Expanding the Lifestyle Medicine Inpatient Consultation Services at Loma Linda University Health: A Transformative Tool for Chronic Diseases Management in Tertiary Care Settings

Abstract

Lifestyle Medicine (LM) is an emerging field dedicated to the prevention, management, and reversal of chronic diseases by promoting healthy lifestyle choices. LM utilizes six pillars targeting the root causes of diseases to promote health, improve clinical outcomes and significantly enhance overall quality of life. They include plant-based nutrition, physical activity, sleep health, tobacco cessation/managing risky alcohol use, and spiritual/emotional well-being. LM holds great promise as an evidence-based solution for the rising rates of chronic diseases and healthcare costs in the United States. Loma Linda University Health (LLUH), a pioneer of LM, has successfully implemented a phased expansion of its novel LM inpatient consultation services to positively impact the trajectory of morbidity and mortality among patients with chronic conditions and/risk factors admitted to the hospital. This was achieved by boosting awareness, hiring LM-trained providers to meet growing demand, and making consultations accessible hospital-wide. The service has been very well received and saw a 50-fold increase in consultations between 2016 and 2022. It is also reimbursed by all major insurers.

LLUH’s experience shows that establishing and growing an inpatient LM consultation service is a viable clinical and cost-effective chronic care model that can be utilized in a tertiary care setting.

“The service was positively received by both patients and providers, resulting in the decision to expand to most adult specialties within the LLUH main hospital campus.”

Background

Lifestyle Medicine (LM) is an emerging healthcare field that can transform healthcare delivery practices. At its core, LM promotes a sustained adoption of healthy lifestyle choices to enhance patient recovery, mitigate the acquisition of related comorbidities, and improve quality of life.^1,2 It is the non-medicated and non-invasive management of chronic diseases ³ particularly suited for patients with chronic conditions in an era of staggering health costs and primary care shortages. LM aids in controlling escalating medical costs by addressing the root causes of these diseases, without the exorbitant prices and detrimental side effects commonly associated with pharmacologic or interventional therapies.

In 2018, almost one-third (27.2%) of adults in the US had multiple chronic diseases, and over half (51.8%) were diagnosed with at least one chronic condition. ⁴ In the US, obesity rates rose by 11.4% in the 20 years since 1999, ⁵ incurring $173 billion in medical costs—$1861 higher than for those with a healthy weight. ⁶ Health care spending in the U.S. in 2021 was $12,914 per person, ⁷ which is more than twice the amount spent per capita in comparable countries. ⁸ It is projected that by 2030, half of the adults in the US will be obese and health costs will continue to rise ⁹ and if nothing is done to stem the tide, these numbers will spiral and eventually overwhelm the US healthcare and financial infrastructure. ¹⁰

This snapshot of the current unfavorable healthcare situation in the United States emphasizes the crucial importance of investing in and utilizing Lifestyle Medicine (LM), a low cost, evidence-based modality for managing chronic diseases in tertiary care settings.

This paper provides a detailed account of how Loma Linda University Health (LLUH) pioneered its unique inpatient Lifestyle Medicine consultation service as a long-term solution to healthcare challenges in the United States. We discuss the process, strengths, and challenges in expanding the service. By highlighting our experience, we promote Lifestyle Medicine as a cost-effective and practical clinical model for managing chronic diseases in tertiary care settings and improving patient outcomes.

Methods

The timeline for the expansion of inpatient LM consultation services covers the six years following the founding of the service at LLUH in 2016. We targeted the adult inpatient population for expansion of our services, with a focus on two main locations: the rehabilitation/stroke inpatient hospital campus and the main LLUH hospital campus.

Team observations and interviews, electronic health records, and provider schedules were the data sources for this report. The key tools for the expansion of the service included growth of the trained workforce, broadening of the patient panel, as well as increasing visibility and accessibility of the consultation service, with an emphasis on building a strong referral base for multi-condition and multi-disciplinary consultations.

A strategic decision was made to hire LM-certified providers (MD and APP) with varied clinical backgrounds who could work synergistically with other medical specialties to offer multi-pronged and targeted intensive LM care to patients during their hospital stay. Consultations were provided to patients who met the criteria in terms of chronic disease comorbidities or risk factors, irrespective of the reason for admission. For example, a patient admitted for a femoral fracture following a motor vehicle accident would be eligible for a consultation if that patient also had a chronic condition like obesity or alcoholism. Consultations were provided on an individual basis, with additional group sessions/visits provided for patients at the rehabilitation hospital campus to take further advantage of their prolonged inpatient stay.

It was important to convey to referring providers that patients needed to be stable and alert or have a family member present during the consultation as LM consultation requires the patient to be an active participant to some extent.

During the pandemic, most visits, especially for patients admitted with COVID-19 were conducted virtually so despite stringent isolation precautions, patients were still able to benefit from LM consultations.

Results

The number of LM consultations has increased exponentially from only 3 per month per month in 2016-2017 to 152 in 2021-2022. The consultation service now operates every day of the week, in contrast to only 1 half a day at inception. The workforce grew from one LM certified attending physician and two rotating residents on the consultation service, to one LM certified attending physician, one LM certified advanced practice provider, one LM fellow-in training, and several rotating residents and medical students providing consultation services across the 2 hospital campuses.

Service provision was expanded beyond primarily consulting for neurology rehabilitation stroke to all major clinical areas including the hospitalist, cardiology, general surgery, OBGYN, and neurology services, essentially catering to the entire adult medical patient population, with at least one chronic condition or risk factor within the LLUH main hospital campus, excluding the pediatric, orthopedic, and behavioral health medical centers.

