A Landmark Accomplishment for ACSM & Exercise is Medicine® (EIM) – Part II: Implementing the EIM Solution!

By Adrian Hutber, Ph.D., Phil Trotter, B.S. and Felipe Lobelo, M.D., Ph.D.
Adrian Hutber, Ph.D. Felipe Lobelo, M.D., Ph.D. Phil Trotter, B.S.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM.

Adrian Hutber, Ph.D., has served as vice president of Exercise is Medicine® at ACSM, since 2008. Previously, he served as vice president of a major fitness corporation and as the director of the distance education division of the publisher, Human Kinetics.

Phil Trotter, B.S., leads the EIM Solution on-the-ground team. This is a key component of EIM that supports the implementation of community stakeholder groups and the resources to make physical activity a standard element in the delivery of health care to all patients. Phil is a community care thought leader and collaborative subject matter expert. He consults with leaders of health systems, as well as executives and their staffs in population health management.

Felipe Lobelo, M.D., Ph.D., is an associate professor of Global Health at Emory’s Rollins School of Public Health. He directs the EIM Global Research and Collaboration Center (EIM-GRCC). The EIM-GRCC is the academic hub of EIM that carries out the lead role in evaluating the EIM initiative. To execute this function, EIM-GRCC collaborates with health care systems, community organizations, and fitness and technology companies.

This is the second installment of a two-part commentary on recent landmark developments in the Exercise is Medicine® (EIM) initiative. See the archived March 22, 2016 issue of SMB for Part I for background on the foundational aspects of EIM. Part II focuses on how the EIM Solution establishes physical activity as a primary behavioral factor in the prevention and treatment of major chronic diseases.

What is the Hurry? With the dramatic shift from volume- to value-based care, health systems are quickly ramping up their value-based payment contracts with the health care payers – i.e., with employers, insurers, Medicaid and Medicare. This is a highly competitive process for health systems, given the necessity to assure that their volume-based revenue is replaced with that based on health value. In making this payment shift, these health systems also must be able to factor in (assume responsibility) for a share of the payer’s population health risk. This is a particularly challenging part of the equation in payer populations that have more people with established chronic disease conditions.

The payer’s share of this risk will be determined, not only by the number of patients with these diagnoses, but also by how rapidly such patients become sicker and progress to higher utilization of the most expensive health services. These turn out to be patients with the more complex medical, behavioral and social issues – caring for this subset, in fact, will typically consume up to 80 percent of total health care dollars! This is where the EIM Solution comes in.

The EIM Solution first establishes target outcomes for both the health system and its payers. Then, based on these outcomes, implementation strategies are devised – each of which are tailored to improve individual health states and, at the same time, reduce financial consequences of these diseases in the overall population. An additional important consideration in selecting these strategies is that each must be demonstrably effective in mitigating disease in that part of the population at higher risk.

The second component of the EIM Solution – establishing and managing a community network for patient referral with a high degree of quality assurance – provides health systems with the essential service that they almost invariably have neither the expertise nor bandwidth to develop themselves.

So how do the clinical care, community care and the collection and analysis of the clinical and community care data all fit together?

Community Care Data and Outcomes. Community care is a new standard in health care delivery. The goal is to achieve lifestyle behavioral change that leads to self-management of chronic diseases. The Population Health Management (PHM) framework underscores how health care is being transformed – in ways designed to maintain and improve health across the continuum of care for individuals at risk for chronic diseases or those who already have been diagnosed with multiple chronic diseases. One of the challenges health systems face is where to refer these population groups for participation in accessible, safe and replicable prevention and intervention programs with adequate quality control. These programs must provide the adequate engagement methodology, duration, and frequency and intensity of exposure that will result in lifestyle behavior changes and the individual skills needed to accomplish self-management. Only in this way will it be possible for health systems and payers to have reasonable assurance of “value return” on their investment.

Figure 1 shows the schema for evaluating EIM effectiveness in a given community. In addition to examining clinical and claims health risk data, this model includes a community-level category that centers attention on validating the effectiveness of PHM interventions that have been implemented. The community data collected and the core outcomes are based on the performance standards set by the EIM-GRCC at Emory University. The EIM-GRCC performs community data standardization, aggregation, and analytics to create actionable summary data and uncover best practices that validate chronic disease prevention and self-management. For further details about how mobile health data acquisition tools are incorporated into EIM programs, see Lobelo et al., in Progress in Cardiovascular Diseases.

The EIM-GRCC role is to lead or collaborate with a given health system’s in-house research center. The process combines clinical, health care utilization and cost data and uses these metrics to assess the overall effectiveness and cost-effectiveness of the EIM solution programming. Results may be compared across different clinical populations and among specific subgroups. These are the outcomes that lead to an understanding of return on investment by health systems from their value-based care and contracted payment models with payers.

Lifestyle behavioral change requires high-touch human engagement that is significantly enhanced when clinical care integrates community care. Health systems are seeking a solution to deliver formerly high-cost services more efficiently in lower-cost settings where patients learn to be better stewards of their own health. Greenville Health is an example of a large U.S. health system that has accepted the challenge of being an EIM leader by adopting and integrating the EIM Solution model and linking its clinics with EIM credentialed exercise professionals at access points provided by the YMCA, which is the community partner organization for the Greenville area.

To validate success, community data and core metrics must make the case that community care works. The ACSM, American Council on Exercise and Medical Fitness Association coalition represents the organizational and professional resource to make community care a reality for health systems.