Good evening, late afternoon to everyone. I'd like to introduce our speaker tonight. It is a real pleasure to introduce Dr. Heidi Prather. There are a few people that I admire and respect as Dr. Prather. She graduated from the University Health Sciences College of Osteopathic Medicine in Kansas City, Missouri, and she completed a residency in PM&R at Northwestern University Feinberg School of Medicine. She was one of Joel Press's first, we'll say, fellows, although she has a story about that, at the Rehabilitation Institute of Chicago, now known as the Shirley Ryan Ability Lab. She's a diplomat of the American Board of PM&R, as well as the American Board of Lifestyle Medicine, and she has a CAQ in sports medicine. Early in her career, she took a position in the Department of Orthopedics at Washington University in St. Louis. And in doing so, she began a career that foreshadowed the AAPM&R BOLD initiative. And what I mean by that is about to be displayed to you. Over the course of several years, she built a program in the Department of Orthopedics that has become one of the best physiatry programs in the United States. She began with her partner, John Metzler, who was a medical student of mine once upon a time. She trained many fellows over the years and now has left a group of exemplary musculoskeletal physiatrists. During her tenure at WashU, she served as Professor and Vice Chair of the Department of Orthopedics. She was Founder and Division Chief of Physical Medicine and Rehabilitation in the Departments of Orthopedic Surgery and Neurology. And before she left, she founded the Living Well Center at WashU. Not a small accomplishment for a very old school group of orthopedic surgeons. Dr. Prather is a respected researcher and she has published numerous articles, book chapters. She's also the founding editor of the journal PM&R. She was past president of PASOR, which is the Physiatric Association of Spine Sports and Occupational Rehab for any of those who don't know what that is, probably many of you. And she's been past president of the North American Spine Society and served as co-director of the North American Spine Society's Recognized Spine and Intervention Fellowship. She began retooling her career while at WashU and founded the Lifestyle Medicine Program there. She has since moved to Atlanta with her husband and she recently joined Dr. Press at the Hospital for Special Surgery. Dr. Prather has long been an advocate for physiatrists in the continuum of care of patients and now in the science of lifestyle medicine. In my opinion, if you're going to emulate anyone, it should be Dr. Heidi Prather. And with that, I'd like to turn it over to Heidi and let her speak to us on lifestyle medicine. Dr. Prather, it's all yours. Thank you very much. Can you see my slides there? Yes, ma'am. All right. Thanks for the introduction. That's very kind of you. I agreed to do this because John Cianca asked me to do it. So John and I share a lot of common values and I'm grateful to do this. I am very impressed that this many people are interested in this topic. If you're older like John and I, you probably know these things are what patients need and may be interested in how it applies to your own practice. Thanks for enduring and being on Zoom when no one wants to be on Zoom anymore. If you're in your mid-practice and you're seeing the light that I want to offer patients more than what my traditional training has been up until that point, hopefully I can get you excited about this. And anybody who's new to physiatry, who's a new learner in our field, you're the group I'm really after because you have a lot of energy towards this topic. I get approached most often by med students and people early in residency that are interested in this approach to medicine. So I hope I can interest everyone. I think this area and this area of expertise is something very well suited for physiatrists. We need a little extra training, but there's a lot of things that are kind of inherent with what our basic training is. So I'm going to touch on what lifestyle medicine is, an intensive program, what that is, how I've taken it from the primary care world and adjusted it to the musculoskeletal world, tell you a little bit about program we developed at WashU, which there may or may not be some WashU folks on tonight. I hope they chime in with me and then talk to you about the plans in New York. I am talking to you from New York in my apartment. There's a lot of steam here, so the windows are open, and I'm right by New York Presbyterian. So if you hear an ambulance, I apologize. So my disclosures, my only financial disclosure is I am still one of the old senior editors at the PM&R Journal, which please submit, submit often. And these are my other non-financial disclosures, which kind of gives you what my biases are. So to start out this off, we're going to build the stage of why this is so important, and everyone here knows why it's important, but just some statistics if you need them when you're trying to sell this, either in your healthcare system, your university, your employer, or if you're in private practice or independent practice, these numbers are helpful. We know there's a lot of broader implications for despair in our patients, particularly with musculoskeletal problems. We know that people that have two areas of pain are six times more likely to have depression. We know 35% of our patients with chronic pain will experience some form of an anxiety disorder. Each new generation of people reports more pain at any given age than the generation before it. 63% of regular opioid users suffer from some form of chronic musculoskeletal pain, and we know those with functional disability are two times more likely to die of despair. And this graph here on the right side was produced by the value team here at HSS in a compilation of a couple of studies, and it's showing you the parallel between suicide, the suicide axis here, and folks with chronic joint pain and folks with sciatic pain. This is a study that was, a survey that was conducted by December of 2020 in the pandemic, and what the pandemic has really done is probably brought the idea of forefront that we really do need to talk about things that keep us healthy. In the U.S., between January and June of 2019, 11% of people were reporting symptoms of anxiety and depression, and by December of 2020, that was over 42%. My guess is if we surveyed that again today, it would still be climbing. I give that as ammunition of we know people need help with mental health disorders and stress disorders, but we don't have a lot of ways of providing that for people, so that elephant that's in the room is smelling bad as well. So this slide I've adapted in the Bodie study from the Permanente journal. It's a way of trying to show simplification of how we get to an unhealthy lifestyle. So on the left side in the blue box, it talks about unhealthy diets, sedentary lifestyle, high stress, and medications. We know that the combination, especially multiple ones of us, can then lead to microbiome dysbiosis, which is that imbalance between good and bad bacteria, which has an effect on absorption, effect on neurotransmitter release, and so forth, oxidative stress, and cellular injury. The combination of those three results in chronic inflammation, and we know that chronic inflammation, and we mean it from a systemic standpoint, is what's involved and leads to obesity, type 2 diabetes, cardiovascular disease, some cancers, and depression anxiety. So this is Heidi's adaption, so remember that, not the published one. If we look at osteoarthritis, musculoskeletal spine conditions, guess what? They're