to make changes (internal motivation). Part of this process should include the identification of potential roadblocks that might impede progress and the development of strategies to overcome such barriers when they arise. Physicians and other healthcare providers usually do not have the time or expertise to provide such coaching. Thus, there is the opportunity and need for fitness professionals to include this as part of the service they provide.
It is critical that professionalism is maintained at all times by the fitness professional. This is especially true while communicating, whether written or orally, with the referring physician and/or healthcare provider. It is also important that this professionalism is maintained during all client interactions. Clients will report their experiences back to their referring provider, and it only takes one negative incident to dramatically impact future referrals from that provider.
In line with professionalism is the critical importance of integrity. Physicians have little patience with people who are not truthful, who lack follow-through, and who oversell their skills. Transparency is important, so don't be afraid to admit when a mistake is made and to ask for additional support and direction when situations arise that are beyond the fitness professional's area of expertise. Be careful to follow through with all commitments, to contact referrals within specified time periods, to prepare and send timely reports, and to maintain open and honest communication with all clients and referral sources.
Referrals: A Two-Way Street
While the primary direction of a referral is from the physician and/or healthcare provider to the fitness professional, there are times when it is appropriate for the fitness professional to make a referral to a physician. Because some may self-refer or be referred by friends or community programs, the fitness professional should have a strong screening/risk stratification system in place and, when appropriate, refer people to a healthcare provider for exercise clearance and/or clarification of program goals, objectives, and restrictions.
Fitness professionals that are well organized and easy to refer to will be attractive to healthcare professionals and physicians. Forms should be simple and easy to fill out by the referring provider, and the required provider paperwork should be kept to a minimum. It is important that messages are returned promptly and appointments are kept. Client appointments should be carefully planned and make efficient use of time. For a complete Exercise Is Medicine action and promotional tool kit and specific resources for fitness professionals, go to
Perhaps one of the greatest challenges fitness professionals experience, especially those not associated with a medical fitness facility, is introducing themselves to potential referring physicians and other healthcare providers. Clinicians have extremely busy schedules and gaining an audience to market services can be quite challenging and frustrating. Concise, professionally written information that introduces the fitness professional and the services provided is essential. The material should contain easily identified information regarding education, certification, experience, and programs offered. A marketing tool kit may contain items such as contact information, resume (detailing education, jobs/experience, programs run, testimonials, and references), documentation of liability insurance, sample forms, and, perhaps, a brief summary of previous outcomes.
Generally, the first point of contact with a physician's office will be with the office staff and/or a nurse. It is important to be polite and to briefly explain what you do and that you would like to leave a packet of information for the physician. Follow up in a few days to confirm that the physician received the information and to inquire whether there are any questions that you might answer. Ask the staff if there is a good time for you to contact the provider to review your services and answer questions. Should you choose to contact the healthcare provider by telephone, be sure to call during non-office hours when the provider's focus is not on his or her acute patients.
The Exercise Is Medicine (www.exerciseismedicine.org) website offers some excellent materials and information for developing marketing strategies.
Facilities that Use Exercise Is Medicine Programming
A number of health and fitness centers have developed and implemented programs in support of the Exercise Is Medicine initiative. These facilities range from standard fitness centers and YMCAs to medical fitness centers. Most medical fitness centers offer programming for both healthy populations and populations with known risk factors and chronic health conditions. These facilities employ fitness professionals, both clinically trained and nonclinical professionals, to serve their various populations. Medical fitness centers and some YMCAs and standard health and fitness facilities have developed strong ties with their respective medical communities and provide excellent opportunities for fitness professionals to work with physician-referred clients. The following is a summary of a few sample programs.
ACAC Fitness and Wellness Centers (www.acac.com), founded by Phil Wendel in 1984, are located in West Chester, PA, Charlottesville, VA, and Richmond, VA. Convinced that gyms should not just be for the young and fit, Phil set out to operate a health club where everyone would feel comfortable exercising. Once Phil refined his mission – to change lives – the business model became apparent. "In order to appeal to the nonexerciser, we had to re-evaluate our services, facilities, and programming," says Phil. "We wanted to get away from the ‘gym' stereotype and reach out beyond the iron-pumping, string bikini crowd." By emphasizing health and wellness in facilities known for their cleanliness and friendly team of professionals, Phil has crated a new type of fitness center that strives to meet the needs of individuals at every stage of life.
