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Mayo Clin Proc Innov Qual Outcomes
Mayo Clin Proc Innov Qual Outcomes
Mayo Clinic Proceedings: Innovations, Quality & Outcomes
2542-4548
Elsevier

S2542-4548(24)00042-0
10.1016/j.mayocpiqo.2024.07.001
Editor Invited Waived Article
Redesigning the Care of Musculoskeletal Conditions With Lifestyle Medicine
Artz Kristi E. MD kristi.artz@corewellhealth.org
a∗
Phillips Timothy D. PT, DPT b
Moore Janine M. PT, MS, OCS b
Tibbe Kara E. MBA a
a Lifestyle Medicine, Corewell Health West, Grand Rapids, MI
b Population Health, Corewell Health West, Grand Rapids, MI
∗ Correspondence: Address to Kristi E. Artz, MD, 435 Ionia Ave SW, Ste A210, Grand Rapids, MI 49503. kristi.artz@corewellhealth.org
12 8 2024
10 2024
12 8 2024
8 5 418430
15 3 2024
18 6 2024
1 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Value-based health care has been accelerated by alternative payment models and has catalyzed the redesign of care delivery across the nation. Lifestyle medicine (LM) is one of the fastest growing medical specialties and has emerged as a high-value solution for root cause treatment of chronic disease. This review detailed a large integrated health care delivery system’s value transformation efforts in the nonoperative treatment of musculoskeletal (MSK) conditions by placing patient-centric, team-based, lifestyle-focused care at the foundation. With an economic and treatment imperative to reimagine care, recognizing more intervention is not always better, a collaborative approach was designed, which placed functional improvement of the patient at the center. This article described the process of implementing LM into an MSK model of care. The change management process impacted clinical, operational, and benefit plan design to facilitate an integrated care model. A new understanding of patients’ co-occurring physical impairments, medical comorbidities, and behavioral health needs was necessary for clinicians to make the shift from a pathoanatomic, transactional model of care to a biopsychosocial, longitudinal model of care. The authors explored the novel intersection of the implementation of a biopsychosocial model of care using LM principles to achieve greater value for the MSK patient population.

Abbreviations and Acronyms

BPS biopsychosocial

CHW Corewell Health West

CHWC certified health and wellness coach

CMS Center for Medicare and Medicaid Services

CoCM collaborative care model

IPU integrated practice unit

LBP low back pain

LM lifestyle medicine

MSK musculoskeletal

OA osteoarthritis

SPACE sleep, pain, affect, cognition, energy
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pmc Article Highlights

• Musculoskeletal (MSK) conditions are highly prevalent in the United States, carry substantial health care costs, and often coexist with metabolic and mental health conditions.

• Chronic inflammation contributes to the experience of pain and poor functioning in patients with MSK conditions.

• Treating patients with evidence-based lifestyle medicine within a biopsychosocial model of care can address patients’ pain, poor functioning, metabolic, and mental health needs.

• The redesign of care for patients with chronic MSK conditions using a lifestyle-focused, biopsychosocial model of care requires strategic planning, cross-service line collaboration, and change management to be successful.

• Iterative processes that respond to real-time challenges and barriers are key to success in care redesign.

The Centers for Disease Control and Prevention estimates that 90% of the nation’s $4.1 trillion in annual health care expenditures is directed toward the treatment of chronic physical and mental health conditions.1 In addition to being costly, these chronic conditions are the leading cause of disability and death in the United States.2 Notably, the presence of multiple chronic conditions is associated with exponentially higher health care cost, utilization, and lower quality of life.3 Chronic musculoskeletal (MSK) conditions such as arthritis affect 21% of US adults with more than half of cases occurring in the presence of other chronic conditions.4 Pain due to chronic MSK conditions creates functional impairment and is associated with a decline in mental health, with nearly 1 in 5 adults with arthritis experiencing symptoms of depression and anxiety.5

Globally, the impact of low back pain (LBP) is reported as the primary cause of disability. Low back pain impacts 619 million people globally, more than 1 in 4 US adults, and is more common with increasing age.6,7 An estimated 15.4% of the US population has lost work owing to LBP, an economic impact of 264 million lost workdays. From 2012-2014, the United States spent $364 billion on care for LBP, with most of this spend in lumbar operations.8 An analysis of health care expenditures in the United States revealed that in 2016, low back and neck pain ranked first among the 154 health conditions with an estimated $134.5 billion spent; other MSK disorders accounted for the second highest amount of health care spending at $129.8 billion, and osteoarthritis (OA) ranked eighth at $80.0 billion.9 The Center for Medicare and Medicaid Services (CMS) has cited total joint replacement as the most common operation that beneficiaries receive. With more than 1 million operations performed each year, CMS covers 60% of this volume, and these numbers are expected to rise to 2 million operations per year by 2030.10 This trend is a considerable economic concern, with CMS implementing new regulations to ensure quality care is delivered.11 Owing to the economic impact of these MSK conditions, effective options for nonsurgical care must be developed.