based in the same issues around systemic inflammation, and we know that oftentimes our patients with these conditions have coexisting other disorders that are chronic lifestyle-related diseases here in the red box. diseases here in the red box. We know that our folks with osteoarthritis and musculoskeletal conditions, we're really talking a lot morbidity, so function, quality of life, and our chronic lifestyle disorders, when we can correct these, we actually know we increase longevity or decrease mortality. So the marrying of these two things in a treatment plan seems pretty obvious by the literature, and I'm going to hopefully show you some of that. We spend a lot of money on this. $281.5 billion in annual costs are spent on joint and arthritis pain. By 2030, $4.4 million lower extremity total joint procedure will be reformed, costing over $154 billion. There are $147 billion costs associated with people who are overweight or obese. That's their total health care costs, it's not just what's related to that. So there's this spread of costs that goes with that. $42 billion a year spent on anxiety, and about half of that is in patients who come to us for repeated health care services who often have some form of somatic complaint. And we all know a lot of us see those people. We also know there's this trajectory, if we decrease the accelerated climb of obesity that's projected out there, even by 1% we can save billions of dollars by 2030. So I want to give you some data on how does lifestyle impact patients with musculoskeletal conditions, and I picked just osteoarthritis because that's such a general condition that all of us see, whether we're doing inpatient, we're doing outpatient, we're doing a combination of those, all of us probably in some form or another attend or care for patients with us. So we know the progression of OA is correlated with an upregulation of the inflammatory processes. We know that modifiable risk factors increase the risk of developing OA, including obesity, diabetes, and hypertension. We know that patients with type 2 diabetes more often have bilateral hip and knee OA, and they also have greater progression of that OA as compared to those without type 2 diabetes. We know metabolic syndrome, which is a combination of some of these chronic diseases we talked about, diabetes with obesity, with hypertension, with hyperlipidemia, those patients are more frequent to have OA than those that don't. We also know that cardiovascular events are much more prevalent in people with osteoarthritis, and we know that the more the different types or components of a metabolic syndrome the patient has, and central obesity and hypertension are also associated with increased risk of severe knee OA, and the kicker to remind people is that it's independent of BMI. So this isn't just people that are obese and what distribution of weight does to their joint, it's the inflammation of the fat cell that's exuding that inflammatory component on a regular basis. So we have to get back to the physiology and biology in addition to the biomechanical components that we're well aware of. What are some of the behavioral health links in osteoarthritis and at Lifestyle Medicine? Well, 20% of people with OA have symptoms of depression anxiety. Anxiety and fear avoidance beliefs are associated with worse function in patients with OA, and we know depression anxiety is also associated with inflammation, and this association is mediated through unhealthy lifestyles among those folks. So when I start talking about our program and with some of the things we measure, one of the things we'd really like to look at is, as an inflammation marker comes down, does self-management and anxiety go down particularly? This is a study that came out this last year. It was looking at women that were age 50 and older with knee pain, and they looked at just nutrition, and what they found was that those who had poor nutrition actually had worse problems in knee pain independent of their weight and the degree of their osteoarthritis. So again, more evidence to suggest that we really need to start thinking about this in a different way and not be uniform in just the biomechanical approach and this exercise approach, but how do we add to that with other things that we know contribute to the problem? What are some of the other things? So relationship of smoking and reporting of pain. Everybody's well aware that you have more pain, you report more pain if you use tobacco. The relationship of alcohol use and OA is a little confounding, but there's no real clear consistence on what the biological effect is on radiographic or cartilaginous change, but it is out there pretty emphatically that chronic alcohol consumption seems to be a worse prognostic indicator and more likely to see OA changes and greater OA changes over time. So what are the factors that inhibit our patients' progress? So on the patient side, you know, weight can be a thing, disordered eating, so maybe they're not that overweight or not overweight, but what they eat is affecting their physiology and that oxidative stress and systemic inflammation that we talked about. Obviously tobacco addiction. There's biopsychosocial and economic risk factors, and I put both of those together for reasons. One, we know stress is an important thing that needs to be relieved for people to manage any kind of health condition and just manage life, but there are also economic risk factors that a lot of patients experience that we care for. People with healthcare disparities, people with food, avoidance of appropriate food available to them, and eventually my heart is in making sure a program like we're developing is accessible to that community. Pain processing disorders, and what I mean by that is the ability to accept a nociceptor and people that are prone to chronic pain syndromes versus regional pain and that type of thing, and lacking or poor self-management and education, and part of that is on the health system, in my opinion. So if we look on the health system side, we aren't really reimbursed to educate, right? There's not a box you flip in Epic or wherever you are, Cerner, that says I educated for 20 minutes, please pay me more. We just don't have that inherently built into the system, and therefore we're not really incentivized. Comprehensive patient goal-directed integrated programs are few and far between because honestly a financial model for them doesn't exist yet, especially in the fee-for-service model. But it's coming in value-based care and provision for evidence-based services that are not covered by a third-party payer. Again, it gets back to that population who can't pay for all the services they need. We have evidence that they're helpful, but insurance companies or third-party payers may not recognize them. Example being two-thirds of this country is overweight or obese. Two-thirds of this country is pre-diabetic or diabetic. Most primary health insurance companies, including the government, pay for a dietician who makes not a lot of money a year, benefits for that. It's kind of crazy. So those are kind of the things that weigh on all of our minds when we're trying to care for patients that are complicated with these disorders. This is a graphic taken from European Journal of Physical Medicine and Rehab that I use all the time because it is the cycle of crazy that we deal with often. So patients with pain have catastrophizing, they have pain-related fears, and then they stop moving. And when they stop moving, they gain weight, they become obese, they move less, and they end up with impairment, disability, anxiety, depression, and the cycle continues. Most of us spend