Consultations were provided at various locations within the hospital including patient rooms, emergency room (ER), as well as the ICU and peri-operating areas if they were stable. Telehealth and language services, including American Sign Language (ASL), were utilized if needed.

Patients who were open to nutritional changes while on admission were encouraged and supported in making healthier food choices. Targeted educational and motivational LM videos, websites, books, pamphlets, QR codes, articles, and even plant-based trial meal plans were provided to educate and support patients and their family members, and were well received. A grant-supported effort is underway to provide plant-based hospital menu options so that patients can experience healthy plant-based foods and jump-start their nutritional and overall recovery while still being admitted to the hospital.

Some of the most common reasons for consultations included disorders related to tobacco or alcohol use, obesity, type 1 and 2 diabetes mellitus, autoimmune diseases, chronic obstructive pulmonary disease (COPD), cancer, obstructive sleep apnea (OSA), non-ST elevation myocardial infarction (NSTEMI), ST elevation myocardial infarction (STEMI), heart failure, hypertension, and chronic kidney disease (CKD). All major insurances including Medicare, Medicaid, and commercial insurers covered LM inpatient consultation services during this period. Billing was done using Relative Value Units (RVU) coding at levels 2 to 4 depending on whether it was a new patient visit, follow-up visit, or patient is being seen as part of a group visit model.

Of note, all major insurers covered reimbursements for inpatient LM consultation services during this period allowing for availability of the consult service to more patients irrespective of type of insurance and covering a wide range of chronic medical conditions. Patients who would not have had any opportunity to access LM services were able to do so irrespective of the type of insurance they had.

Discussion

In 2016, LM physicians at LLUH pioneered and implemented a novel hospital-integrated LM inpatient consultation service in response to the disease and financial burden facing patients with chronic diseases. A 6-week trial was launched after two years of planning, testing, and resource development. The goal of the trial was to reduce the risk of hospital readmission for neurology rehabilitation stroke patients. The trial involved providing these patients with a consultation service within the LLUH rehabilitation hospital. ¹¹ The service was positively received by both patients and providers, resulting in the decision to expand to most adult specialties within the LLUH main hospital campus.

Although outpatient LM services are more commonly seen in outpatient and group settings, offering LM services in the inpatient setting is both innovative and bold, and until LLUH, had not been attempted in the United States. In this unique initiative, LM-certified providers deliver LM interventions to inpatients with various chronic medical conditions in a tertiary care setting.

Inpatient consultations are particularly valuable because patients are often more receptive to messaging on lifestyle change after a serious or life-threatening event. Family members are also more likely to be more supportive of patients during this time.

By employing motivational interviewing, providers evaluated patient readiness for behavior change, elicited barriers to change and helped patients anticipate and plan for potential pitfalls to maintain the changes made. They also help patients set SMART (specific, measurable, achievable, realistic, and time-bound) goals which were utilized to build a longitudinal care plan for the patient both while on admission and after hospital discharge.

Our strengths included the capacity to provide high quality, standardized, and comprehensive LM care by LM certified providers, who have undergone specialized training and/studying, passed a rigorous board exam and were board certified as LM physicians/providers by the American Board of Lifestyle Medicine (ABLM for MDs) and the American College of Lifestyle Medicine (ACLM for APPs). Another plus was our ability to deliver LM services to inpatients with a wide variety of chronic conditions and risk factors throughout the duration of hospital stay and regardless of the type of insurance coverage they had. Finally, we had an infrastructure already in place for LM outpatient follow-up care which was also covered by insurance.

We must point out that challenges are an expected and necessary part of an endeavor such as this because it allows for learning and growth. We set out to identify and tackle the following main challenges; initial buy-in from hospital stakeholders and colleagues, optimizing patient recruitment to ensure the service’s viability and to increase its reach, as well as tackling loss to follow-up as evidenced by the less-than-ideal uptake of outpatient LM services after hospital discharge.

A robust communication and action strategy was deployed to increase awareness and optimize patient recruitment. Several processes were analyzed and instituted including but not limited to meetings with department heads and clinical teams, peer to peer requests, strategically placed flyers around the hospital campus and clinical areas, intra-hospital emails, calls and EMR staff messages and we obtained pragmatic feedback on ways to improve our service.

To further support patient recruitment, business process automation (BPA) is being added to the EMR system to alert referring providers of eligible patients based on set clinical parameters. The BPA will also automatically generate a consultation request within the EMR for the provider to sign, streamlining the process and making it easier for busy providers to place a consultation request.

Enhancements were made to promote continuity of care by providing information to patient while on admission about the availability of insurance-covered outpatient follow-up care and then on discharge outpatient LM appointments, preferably with the provider they saw while on admission were made and added to their discharge paperwork to make it easier for patients and their family members to remember and plan toward. Reminder calls were also sent to patients from the outpatient clinic close to their appointment dates. Patients, however, must use available outpatient follow-up services for continued support to successfully sustain long term lifestyle changes.

Conclusion

Lifestyle Medicine (LM) is vital for the future of US health care. Its potential for transformative impact on healthcare delivery, including quality of life improvements and cost savings, cannot be overstated. Adding LM to the inpatient and acute care toolkit for managing chronic diseases is a step towards addressing the nationwide chronic disease epidemic and rising healthcare costs.

LLUH has successfully implemented a hospital-integrated inpatient LM care delivery model that is leading the way in the field. With the expansion of inpatient services, more patients now have access to LM services than ever before. We have demonstrated that the inpatient LM chronic care model is feasible and can be replicated in like settings.

As we continue expanding our services, the focus will gradually shift to building capacity for efficacy measurements of LM interventions.