Models of care have been developed, which shift care from episodic to longitudinal support of patients across the continuum of disease.12 The biopsychosocial (BPS) model has been promoted across clinical practice guidelines for MSK conditions owing to the prognostic value of psychosocial factors such as pain catastrophizing, depression, anxiety, and recovery expectations.13, 14, 15, 16, 17, 18 The BPS model of care includes interventions directed at each domain and delivered in a team-based model. The biological aspects of the condition are assessed and treated by a physician or physical therapist. The psychological aspects are assessed and treated by a behavioral health specialist, psychologist, or other similar professional. The social aspects of the condition are managed by a community health worker, health coach, or social worker. To illustrate the value of the BPS model, recent Cochrane review highlighted the bidirectional interaction between exercise and health beliefs, social functioning, and depression and fear avoidance in population with hip and knee OA.19

Lifestyle medicine (LM) is a rapidly growing medical specialty with evidence-based treatment principles aligned with the BPS model of care.20,21 Lifestyle medicine delivers whole-person care and has shown effectiveness in treating multiple drivers of chronic disease such as systemic inflammation.22 Lifestyle medicine treatment is grounded in behavior change science and the 6 pillars of health, which include high-quality dietary patterns, regular physical activity, stress management, restorative sleep, social connection, and avoidance/reduction of risky substances.23,24 In a narrative review, Prather and Cheng25 evaluated the role of LM interventions to reduce systemic inflammation associated with metabolic OA or OA in the presence of diagnostic criteria of the metabolic syndrome. Their review supports the use of LM to treat and prevent progression of metabolic OA based on the following: (1) reduced pain and improved quality of life with adherence to a whole-food plant predominant dietary pattern; (2) reduction in mediators of inflammation with physical activity; (3) impact of sleep disruption on central pain processing; and (4) reduction in levels of inflammation with mindfulness training.26, 27, 28, 29 Additional evidence exists in support of a micronutrient-rich dietary pattern to maintain optimal weight and reduce inflammation associated with OA.30 Taken together, use of LM treatment for MSK conditions can reduce underlying chronic inflammation and improve lifestyle factors to improve pain and quality of life for patients with these conditions.

Linking Pain and LM Interventions

A reconceptualization of treatment provided for the spine pain and lower extremity OA population has been necessary owing to the progress in scientific literature and lagging implementation in clinical practice. A modern neuroscience understanding of pain yields new important insights. The first insight is that pain is the product of a complex interaction of biological, psychological, and social factors, not a product of sensory neuron stimulation.31 Pain processing and mood are regulated by common neurotransmitters such as serotonin, norepinephrine, glutamate, and γ-aminobutyric acid, and these have a marked effect on the experience of pain32 (Figure 1). Second, pain can be potentiated or sustained by the presence of inflammation: local, systemic, or neuroinflammation.25,33, 34, 35 Specific to OA, a growing body of literature has identified this condition as an expression of metabolic syndrome, suggesting significant crosstalk among chronic inflammation, oxidative stress, and endothelial dysfunction, which occurs in other metabolic conditions such as obesity, type 2 diabetes, depression, and cardiovascular disease.36 Finally, chronic pain is inherently more complex to assess and treat than acute pain. Acute pain mechanisms may be sufficiently addressed within a pathoanatomic model with acceptable outcomes (eg, a broken bone requires fixation to heal). However, a pathoanatomic framework is insufficient and has not produced equivalent outcomes in the chronic pain population. The complex social and neurobiologic processes that are responsible for the progression from acute to chronic pain indicate that the treatment targets for improved function and decreased discomfort due to pain have less to do with nociception but rather the “ecosystem” within and surrounding each patient.37, 38, 39 This may partly explain why pathoanatomic treatment models have failed to address the chronic pain epidemic. A comprehensive review of the neuroscience of pain is beyond the scope of this article; however, the authors recommend few resources for further exploration on the topic.40, 41, 42, 43Figure 1 Shared neurotransmitters responsible for common pain impairments summarized as sleep, pain, affect, cognition, and energy (SPACE) and the lifestyle medicine pillars. CNS, central nervous system; GABA, γ-aminobutyric acid. Adapted from David Williams, PhD. Used with permission.