a lot of time wondering how am I going to break this cycle or how do I enable this patient to break the cycle or feel defeated by this system. I don't, I'm not enabled to do this because the resources aren't there. This same cycle is the cycle that's, is accountable for chronic lifestyle-related diseases. Hypertension, cardiovascular disease, hyperlipidemia, type 2 diabetes, and some cancers. We know that these are both rooted in inflammation as root cause. So we know that lifestyle medicine that's been advanced here over the past 15 years and is primarily directed at attending to these specific chronic lifestyle-related diseases improves and even reverses and can prevent some of them. So why would we not try to do both in our patients with these comorbidities and a musculoskeletal condition? Because they do share the same roots. So that's my whole justification for trying this. Okay, so what is lifestyle medicine? Well, there's all these different types of categories of medicine I've got listed here. So traditional medicine that we're all born and raised in and is, you know, evidence-based, but typically the patient is a recipient of something passively given to them, right, or encouraged to do, but they're typically a passive participant. Integrative medicine is where we integrate the experience-based and complementary evidence-based treatments. Complementary and alternative medicine is an approach to care. It may be more unconventional. There is some, obviously, some evidence-based approaches, but as things evolve and are new, some of those things can or can may or may not fit an evidence-based model. Functional medicine, it focuses on the physiology and the biomechanical imbalances and processes of cellular metabolism. They look a lot at detoxification and controlling oxidative stress. Some of this is evidence-based and some is, you know, evolving, and part of that, I would say, is because we don't always have the right tools to measure the exactness of some of the interventions and theories that are behind functional medicine. Then there's mind-body medicine, which is integrating the interactions between our emotion, our behavior, and how we feel. There's a spiritual aspect to this, and there's some, the treatments here may be somewhat mixed between evidence-based and not. There's preventive medicine, which includes all the aspects of mortality and mobility, and it's really looking at more evidence, it's evidence-based, but it's looking at population health, which we're now all more familiar with after a pandemic. And then there's lifestyle medicine. So what is that? So lifestyle medicine focuses on educating and motivating patients to change personal habits and behaviors, and it's directed through these six pillars. Nutrition, which is a whole food plant predominant dietary lifestyle, regular physical activity, restorative stress management, elimination or reduction of risky substances, and positive social connections. All the treatment recommendations are evidence-based, and the big thing is that the patient has to be an active participant in their care. This is not something I can possibly give to somebody, and not everybody is at a point to do it. So picking people that are right for this is really, really important. So there's six, these are the six powerful interventions, and these are the six pillars. I'm giving you a little bit of the evidence on osteoarthritis that fits some of these, and hopefully that's helpful to you if you're trying to promote this in your practice. Also know that there's many people endorsing this, that the lifestyle change is the first line of defense, and the clinical guidelines that state that diet and physical activity changes are critical first treatment for many chronic conditions, and can often be utilized in people prior to medications if they're in early stages or in a stage where they would like to make a lifestyle change. Again, it's reinforced by some of these leading national and international organizations, including USDA, Harvard Public Health, the Culinary Institute of America, American Diabetes Association, American Heart Association, etc. We know lifestyle change has this power to prevent disease. I've just got one or two slides, again, if you can use these. The Diabetes Prevention Program has been shown that 58% of people had the reduction, it was like 58%, sorry, reduction in incidence of diabetes in people who adopted this plan of treatment. So you can see the graph here where the placebo is, people treated with metformin as the typical first line of offense in people who are diabetic and lifestyle. So that's a real life example of that. Again, what is lifestyle medicine? We just talked about it, but the three take-homes is treat, reverse, and prevent by using lifestyle changes. If you're looking for more information about how to get educated, coursework, CME, a lot of it they've got for you online. The best first place to stop is the American College of Lifestyle Medicine. It's a truly interprofessional group of people and healthcare providers that provide education and certification, and they're trying to bring this. It's a different type of organization. They're trying to bring these evidence-based treatments to full light so that they can become a part of our usual baseline healthcare education. So as a result, they have a big push towards giving as many things away because the more word they can spread, the more they attain their goal. So why UI now? I would say, I'll give my spiel again here at the end, physiatrists are well-suited for this. We all need a little education, which is accessible to you, and as we go towards value-based care, this is the place to be. It's very hard in the fee-for-service model, which I'll show you here in a minute, but again, this is a great time to be thinking about it. And we know it works. So the diabetes prevention, we talked about 58% versus 31% of people with pre-diabetes actually avoided getting type 2 diabetes through lifestyle interventions, almost twice as many as those who took a common prescription drug, which is a metformin. The CHIP program, which primarily focuses on nutrition and stress reduction out of Vanderbilt, showed that the return on investment was around, they saved about $67,582 to be spent on people who adapted these lifestyle changes and had diabetes. So there's an economical benefit to certain people, right? So self-insured and companies are very enlightened into this. Probably our third-party peers are, if we can figure out how to package for it. And then we've published on the work out of WashU that shows the program is feasible, and this was one of the initial cohorts out of the program in the pilot. 81% of our patients were able to complete the program. 