In its first year of operation, ACAC had fewer than 1,000 members. Today, more than 30,000 people are members of an ACAC club. Representing all ages and stages of life, 44% of ACAC's overall membership includes families, and 17% are master members over the age of 55. ACAC offers extensive children's facilities, diverse adult programming, and medically based health and wellness services. As partnerships with area hospitals, physicians, and other healthcare professionals increase, many members will use ACAC's medical services and programs. One of those programs is the Physician Referred Exercise Program (PREP).
PREP started in 2004 to give physicians a specific exercise program to which they could confidently refer patients. The model was simple and focused on introducing patients gently to the habit of regular exercise. The design of PREP is based on the following observations:
- Physicians do not want to prescribe expensive "therapies" to patients, especially if they are concerned about compliance.
- Physicians do not want to sell memberships.
- Physicians do not necessarily know how to teach a patient to start exercising, nor do they have the time to spend on physical activity counseling.
- Physicians worry that patients may not receive quality instruction in a fitness facility and will hurt themselves.
- Patients are reluctant to purchase a 12-month membership when they have not previously been successful with exercise.
- Patients are afraid no one will want to help them and may be too embarrassed to ask for help.
- Patients do not want to commit to 1 hour of exercise, most days of the week.
The program was designed to respond to all of these concerns and to help the uninitiated create a habit of regular exercise. It can be conducted in any facility, right on the fitness floor, and requires only a few qualified people (nurses, exercise physiologists, NCCA-accredited personal trainers) to run it. These people are the cornerstone of the program, however, and their selection is important to the success of a program.
Marketing the program is another very important role and may initially be accomplished by one of the program staff. This individual is responsible for reaching out to the medical community and generating referrals. Traditional marketing (print, TV, radio) is effective and is best used in conjunction with a good outreach person.
Other elements integral to the program's success include correspondence with referring physicians, health outcome measures, and communication and collaboration with other departments in the club to ensure the optimal experience for program participants.
PREP has been wildly successful in ACAC's Charlottesville, VA, clubs and has also done very well in the Richmond, VA, and West Chester, PA, markets. ACAC has learned that a strong club brand is extremely helpful in launching such a program. Younger clubs that are still attempting to establish themselves in the community will not necessarily meet with the success that has been experienced in Charlottesville. Even so, this program can add valuable, loyal members to the club who may not have otherwise considered membership at a health club.
PREP Stats since 2004
- To date, more that 7,000 patients have enrolled in the PREP program at ACAC.
- 63% of participants continue to exercise, either on their own or at ACAC, after the program ends.
- 42% of all enrollees purchase an annual membership, generating 2,940 new memberships from this program alone.
- Nearly 800 doctors have referred patients to PREP.
- If membership is about $1,000/ year, PREP has generated $2,940,000 in new membership sales.
- If each member stays an average of 2.5 years – that's $7,350,000 for ACAC in just 5 years from PREP alone.
Dedham Health and Athletic Complex Program
Located in Dedham, Massachusetts, the Dedham Health and Athletic Complex (DHAC) (www.dedhamhealth.com) opened its doors in 1977. In 1992, under the leadership of company president Roberta Gainsboro, DHAC began to develop and implement strategies to integrate exercise and clinical services. Since 1992 it has been DHAC's goal to provide "exercise as medicine," and to help fulfill this goal they instituted as a mandatory hiring policy that requires all facility trainers have a minimum of a bachelor's degree in exercise physiology.
In 1995, DHAC established a partnership with New England Baptist Hospital, one of the nation's leading orthopedic centers. This was followed in 1999 with a partnership agreement with the Joslin Diabetes Center, one of the world's most respected diabetes care facilities. As part of this partnership, DHAC staff members are trained to write and fill prescriptions for exercise for individuals with diabetes (types 1 and 2 and gestational).
DHAC has also developed relationships with Beth Israel Deaconess Medical Center, Massachusetts General Hospital, and Walden Behavioral Care in building their exercise-as-medicine programs. The partnership with Massachusetts General was formed to implement a pilot program and associated clinical study on childhood obesity. The Fitness Fundamentals program addresses low fitness levels, sedentary lifestyles, and low self-confidence and teaches kids the importance of exercise and healthy eating habits.