Shared neurotransmitters and the central nervous system changes responsible for chronic pain conditions reliably lead to the concomitant impairments of fatigue, disrupted sleep, problems with cognition, physical dysfunction, and disturbances in affect (ie, anxiety, anger, and depression) that have been summarized as sleep, pain, affect, cognition, and energy (SPACE).44 Therefore, the goal of lifestyle modification as part of a comprehensive MSK treatment plan is to directly treat the SPACE deficiencies using behavioral change strategies around nutrition, exercise, sleep hygiene, socialization, and cessation of substances like tobacco and nicotine (Figure 1).

The Journey to Value for MSK Conditions

Corewell Health West (CHW) is an integrated health care system in West Michigan in risk-based partnership with the health plan Priority Health. Corewell Health West has been on a value transformation journey, which began in 2021 with the redesign of primary care.45 The LM team is part of the CHW Population Health department and functions across clinical service lines to accelerate value transformation projects in addition to operating as a medical group specialty practice within CHW. Given the high prevalence and cost of caring for patients with chronic MSK conditions, value transformation efforts were spread into specialty areas of orthopedics and neurosciences in 2022. The value efforts for MSK conditions are focused on improving the delivery of nonoperative care for hip and knee OA, LBP, and neck pain. These value efforts’ strategic goals are to improve the health of this population and reduce the need for surgical care, specifically total joint replacement and elective spinal fusion operations. A nonoperative model of care was needed for patients who:• do not want operation

• have chronic pain that operation may not address

• have poorly controlled metabolic conditions

• need optimization before operation

• have significant psychosocial and social determinants of health barriers

• are at high risk for emergency department visits, hospital readmissions, repeat operation, or failure to regain function after operation.

Following the examples of pioneering organizations such as University of Texas Health Austin, Virginia Mason, Hospital for Special Surgery, and University of Pittsburgh Medical Center, CHW determined that developing an integrated practice unit (IPU) may be of greatest benefit to support goal achievement.46 As described by Porter and Lee,47,48 the IPU model of care is a distinct entity that matches care to the specific needs of the population it serves. The IPU model uses a multidisciplinary team in which each member brings a specific skill set matched to the population’s needs. Because of the diverse skills and perspectives, the IPU model enables implementation of the BPS model of care necessary to treat the different factors contributing to the pain conditions present in the MSK population. The IPU provides longitudinal management of the population and offers the mechanism for the following: (1) delivering care focused on lifestyle behavioral changes; (2) collecting and tracking patient progress over time; and (3) adapting care based on interval outcomes. Transitioning from transactional, disease-focused care to longitudinal, health-focused care allows for time-dependent treatment effects to occur, such as those provided by LM. Engagement with patients over a longer term affords the opportunity to best match treatment to patient goals and to optimize health. Optimization of health may also benefit those patients who do engage with operation, as noted in published literature on the prehabilitation potential of lifestyle modification.49

Organizations such as those cited earlier have each been successful in lowering the cost of care for the MSK population.50, 51, 52, 53, 54 Both improved health outcomes and reduced surgical utilization are aspects of this reduction. There is ample published literature around patient dissatisfaction and outcomes with current models of care that ultimately result in a surgical event.55, 56, 57, 58, 59, 60 This dissatisfaction usually centers on continuation of pain or failure to improve function. Of patients who undergo a total knee replacement, 1 of 5 will not be satisfied with the procedure. In the total hip arthroplasty population, recent literature suggests a 1 in 10 dissatisfaction rate. In the spine fusion population, the results are even more varied with some studies citing nearly 50% of patients not achieving expected surgical results.61 Despite the high variability and low generalizability within the spinal fusion population, spinal fusion operations are generally regarded as a low value procedure owing to the high cost and inconsistency of outcome.

This evidence combined with a third-party vendor analysis of CHW claims data suggested that overutilization of surgical procedures was occurring within the organization. This led CHW leaders to establish a surgical reduction target in 2022 for patients who are less likely to benefit from surgical intervention. This target was set as a change management tool, or “true north,” which teams could use to determine success of the novel model and associated interventions in reducing cost of care for the population. Outcomes were assessed using patient-reported outcome tools and monitoring admissions and emergency department use to ensure high-quality care is delivered.