60% of those people achieved their goals, and although we don't have outcomes out on it yet, because I've got masterwork, Abby Chang and Daviani Hunt are still working on cleaning that data, but I'm hoping you see it soon from WashU on the very specifics of the outcomes. An early finding was that we reduced anxiety. That was actually one of our biggest findings. So it was great. When we reduce anxiety, we know people can go towards self-management. So what about the program? So the program I'm talking about specific is an intensive lifestyle medicine program, which means, what I mean by that is it's 90 to 150 days. So there's a start and a stop, and the patients receive services simultaneously. And so this interprofessional team approach then really puts community and support around patients who are ready to make a change. It's innovative because it's patient-driven goal setting with an interprofessional team, again, delivering this care, and we are trying to address root cause of pain and poor function with personalized medicine and engaging the patient to direct us based on their own goals. What I mean by that is, I'm going to enter this program. I have diabetes. I'm overweight, and my knee is killing me. What are your goals? Well, I want my knee to feel better, but I want my diabetes to be more managed, so I know I need to lose weight and become more active. So we set those as the goals. So we say goal achievement is that was that patient's goal. Did they achieve it or not by end of program? There are the interprofessional goals. Again, we're trying to improve patient outcomes related to the musculoskeletal spine care. We want to improve management and reverse their chronic lifestyle-related conditions, and then a big plan. The big goal is that they do this and that we can get a significant number of people to adopt these changes for the long haul because we know they're going to be healthier. You're going to be able to self-manage their musculoskeletal condition better, and the healthcare system is going to benefit from a cost sampling. Again, what is the financial gain? Again, if financial portion of this, again, if we can improve pain and function in these co-founding disorders, the co-founding disorders have associations with money saved. If we can help patients mitigate risk prior to elective surgeries, then we'll have more patients without chronic problems or complications after surgery. Example is I work with a lot of joint replacement surgeons, and they have patients that need to have risk mitigation prior to surgery. We enter the program, and the goal is to hit the jackpot and be able to have that hip replacement. Again, our overall overarching goal is if we can show we actually save the money system, we're going to find a way to get paid for doing this to make people healthy. This is the Lifestyle Medicine Center at Washington University. It's called the Living Well Center. It took about five years for us to get to this point. That's me with my former partner, Daviani Hunt, who serves as a medical director and is really instrumental in introducing especially the form of nutrition and how we can affect people. We actually had a physical space, and guess what? It opened on the Friday before the pandemic, so we got to pivot quickly into hybrid mode. Honestly, it's beneficial because there's much of this you can deliver virtually. I'm over here on a Zoom. That was our first Zoom meeting, and I'm pointing to the kitchen. I always have to show the kitchen because I gave away the third child. I never had to get that, but we have a demonstration area. You can Zoom in and out of there. There's a conference room associated with it, so we can have small group gatherings for educational things for patients in the program, and it's just a really cool space. What did our feasibility show? Again, this is an intensive program that was performed there, and this is from the publications. This is one of the cohorts in the pilot group. It was about 26 patients age 58. Again, we had a large age range. 19 had a primary spine diagnosis. 10 had osteoarthritis, and 3 had both a spine and a peripheral joint-related pain problem. 20 patients had set the goal of avoiding an elective spine or joint orthopedic surgery and managing their condition on their own better, and 6 had the actual goal of optimizing their metabolic comorbidities in order to become a candidate for surgery and reduce their risk. Here's just what the patients looked like. We had, you know, it was about 50 percent women, and the little figure here is showing all the different comorbidities they had. Obesity obviously was a common one, depression, anxiety, cardiovascular, pulmonary, and even endocrine there. Again, 81 percent of them completed the program, and 62 percent met their goal. This is an important slide because, you know, I would have assumed if you give Heidi a resource, she's probably going to use it too much, right, because she's been dying to work with a dietician and counselor for 20-something years, so she's probably going to overuse it. Well, that's not what our data showed. Our data showed that the mean total visits for people and their average range was about 120 to 150 days in the program. Their total visits was somewhere around 10. Now, this is an average. We had some people far less and some people far more, but that mean was somewhere around 10, and depending on which profession they worked with, and they usually worked with two to three at a time, not more than that, on average they did individual visits with those folks between three and five times. So, oh, I didn't spend as much time on those folks that I thought, but I think it speaks to the fact that we're giving it simultaneous care, and we meet about the patient. I'll show you that here in a minute. On a regular basis, the team meets, and you could change the course of the care as it evolved and the patienthood changes. Again, here's our MCID improvements in anxiety that we're quite proud of, and going forward, hopefully you'll see some more specific outcomes coming out of that. So, what did we learn out of the pilot at WashU? Well, the model works. The most utilized services were, guess what, the ones patients don't have access to most of the time, which is the dietitian behavioral health and acupuncture. We found that picking the right patients was key, and in the beginning, you know, seeing a lot of heart patients in my life, been at it a while, I know exactly who needs this. That wasn't right, and I'll go through what we learned on how to pick patients right for this. Referral patterns within our department was actually slower than I thought it would be. I had a lot of people saying yes, yes, yes, but then when it came down to referring, there was a gaposis there, and so I've learned from that and trying to avoid those still, those things here in New York as I started the program here, and then payment is the biggest issue, right? Fee-for-service model, patients have to be able to afford those services that are out of pocket. Our healthcare system was willing to let us try this, but the hospital is not willing to supplement, so there was a lot of philanthropy on my part to get that up and going, and that's just not a sustainable model over time. This fee-for-service model enables us and encourages us to spend money. It does not encourage us to save money, right, and so that's it's the whole quagmire why things, you know, don't work well for particularly patient populations like this. So this is a little bit busy, but lessons learned. This is how I'm starting the program at Hospital for Special Surgery. So I'm going to, I'm primarily starting with osteoarthritis patients just as a pilot program, and I've got six people in. I'm very proud of that. We just got off the ground, so you can see the little figure over here. The person with the patient has osteoarthritis, and if they are or are not indicated for surgery, determines their pathway. We're developing an osteoarthritis comprehensive center here, and I'm also helping lead that. That's going to be value-based and cost-shared savings. So we end, they go into a conservative pathway, and we've got it, we've got guidelines for that, and if the patient is in that conservative pathway and they seem to be a lifestyle medicine candidate, but multiple comorbidities and a osteoarthritic painful process, they may be offered the Lifestyle Medicine Intensive Program and continue on through a conservative path. On the same side, if they see a surgeon and they have, they're a candidate for surgery, but their health care risks are