The 60/60 (60 days for $60) program at DHAC is a physician-referral program designed specifically for the deconditioned population and for those who have specific health concerns, such as diabetes, high blood pressure, heart disease, and weight management. The 60/60 program provides an introduction to exercise and movement and consists of an initial evaluation, a physical activity program that requires a minimum of two 30-minute workout sessions each week, and periodic reassessments. Core measures include:
- Subjective Feel Good Data Value
- SF-36 Merlin Questionnaire by Merlin
- Objective Biometric Data
- Body weight (DHAC exercise physiologist takes measurement)
- Waist-to-hip ratio (DHAC exercise physiologist takes measurement)
- Body fat % (DHAC exercise physiologist takes measurement)
- Resting heart rate (DHAC exercise physiologist takes measurement)
- Blood pressure (DHAC exercise physiologist takes measurement)
- HDL (blood test)
- LDL (blood test)
- Triglycerides (blood test)
- Total cholesterol (blood test)
- A1C glycohemoglobin (blood Test)
From 2006 thru 2008 the program generated 2,112 physician referrals and is projected to receive 1,500 referrals in 2009. Over this 3-year period, 1,386 (65.6%) of the referrals actually enrolled and 1,247 (90%) completed the program. Of the people enrolled in the program, 39% converted to a DHAC membership at the conclusion of the 60/60 program.
The Summit Medical Fitness Center
The Summit Medical Fitness Center (SMFC) (www.summithealthcenter.com), located in Kalispell, Montana, is a 114,800 square foot medical fitness center that has been in operation since January 1996. Located on the campus of Kalispell Regional Medical Center (KRMC), SMFC is closely aligned with the medical community and owned by Northwest Healthcare. The clinically integrated facility offers Phase II and III cardiac rehabilitation, pulmonary rehabilitation, physical, occupational, and speech therapy, occupational medicine, NWHC employee health, community health promotion, and a variety of other specialized clinical programs. Facility staff includes physicians, nurse practitioners, nurses, clinical exercise physiologists, personal trainers, wellness coaches, physical and occupational therapists, dieticians, athletic trainers, health educators, and other health and fitness professionals. SMFC works closely with a ten-person physician advisory committee that meets quarterly and provides medical oversight for SMFC's emergency response program and all clinical and nonclinical programming. The facility works closely with KRMC's diabetes program, was one of the sites for the nationwide HF-ACTION study on heart failure and exercise, and has a strong youth program.
In response to the Exercise Is Medicine initiative, SMFC launched its Journey to Wellness program in late spring of 2009. The Journey to Wellness program, 90 days for $90, requires a physician's referral and is specifically formatted for individuals with chronic health challenges who are not physically active. The program is self-pay and participants who desire to continue their program at the SMFC facility beyond the 90-day period have their registration fee waived. The Journey to Wellness staff consists of a clinical exercise physiologist, nurse, dietician, and personal trainers.
The primary objective of the Journey to Wellness program is to help each referred person develop a regular pattern of physical activity. The initial focus is not to get to the recommended dose of physical activity for health benefits immediately but to establish a habit of regular physical activity. Once this habit is formed, intensity, duration, and frequency can be progressed gradually. Additional program objectives include identifying the participant's other health goals; identifying potential barriers and strategies for addressing exercise adherence; providing health education information; and measuring outcomes. An essential component in the program is a follow-up visit with the referring provider. This visit is scheduled at the initial program visit and includes an outcome report generated at the end of the program. During the 90-day period, participants have full access to the facility and, as required, attend supervised exercise sessions.
Upon entering the program, the clinical exercise physiologist conducts an initial assessment using interviewing techniques to identify potential challenges faced by the participant and strategies that will increase his or her intrinsic motivation to be physically active. Strategies to overcome potential barriers to success are put into writing and reinforced throughout the 90 days. The initial assessment is critical to identifying an appropriate physical activity starting point for each individual. Included in the assessment are a number of outcome measures that are repeated at the completion of the program and reported to the referring physician. These measures include the Dartmouth Quality of Life questionnaire, the PQH-9 Depression Tool, vital signs, a fitness assessment, and the Epworth Sleep Scale.