Design of the IPU

For the MSK IPU development, a population health analysis was conducted, which included patients with hip, knee, neck, and back pain conditions that might lead to total joint replacement or spinal fusion operation, respectively. A review of patient characteristics of potential IPU patients was performed. Groupings of diagnoses of interest were created with the assistance of physiatrists, sports medicine physicians, and surgeons. This analysis revealed health determinants that were meaningful to the condition of interest and common among the population. This helped the team understand the needs of the population and the appropriately matched treatments (Table 1).Table 1 Population Health Analysis of Knee, Hip, and Back Pain by Health Determinant

Health determinant	Knee	Hip	Back	
Patient volumes in total population	
High risk	Low risk	High risk	Low risk	High risk	Low risk	
JH ACG RUB							
 Healthy		334		89		1636	
 Low		1465		406		3733	
 Moderate		14,180		6009		36,998	
 High	11,548		5692		29,894		
 Very High	11,435		6758		29,075		
BMI							
 <25		15,038		9592		17,112	
 25.1-35.0	37,520		20,478		42,696		
 35.1-40.0	16,038		7541		14,153		
 40.1-45.0	8940		3871		7373		
 >45	5327		2063		4347		
JH ACG depression	18,566	37,491	10,739	18,395	38,770	66,166	
JH ACG diabetes	11,221	45,672	6158	23,461	15,637	57,312	
Smoking status							
 Never smoker		32,675		15,769		36,443	
 Former smoker	18,422		10,551		25,998		
 Every-day smoker	4617		2875		8575		
 Someday smoker	969		566		1592		
 Passive smoke exposure	772		269		110		
 Light smoker	299		132		329		
 Heavy smoker	41		20		54		
BMI, body mass index; JH ACG, Johns Hopkins Adjusted Clinical Group; RUB, resource utilization band.

Based on the identified population characteristics and review of evidence for the best practice treatment recommendations for these populations, a team of experts was assembled to create a model of care that would help deliver improved health outcomes to patients (Figure 2). Consensus building meetings were held to attain stakeholder alignment and agreement on what best practice care would include for these populations. An LM-certified physiatrist was a key stakeholder in this process. As demonstrated in Table 1, the impact of comorbid concerns such as high body mass index, depression, and diabetes in the population could be improved by integrated LM services. Therefore, the inclusion of LM services was a core element of the IPU design to support patients in making changes in nutrition, exercise, sleep, and stress management. This was done to treat underlying inflammation and the co-occurring metabolic and behavioral health conditions present in the IPU population (Figure 3).Figure 2 Patient journey map for risk contracted patients. IPU, integrated practice unit; LM, lifestyle medicine; PRO, patient-reported outcome; PT, physical therapy.

Figure 3 Musculoskeletal integrated practice unit (IPU) services with lifestyle medicine embedded health coach and virtual or telephonic collaborative care model (CoCM). Core team: (onsite)—ATC, athletic trainer certified (triage, ∗virtual); BHS, behavioral health specialist; LM, lifestyle medicine; non-op ortho, nonoperative orthopedic physician; PM&R, physical medicine and rehabilitation; PT, physical therapist; PH RN, population health registered nurse; surgeon. By referral—bariatrics; CHW, community health worker; lifestyle medicine; pain psych, pain psychologist; psychiatry; sleep medicine; SOC, surgical optimization center; SUD specialist, substance use disorder specialist. Lifestyle medicine CoCM: behavioral care manager; exercise specialist; health coach; psychiatrist; registered dietician; RPM technician, remote physiologic monitoring technician.

Patient-reported outcome measures were implemented to support a BPS assessment of the patient population. The Keele Subgroups for Targeted Treatment (STarT) MSK tool is a valid tool for patients with back, neck, knee, shoulder, and multisite pain, which includes questions that are relevant to self-efficacy, pain catastrophizing, depression, and recovery expectations.62,63 The STarT MSK tool was implemented for patients entering the IPU to stratify patients by risk of chronicity and disability and match them to evidence-based interventions. Those patients scoring 8 or more on the STarT MSK tool were given the Central Sensitization Inventory (CSI).64 The CSI has been shown to identify patients that are at high risk for a poor surgical outcome in the spine operation and total joint arthroplasty populations.65, 66, 67, 68, 69 The electronic health record was modified to group the CSI questions and responses into categories that support the SPACE pain impairments and elucidate the potential benefits of a LM intervention to both providers and patients.