too high, their diabetes out of control, they're too obese, or they have too much hypertension, then they can come to the Lifestyle Medicine Program. We'll help mitigate those risks and send them back to their surgery. So this is the only way I know in the MSK world to kind of help it local log in the fee-for-service model because I can enable people to get surgeries to pay the bills in the fee-for-service model, but because, you know, we're sneaky, we know it works well in the conservative management group. We actually know there will be some people that might avoid surgery. I won't tell the president of the hospital that, but probably that's going to happen, at least for a period of time, and that's, you know, that's extending or reducing morbidity, improving function, reducing pain, and if we get some longevity out of it as well, just what we're in it for the long haul, that will be helpful. So the purpose of the HSS pilot program is, I've been told, they've unleashed me and said, just find some people and get them healthier, produce some data, and then we'll go and ask for resources to become a full program. We'll work towards a sustainable model, and we're going to, big thing is changing thinking, and that's really the hardest thing is that mindset of what patient will do well with this and that we actually can help them by enabling them to make the change they need. So this is the graphic for how a patient proceeds to the program. So the patients refer to the program, and we do an extensive risk screening, includes BMI, blood pressure labs, smoking and alcohol intake. We do their abdominal and their neck measurements. We do a sleep analysis, not a sleep formal testing, but just sleep, pain to wake you up, quality of sleep. Their physical activity, we look at are you an active participant in your health care, and do you have a social support system, because we know patients are much more likely to make it through successfully if they have a community with them that will help them, enable them to make these changes. I'm using, we're using the PROMIS-10 general health and mental health score, and then I'm also asking everyone at PHQ-4. The PHQ-4 is one of the more standardized mechanisms of helping establish anxiety, depression. It's just four questions, so I'm using the four one because this is a lot of intake for folks. The biggest thing that predicts the person that will do well in this program are people who ascribe to these next two questions, and it's based on the trans theoretical model for change. So the questions we ask are, are you interested and willing in making a lifestyle change to improve your health on a scale of 0 to 10, and those who score 7 to 10 on that scale of 0 to 10 are more likely to be successful in this. We also ask the question, how confident are you in making this change, and again on the same scale. So I'm, you know, I'm stacking the deck in my pilot program. I'm trying to find some 7s to 10s so I can have some ringers and have some good data, but I also know, and there's a lot of folks that fall in that 4 to 6 range, and we can have other programming later that will help address those, and maybe somebody comes into an intensive program later. So the patients then enrolled in the program, we do a goal-setting session, which is what are your goals, and how we, how do you plan to get there, and how can we help you, and then we actually help coordinate their care. At that enrollment and goal-setting session, it's right now that's being done with me, we really talk about what have they done specifically for their musculoskeletal health in the past, and what did or didn't work, and then we devise the program based on that, and then where they've struggled with on the metabolic side, what has or hasn't worked, and that's where the patient with me comes up with an informed way of picking which professions should they start working with first, and then how it'll evolve as they go through the program. We actually help coordinate their appointments. I've had some people say, I'll come just because you're going to make the appointment for me, because that's such a big hurdle in our health care system, and then we take metrics along the way. So we look at blood pressure, we look at their BMI, obviously, as they progress through, and then, so the patient starts on their path. Let's say, you know, in our program we have physical therapy and exercise kinesiologist, we have smoking cessation, nurse practitioner, we have dry needling, we have medical massage, we have a whole food plant-based trained dietitian, and we have a health coach that's a licensed social worker. So of all those things, what are the two to three things they can handle doing at once over, you know, every other week? They say one to two or three providers, and we start them on these individual sessions, and then about halfway through, their care team. So if they're seeing the physical therapist, the dietitian, and the counselor, those three people meet with me, and we discuss the patient's goals. Are they adhering? What are their struggles? Have they accomplished something and might need help from another service? So the patient's course of care is very individualized as they go through the path. That meeting is super important. It helps us speak the same language to the patient, it helps us alter the course of their care, so we can get rid of services they may not need anymore and add ones they do, and it also is a great training ground between professionals. So we found that extremely helpful. It is something that's very unique to this program versus other intensive programs for, say, diabetes or cardiovascular disease. So the patient may hit their goals, and they would graduate from the program. In the effort to create community around this, we also have group programming, and there's ways to build for that, and that may be something you may want to just start on your own as a way you do it as an individual, where you can have 10 people on at a time. You can charge for that. There's a way you got to do it and a way you got to code, but it allows you to get this educational piece out in a group setting. There's community in the group setting, and patients can get their questions answered. I find that very rewarding. It's a very fun part of it. Our first group programming session will be on sleep. Wash U has now got an entire curriculum on this. It has taken a long time to build, and so I'm just in the throes of getting that started again. One thing that's really unique about the program where you do the goal setting is actually sign a contract with the patient. I find this very enlightening compared to other ways. I've had practiced medicine in the past where a patient says, these are my personal goals, and they sign, and then I sign below them saying, I'm going to do everything I can to help you get there, and it's a very wonderful type of it's a moment in time that the patient recognizes this is different. It's different this time. I've got a team behind me that's going to help. Here's our bi-monthly team conference and all the different people that are at the table and communication. We've actually got a qualitative study on this coming out of Wash U. We work with the Brown School of Public Health on it. I can't wait for you to see that. This is my pilot status now. I've got about six people enrolled. Two are trying to have a total joint replacement, and four are trying to feel better and manage their problem, and this is a big collaboration across the system that's not necessarily used to having collaborations, so it's not easy. I'm used to being told no. I've had a lot of encouragement and support