The initial assessment is followed by an individualized coaching session that focuses on implementing the physical activity program and emphasizing the importance of regular engagement. Depending on the participant's initial physical activity status, health condition, and desires, the program may include a variety of physical activity options ranging from supervised classes, other SMFC classes on land and/or in water, a pedometer program, and other activity that will get the individual moving and begin establishing the regular pattern. The physical activity intervention is developed using the contemporary theory of human motivation called Self-Determination Theory to foster exercise adherence. Specifically, every attempt is made for the exercise environment to be:
- Autonomy-supportive, so participants will want to participate.
- Structured, so participants feel competent and have confidence in the program.
- Socially involved, so participants feel a sense of belonging in the environment.
Journey to Wellness participants are contacted weekly to provide support, answer questions, and track progress. As challenges arise, pre-identified strategies for addressing them are reinforced. Participants are encouraged to attend appropriate support group meetings and wellness educational sessions that are taught by physicians, pharmacists, dieticians, and other health professionals. Examples of topics include inflammation and chronic disease; mindfulness-based stress reduction; probiotics, supplements and medications; and positive coping strategies for healthy eating and body image. The educational seminars are scheduled on a rotating basis throughout the year so participants have the opportunity to attend the entire series, regardless of their starting date.
Participants are also provided with an interactive approach to fitness through the use of a comprehensive online wellness-promotion tool called Motivation – BSDI. Each participant receives a personalized account that allows him or her to record and track progress toward individualized goals. The site also features detailed health information and allows for direct email contact with mentors and coaches.
Communication with referring physicians occurs at regular intervals throughout the program: at program entry (outlining the participant's goal and action plan); during the program if health challenges arise or the participant drops out; and at program completion (summarizing outcomes and recommendations/next steps). Participants and staff use an electronic tool for tracking progress and associated outcomes. Following the program, participants are asked to fill out a Journey to Wellness Satisfaction Survey that provides feedback for improving program quality and outcomes.
While the Journey to Wellness program does not have the history of the ACAC and DHAC programs, SMFC has had numerous programs for people with a variety of health conditions in place over the past 14 years (phase 2 and 3 cardiac rehab, pulmonary rehab, CHF, arthritis, fibromyalgia, musculoskeletal injuries, and eating disorders). The Journey to Wellness program brings some of these specialized programs together into one program with a common goal of developing a regular pattern of physical activity. It expands access to many more people with other chronic health challenges and to those who are physically inactive. Early results have been very positive with a strong physician referral base, clinical outcomes, and a 30% conversion rate to regular membership. One individual, a chronic pain patient, went from a totally physically inactive state to regular exercise 3-5 times a week. The person lost significant weight and experienced a dramatic reduction in daily pain by the end of the 90-day period. As a result, this individual has now enrolled at the local college to become a fitness professional in order to give back to other people suffering from chronic pain conditions.
Summary: Opportunities or Just More Rhetoric
There is little question regarding the importance of physical activity for health – more research is not required to substantiate that. However, strategies are needed to actually produce the outcome of moving people off of the couch and into a physically active lifestyle. Exercise Is Medicine is one of those key strategies. By engaging physicians in the assessment and coaching process and by providing appropriate behavioral change methods, many people will make the transition. Fitness professionals fill a key link in this process by providing their expertise and time to partner with physicians to encourage and move people along the activity trail.
About the Author
Brad A. Roy, PhD, FACSM, FACHE, is a fellow at the American College of Sports Medicine and the American College of Healthcare Executives. Dr. Roy is the Administrator of the Summit Medical Fitness Center and VP at Kalispell Regional Medical Center in Kalispell, Montana. His duties include overseeing the Summit Medical Fitness Center, Cardiac and Pulmonary Rehabilitation, Occupational Medicine, Employee Health, Home Care, Hospice, Private Care, In-patient Pharmacy ,and the Retail Pharmacy. He has over 30 years of experience in clinical exercise physiology and serves as an editor for a number of peer-reviewed journals. Dr. Roy is an avid runner and enjoys a multitude of outdoor activities in Montana.