Hip and knee OA outcomes are the Hip dysfunction and Osteoarthritis Outcome for Joint Replacement and Knee injury and Osteoarthritis Outcome for Joint Replacement questionnaires, respectively, as well as the Patient-Reported Outcomes Measurement Information System 10 Global Health v1.2 short form.70, 71, 72 Back and neck pain patient outcomes are assessed with the Patient-Reported Outcomes Measurement Information System Physical Function v2.0 and Pain Interference v1.1 questionnaire via Computer Adaptive Testing delivered through the patient portal in the electronic health record.73, 74, 75

As the IPU model formed, case conferences were a meaningful tool for team learning and improvement. A case conference was designated time by IPU team members to discuss patients who were not improving as expected. Lifestyle medicine was a core conference member, providing insights into patients most appropriate for LM treatment using change readiness assessments to guide this decision. Although only select patients were originally chosen to engage with LM during the formative days of the IPU based on IPU physiatrist recommendation (Table 1), the intention and goal of this collaboration is that all IPU patients enter LM programming by default. Input from physical therapy, pain psychology, and sleep medicine have informed patient care plans and bolstered service line collaboration.

Implementation of LM in the IPU

Introduction of LM services in the IPU (Figure 3) was communicated to patients as care that would occur “between” regularly scheduled visits with the IPU physiatrist. This would allow patients to engage in longitudinal, multidisciplinary treatment care plans that may start with scheduled physical therapy visits then move into supervised exercise therapy by a lifestyle certified health and wellness coach (CHWC) and exercise specialist. Similarly, patients may be paired with a registered dietitian and CHWC to work on an anti-inflammatory dietary pattern to support a healthy weight and reduce systemic inflammation; or paired with a care manager to focus on stress management and/or sleep hygiene strategies. In all cases, comprehensive interventions offered to patients, including their delivery cadence, were customized to the individual to best address their personal barriers and health goals.

Lifestyle medicine care was delivered using collaborative care model (CoCM), which is a measurement-based treatment model with integrated mental health care.76 In essence, CoCM takes the theoretical BPS model and establishes operations to deliver care. In a narrative review by Reist et al,77 CoCM has shown improved access to mental health treatment, improved patient outcomes, and reduction in time-to-treatment of mental health conditions and is adaptable to a variety of patient populations.77 The integrated CoCM model has been widely supported by the American Medical Association.78 Lifestyle medicine delivered in a CoCM model uses behavioral activation techniques to support patient improvement in a variety of lifestyle behaviors, thereby treating the co-occurring symptoms of depression and anxiety highly prevalent in the CHW MSK population (Figure 3).

After an initial in-person visit with the MSK IPU physiatrist and physical therapist, patients are onboarded into the LM CoCM pathway to engage in supportive, lifestyle-focused care. This care is delivered by CHWC and care managers and includes an integrated psychiatry consultant. Billable CoCM CPT codes are used for time-based minutes of care provided to the patient over the preceding 30 days. In collaboration with the IPU physiatrist, the LM physician oversees the measurement-based, treat-to-target approach of CoCM using validated assessments and treatment pathways in each of the lifestyle areas. Symptom assessment of depression and anxiety is performed using the Patient Health Questionnaire-2/9 and Generalized Anxiety Disorder scale 2/7, respectively.79,80 Baseline measurement using validated health behavior assessments of dietary quality, physical function, sleep quality, and social isolation occurs when treatment is started and repeated every 4 weeks for 16 weeks in alignment with the selected 16-week comprehensive lifestyle pathway (Figure 4).Figure 4 Initial and monthly assessments and leading clinical metrics for each of the lifestyle health-related social needs; BMI, body mass index; BP, blood pressure; CAGE-AID, CAGE questions adapted to include drugs; CM, care manager; GAD, Generalized Anxiety Disorder; LSNS, Lubben Social Network Scale; PHQ, Patient Health Questionnaire; PTSD, posttraumatic stress disorder; STC, start the conversation.

Most LM care is delivered using virtual and/or telephonic visits, making care accessible across a wide geographic area. Collaborative care model CPT codes are billed every 30 days based on minutes of care provided to the patient. To enhance longitudinal care, remote physiological monitoring of weight and/or blood pressure is added for patients with corresponding metabolic conditions such as obesity, hypertension, and type 2 diabetes. Clinical and health behavior outcomes are currently being collected; these outcomes will be measured and reported within 12 to 18 months.