at HSS, so it's been great. I work with a perioperative team. I have to relate with billing. There's all kinds of processes you have to go through. Again, American College of Lifestyle Medicine has stuff on their website that's free that can help you figure out what you can do in your system and doing that, and then we're just moving forward. The goal is to have data by the end of the summer that I can then turn into a full program ask of the hospital system. How else can this benefit people? Where's that other target zone? There's your own personal patients, but if you work with someone who's self-employed or you work for or work with a corporate partner who's self-insured, there's a lot of evidence on the increased employee engagement and productivity when lifestyle medicine things are approached, healthier workplace culture, reduced absenteeism and presenteeism. Presenteeism is when you're there, but you can't do your job fully because you don't feel good. There's reduced healthcare cost, care, and insurance costs, lower turnover, recruitment, onboarding costs, and a workforce living, again, the HSS mission. So this is a part of I've now learned, I've gotten a great education at HSS because they have a value team and they have a contracts team and they have several corporate partners here that are very interested in a model like this. So I've learned that my pitch to an employer needs to be very different than my pitch to you to become involved than my pitch to even an administrator. So that's been a good learning curve. Eventually when I go to the head of HSS HR and HSS is self-insured, these are some of the things I'll be asking them to share with us if we put employees through the program. If I can understand what I save on the employee side, I know what it costs to build my program. I can then take that to a corporate partner or third-party payer and say, hey, the package price for this program, regardless if you cover the dietitian or the counselor, doesn't matter, I'm going to package it. Maybe we might take a risk with them in the beginning. This is the package price for somebody with low back pain and diabetes. Send it to us. And these are what our results are. So again, trying to tie pain and function in with these metabolic disorders that have money tied to them, I think will really help us get to a sustainable model for this outside the future service model. So again, at HSS, I have access to, we're self-insured, we're starting the fee-for-service model in an arthritis program, and then there are already existing corporate partners here that we hope to partner with once we figure out what those costs are. Again, kind of big, high lofty ideas, but I think this is the way to get there. So I encourage you that, you know, this wellness approach should become an area of expertise. Yes, we need extra training, a little bit in behavioral management, probably need some training in nutrition. I don't know. Look left, look right. Who doesn't need that in the medical field? You're already experts on exercise. You know about sleep. There's a few things I've learned about food and nutrition and timing, and that's been very helpful to me. This idea of bringing in social connectedness and the emphasis on that has really been helpful. And then you're well-versed in the effects of mental health or stress and musculoskeletal pain. So there's a lot of these things you already have in your toolbox. It's just putting it in a formula that works for you in your practice. So again, I would really encourage us, and again, that same old thinking, we're getting the same old results. Let's get rid of that and think about this as a way to approach healthcare. So I will stop there. If you're looking for resources, the American College of Lifestyle Medicine, they have tons of free stuff on their website that you can start looking at. I encourage you to think about that. The Plantrition Project is all about the nutrition piece and whole food plant predominant and the science behind that. One of the founding members of that is Scott Stoll, who is a physiatrist. And then that's my email address. I love talking about this, you can probably tell because I talk too much. And just email me if you're interested or have questions or how do I get started. I am so interested in physiatry coming to the table and being partners with the primary care people who have started this and done such a wonderful job of showing disease reversal, particularly intensive programs in diabetes and cardiovascular disease. So John. Thank you, Heidi. There's actually several questions. I'll try to go through them in order. And the first was, is there a role for supplements in this model? Yeah, so that's a great question. So on the whole food plant predominant diet, people are going to recommend B12 because you get B12 from the ground that the animal eats. And so the deficiency in B12 can be a problem if you're not assisted. So basically people recommend a B12 supplement. And then, you know, I think most of us advocate for vitamin D3 supplement because there's such a problem with that. Otherwise, yes, supplements can be there. The thing is, is that the problem with dietary emphasis has been that we've pulled apart the pieces of nutrition in the food we eat. Oh, well, this part of this food is really good. So we'll just pull it out and we'll have it over here. But really, the food is considered a package. And the reason that the blueberry is a healthy carbohydrate is because of the fiber associated with the blueberry. When we grind the blueberry down and make it juice, now it's a carbohydrate without the fiber that our body does not push through and absorb and get the nutrient from. So the more that a patient can eat real food and gets the nutrition they need, that's obviously better. You know, some people can't do that and supplements can be helpful. But it really emphasizes eating whole food, particularly because of the importance of the fibers associated with that. I think that speaks to the magic of cuisine. It's probably a good part of health food. Heidi, there's also a question about, and Dr. Zelnick, I'll ask you to clarify because I'm not sure I understand this, do you have a health, do you have a patient navigator or health coach? Yeah. Great question. So, yeah, and you can use all kinds of different people for this. So at Wash U, I had a nurse coordinator, and thank God, because, you know, managing a really complicated system, I needed help with somebody with medical knowledge. At HSS, that care coordinator is a physical therapist who's doing it in another role and she's phenomenal. I think it's anybody that like helps the patient get to where they need to be, can be of multiple different backgrounds. I think you could double dip, which I think is what you might be talking about by using a health coach. And I think the best in the fee-for-service model, the one that may work the best, again, this is trial by error because we hired somebody else and getting reimbursed was hard, is working with a licensed social worker who may have a health coaching certification. You do not have to be a social worker to get that. If you go to the East Salem website, they'll show you the one organization they endorse for well coaching, it's called Well Coaches is the name of it. And they endorse that one because it does go through all the parameters of lifestyle medicine and people can become certified in that without necessarily another advanced degree. But I completely agree. It's a vital part of this. You know, the counseling piece can really be more of coaching for some people. Hopefully a lot of people you attract. So yeah, I agree with that. Next