Overcoming Barriers to a New Model of Care

Similar to many improvement projects, the process of change and development of the MSK IPU has been nonlinear and iterative, yet notably aligns with Kotter framework for change.81 Before launching the MSK IPU, the value analysis established a sense of urgency for change. The data told a story of a large population of patients who were struggling with chronic MSK conditions and co-occurring metabolic and mental health diagnoses. Many patients were often not achieving functional improvement with operative management. These data established the need to create a new longitudinal model of care. The “guiding coalition” for the IPU included diverse perspectives to ensure patient characteristics, or phenotypes, were appropriately identified for nonoperative management. Correspondingly, the importance of communicating the overarching vision was not explicitly to reduce operation; rather, the goal was to get the right patients to the surgeons while optimally managing patients who would fare better with nonoperative treatment.

Removing barriers so that the IPU model could flourish required conversations with our integrated health plan. Patients referred to the MSK IPU are part of our risk contracted population with an attributed Corewell Health primary care physician. Reducing financial barriers through removal of copay and deductible for CoCM charges (for both government and commercial payor products) allowed patients to access services available in the longitudinal LM program. However, we continue to advocate for the removal of copays for follow-up evaluation and management visits with the LM physician for patients with commercial health plan products.

Changing provider practice patterns while straddling fee for service and value models has both informed model development and illustrated lessons along the way. Fee for service practice inertia coupled with patients’ preferences for limited problem-focused care continue to sustain imaging, lower extremity joint injections, and spinal pain procedure utilization over whole-person care, which is antithetical to value-based care. Increasing the time spent at the initial IPU visit educating patients regarding their condition, and evidence-based treatment options using the SPACE pain impairment mnemonic aids in engaging patients in lifestyle-focused, whole-person care. Longitudinal care requires initial and ongoing patient and provider engagement to be successful. Supportive communication from the treating provider, such as the IPU physiatrist, is typically necessary to activate patients to initiate and sustain lifestyle-focused care. An explanation of the interaction among lifestyle behaviors, chronic pain sensitization, and a patient’s ability to take proactive steps to improve functional recovery creates a patient-centered treatment paradigm.

Achieving clinical consensus regarding the nature of MSK patient impairments and treatment from which they may benefit has opened the door for interesting dialogue. For example, treating OA as a metabolic disease with features of underlying inflammation rather than simply a condition of “wear and tear” is relatively new territory. In this example, the LM approach may include linking features of chronic joint pain to poor dietary quality treated with nutrition intervention from a registered dietitian as an initial step rather than proceeding directly to invasive treatments. Surgical hard stop criteria were also considered as important factors when considering patients for IPU care. Patients entering specialty care with significantly elevated HbA1c and BMI may not be most appropriate to proceed directly with operation. Health optimization is an important aspect of improving patient outcomes. Table 2 provides insight into patient volumes with these conditions, how many of these eligible patients were referred to LM, and how many entered care with LM as a result of this referral. Differences in the referred proportion of eligible patients can be noted between orthopedics and neurosciences. The neurosciences’ IPU piloted embedding a health coach from LM to improve patient recruitment. These early findings would suggest that the embedded health coach, which was started in March 2023, does help to improve patient interest and readiness for LM. In addition, although there is greater recognition of anxiety and depression’s influence on patient outcomes in the MSK population, assessing and connecting patients to resources to address these disorders has not typically been in the domain of the MSK clinicians. Ongoing education to shift providers’ and allied health professionals’ understanding of a whole-person, lifestyle-focused care model is a work in progress and has created greater collaboration between clinical teams.Table 2 Biometrics and Referral Trends for Lifestyle Medicine in the MSK IPU

Date	Orthopedics (joint): HbA1c≥8.0	Orthopedics: BMI≥30	Neurosciences (spine): HbA1c≥8.0	Neurosciences: BMI≥30	Orthopedics IPU referrals to LM	Neurosciences IPU referrals to LM	Orthopedics patients in LM	Neurosciences patients in LM	
December 2023	8	11	8	25	3 (16)	6 (18)	1	1	
January 2024	8	21	10	31	3 (10)	11 (38)	0	4	
February 2024	10	14	10	42	8 (33)	17 (71)	0	1	
March 2024	10	18	9	42	6 (21)	22 (78.5)	0	5	
April 2024	10	23	10	38	2 (6)	20 (61)	0	8	
May 2024	13	19	11	37	4 (12.5)	18 (56)	0	5	
BMI, body mass index; HbA1c, hemoglobin A1c; IPU, integrated practice unit; LM, lifestyle medicine.