question, Heidi, is do you coordinate with the patient's PCP and or endocrinologist for optimizing the management? Absolutely. And so and there's a learning curve to that too. So at HSS, I have access to the OVC management internist who's going to be my partner in crime with this. So I've got direct access to an internist if I'm on this alone and the patient doesn't have a primary care. If the patient does have a primary care, I have an introductory letter saying this patient has come and is interested and is a great candidate, will you partner with us and here's what it's about. And what that means is they may need more frequent checks, we're going to be checking their blood pressure often if they're on hypertension or losing weight, that may need to be adjusted. Diabetes for sure needs to be adjusted. If you can work with a dietician who's also diabetes certified, they can help make those recommendations on how to adjust their meds as they go through. So that's another way to problem solve that. But yeah, it's a lot of communication. Okay, Heidi, next question, Dr. Sharma wants to know how you get your institution to pay for your time with patients, but also team meetings and other allied. Oh, you hit the nail on the head with that. So the reason to do a qualitative study on the team meetings was exactly that. We want to show the value of the team meeting and how it's instrumental in developing the patient's course of care. So the point of doing that was that when I do go and ask for a bundle payment model, that that hour, once a month, is paid for in this package price because it's of value. So you're right, that's a big problem. What was the other thing that, on my time? Team meetings. Team meetings. And then my own, yeah. So that's a great question. I can tell you where I am now because they are so interested in this model. No one cares how much time I spend with the patient as long as I get people enrolled. Obviously, that's not sustainable long term. I'll have to have other partners in crime. But yeah, it's kind of a choice you make. For me, it's easy to say that now because this has really revitalized my love of medicine. I feel like a doctor again practicing in this way because I feel like I'm actually promoting health. But you're right, we're better reimbursed for our time now than we have been with the changes in the coding. But yeah, it's an issue. And there's a question, I'll kind of align with the last. Do you ever get your patients involved in the development and delivery of interventions? Absolutely. So in those group meetings that we have with the patients that are in the program, that's a great time to bring in a success story and help motivate that community that's in the middle of that change. And the patients who would come back and do that for us loved it. The big dream goal long term is that you've got repeating curriculum that's available on the web or in a hybrid center, you know, when everybody's actually allowed to be with each other again, that people who've been in the program can attend. And it be kind of a life community base for that person over time, because we all wax and wane with things. And we have to have community behind us making those changes. There's also a question about training. And are there any currently any residency PM&R residency programs that offer anything in lifestyle medicine training? Not that I know of, but I can tell you it's on the radar for Daviani Hutton and I. We would really, really and we may have to do it together to get it up. Here's the beauty. If there's learners on that are med students or residents, they actually have an online curriculum for ACLM. So you take the actual stages and the curriculum is all hybrid or all virtually based. The reading material, all that is supplied. And then to become certified in it, you just have to have a clinical experience with, I think it's three months with somebody practicing lifestyle medicine and you can actually become a diplomat. So Daviani and I are very interested in becoming one of those sites at some point in the future. Okay. I actually have a few questions. With respect to, you know, picking people, I think obviously at this point you want to pick people that can portend success, but ultimately we have to reach more people. And how do you reach people that are reticent, I presume to change, let alone to consider something different? Right. I agree. So you kind of follow the kind of the steps for that, that's out there in the evidence and it shows that people that are in the pre-contemplation stage, which is, I need to lose weight. What do you mean I have to change the way I eat? Right. Okay. They're in that stage. Right. And then there's the people that kind of shift over, like, I need to lose weight. If I run, I can lose weight. I've bought the running shoes, but I haven't put them on, I haven't made it out the door. And then there's the people that are shifting towards, I'm ready to make the change. And then there's the folks, I'm ready, I'm going, I'm looking for that, that group right now because I got to get a sustainable financial model. The literature shows it's about 20% of people are in that seven to 10 range out on a scale of zero to 10. So the other 80% are over here. Right. And we see a lot of them every day. So how do we get that out? So one would be to have a program in addition to an incentive program, which is Wash U they've developed it and it's called Selective Services. So that's a person who comes in and says, is there something way I can eat differently that makes my knee feel better? Or I've tried to lose weight and I've done it before, but is there a different way? And blah, blah, blah. They've opened the door, but they're not really all on board with complete change. Those are folks that they can go through a Selective Services program, which is not tied to a certain timeframe. And they might see one or two of these people in the program at a time. So like they could see the dietician, the counselor, and that might spread over five to six months. And some of those people may convert into something like, hey, I'm all in, I really need the intensive program. And you put them in. So that's one way. Another way I'm being kind of sneaky in doing this at HSS is I'm also in charge of building the clinical piece of a comprehensive osteoarthritis program that's system wide. And this place is in four states and 1% of all total joints are done at this hospital. So it's crazy, the numbers that are here. So they put me in charge of this. And so I, when I was sitting there, I was like, how do you make this different than any other program? And how do you show quality? And what is it that we don't do well with patients with osteoarthritis? Well, what is it? Oh, it's, we're not very good at educating. We need to give them more options for interventions besides coming and get your steroid shot or your visceral supplementation every six months, right? So I came up with the idea, can we, if we flag patients with osteoarthritis in our system, which will be several thousand a month. Every one of those that's not proceeding on to surgery will then be given from, not opt-in, it's given directly to them through their phone, educational information on osteoarthritis and how to live with it and how to manage it better. And guess what I did? I put it in the six pillars of lifestyle medicine. So the goal is you start educating people over here, hey, making a change can help. And you'll start to pick, I'm hoping, momentum is the right word, on getting people to like, hey, there is this alternative and it's over here. And this healthcare system values it and is actually supporting it because of the value they place on it. So that's one way I've done it in my community. I think in your own practice, you know, those messaging through educational events, hey, I'm going to give a talk on how to eat, you need feeling better, and 10 of you can come in and we'll do a Zoom call together. There are ways you can do that through group programming. That would be another way. And out of that, you'll start to see which patients really are motivated for change. Heidi, this is, there's a very insightful question here. It's probably got a long answer to it, but if you could succinctly say what you think, because this is aspirational. But, you know, the elephant in the room is the underserved community where much of these problems lie. How do you envision that these people could be reached and actually partake in such a program? That's my long-term goal. If we can find a sustainable model, we show that we save the healthcare system, this is something that can be accessible to anyone who needs it. Because some of the, and the pandemic has helped us demonstrate who those people are. And I think until we get to a sustainable model, it's going to be for people who can afford it. And we've got to get past that. One example of, you know, and part of it is getting the word out. I'm a terrible tweeter. I'm a terrible everything social media, the computer is probably going to blow up any moment now, but the New York mayor came out endorsing lifestyle medicine as a portion of treatment, reversal, and prevention for chronic disease, including the whole food plant-based predominant diet. And I thought, well, gosh, I wish he knew that, you know, HSS was doing this in a very unique way. And here in your city where you're promoting this and wanting to put money towards it. And so I talked to the administrator of ACLM, and he sent the email introduction to the mayor of New York. So those little things we can do to communicate, whether it's local administrators, whether it's nonprofits in your system, just start putting the word out that you're doing that because it's going to start, it's catching on, it's catching on. ACLM has been around 15 years. They started with, I think, two or 300 members, they're over 10,000 now. They're certifying about 2,000 at a time. It's grown by leaps and bounds. So I think, you know, putting the word out there and putting yourself out there as somebody interested in it is important. And I'm not great at it, I'm working on it, but I think it's important. Well, if you get the ear of the mayor, that'll be more than a little thing. So there's another question about physiatry and getting involved, and how do you, what would you suggest for physiatrists who want to penetrate this sector as either in their institution or in their private practices? Yeah. So one is getting that little bit of extra education. You know, I came up with the idea for the Living Well Center at WashU out of frustration and I knew what people needed. When I was first pitching that at WashU, they were just coming out with like the baseline board book for lifestyle medicine. It was actually published the year, or started to be published the year that I started this. If I had had that as a format, I wouldn't have taken five years. I would have known a lot more. I wouldn't have made as many mistakes in trying to get this going. So I would suggest getting a little bit, you know, getting more education. Again, there's a lot of online, the meeting you'll love because it's like-minded people. There's a lot of networking. The ACLM does a lot to try to get systems together to figure out what works in yours because everybody's payer is different. So I would say that's a good place to go. The Plantrition Project really dives into the nutrition piece because to me that was the hardest thing to learn, the nuances of that. They have evidence on all of those different chronic diseases are there and what's good evidence and what's not good evidence, which is always important. So yeah, I would say those are places to start and you can start with each individual patient. For example, I had a patient that I knew would be great for the intensive pilot program here. And we weren't starting. I said, hey, can you wait till I start? And she said, great. And she was on this crazy diet. And I said, okay, can you go talk to this dietician? Okay, yeah. Center's the obesity management. It wouldn't pay for her drugs. So she's doing it on her own. By the time she's entered the program, because we had one conversation about where to go get the information about nutrition and exercise, she lost 30 pounds before she entered the program. And my administrators can't believe it. I'm like, yeah, you just have to, the door is open, walk through it with the patient, provide that support. And it's very rewarding. So do you think, Heidi, at the private practice level, small or otherwise, it's doable? Yeah. If you go to ACLM, you'll notice that people that are there either work for a healthcare system that's bought into this, work for a third party payer, or they said, screw it with normal healthcare America. I'm going out here. I'm taking a leap. I'm a small group, and I'm going to practice medicine this way. It's very dichotomous right now. So I feel like I'm in this situation where I have an opportunity to try to find a sustainable model because that individual practitioner is just trying to keep the door open. So it is very amenable. You obviously have to have like partners, counselor, coach, or a dietician that works with you. And you have to figure out a sustainable model and a payment model that works to supply that. But that's what you'll actually see when you go there and there's so much networking that goes on and how to do this financially, that you would get resources there. When is the lifestyle medicine annual meeting, or do they have more than one? It's usually in the fall. I believe the next one is in Orlando. I'm not sure exactly. I don't have it memorized. It's usually kind of close to the AAPMNR meeting within usually three weeks. They do record a lot of things. So if you couldn't physically meet, and again, they have this big emphasis on just getting the message out, getting the education out, the more people they can educate, the happier they are. So that some of those barriers, because of their structure, some of those barriers that are in the Air Force and other types of educational things aren't there. So I do encourage that. The Plantrition Project, I believe it's in September of this year, and it's two weeks after Labor Day. It's in California. So that'll be a cool place. Both of these meetings have great food. When you pay, you get fed as well, so it's awesome. Well, Dr. Sommer posted the conference link. Thank you. Thank you. So we're a little over, and I want to thank everybody for participating. We had a lot of good questions, and we had a great turnout, and Heidi, it's always a pleasure to hear you speak. I'm really, really happy that you agreed to do this, and thank you very much, and I'd let you take the final word, if you'd like, anything you want to say. No, I'm just so grateful for your interest. Please email me. Hopefully we'll see each other in real life this next fall, and tell me your stories too, because the more momentum we can get with this, I think it's really going to be a star for our field. All right. Well, everyone, have a good night, and we'll see you next month, I hope, for National Ground to Ground.

Dr. Heidi Prather

lifestyle medicine

physical medicine and rehabilitation

chronic conditions

comprehensive approach

patient care

nutrition

physical activity

stress management

physiatrists