Building the right team to deliver the nonoperative pathway is an ongoing process. Initially, patients were referred to LM after their visit with the IPU physiatrist. However, lag time between initial referral and scheduled visit with LM contributed to low patient engagement rates because there was not a clear connection between their care in the IPU and the services offered by LM. The teams also struggled with clear communication in coordination of care due to lack of standardized documentation and approach to comanaging these patients within each department. Owing to the resulting suboptimal patient engagement into the longitudinal lifestyle-focused care, a change was made to embed the CHWC into the IPU team to aid in patient assessment of readiness and engagement in the longitudinal model. By embedding the CHWC onsite into the IPU in a “warm hand-off” capacity, conversion rates, shared documentation, and patient-centric goal setting have continued to improve, and metrics of success are being closely monitored.

Conclusion

The journey toward delivering a lifestyle and behavior change focused model of care in the MSK population has offered both opportunities and challenges. Designing a model of care aligned to meet the population’s health needs is imperative in any value-based arrangement. Overcoming practice inertia is a real and substantive challenge, for both providers and operators. Lifestyle medicine has been a remarkable change agent for this work both by providing peer support to providers and as staff resources in the form of a CHWC to provide real-time support to patients and the team. The LM pillars of care align perfectly with the SPACE impairments of the MSK population coping with significant pain. Partnership with a payor who will understand the value of these services and is willing to provide the appropriate benefit design to make them accessible to all patients is of critical importance. Health systems interested in value arrangements would benefit from adding LM services to their organization. These services can support multiple clinical service lines in efforts to improve patient health, reduce total cost of care, and drive greater value for patients and health systems.

Potential Competing Interests

Dr Artz is a board member of the American College of Lifestyle Medicine and an advisory board member for Nudj Health. The other authors report no competing interests.

Acknowledgments

The authors gratefully recognize Dave Williams, PhD, for the use of the graphic adapted in Figure 1.

Grant Support: None
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References

1 Health and economic costs of chronic diseases Centers for Disease Control and Prevention Updated March 23, 2023 https://www.cdc.gov/chronicdisease/about/costs/index.htm
2 Health and economic benefits of chronic disease interventions Centers for Disease Control and Prevention https://www.cdc.gov/chronicdisease/programs-impact/pop/index.htm March 14, 2023
3 Hajat C. Siegal Y. Adler-Waxman A. Clustering and healthcare costs with multiple chronic conditions in a US study Front Public Health 8 2020 607528 10.3389/fpubh.2020.607528
4 Arthritis data and statistics: comorbidities Centers for Disease Control and Prevention Updated October 4, 2023 https://www.cdc.gov/arthritis/data_statistics/comorbidities.htm
5 The arthritis-mental health connection Centers for Disease Control and Prevention Updated October 12, 2023 https://www.cdc.gov/arthritis/communications/features/arthritis-mental-health.htm
6 QuickStats Percentage of adults aged ≥18 years who had lower back pain in the past 3 months, by sex and age group—National Health Interview Survey, United States, 2018 MMWR Morb Mortal Wkly Rep 68 5152 2020 1196 10.15585/mmwr.mm685152a5 31895920
7 The Lancet Rheumatology The global epidemic of low back pain Lancet Rheumatol 5 6 2023 e305 10.1016/S2665-9913(23)00133-9 38251593
8 Yelin E. Weinstein S. King T. The burden of musculoskeletal diseases in the United States Semin Arthritis Rheum 46 3 2016 259 260 27519477
9 Dieleman J.L. Cao J. Chapin A. US health care spending by payer and health condition, 1996-2016 JAMA 323 9 2020 863 884 10.1001/jama.2020.0734 32125402
10 Rana A.J. Yates A.J. Jr. Springer B.D. Huddleston J.I. Iorio R. Hip and knee arthroplasty alternative payment model successes and challenges Arthroplast Today 13 2022 154 156 10.1016/j.artd.2021.11.013 35097170
11 Comprehensive Care for Joint Replacement (CJR) Model Centers for Medicare & Medicaid Services https://www.cms.gov/priorities/innovation/innovation-models/cjr
12 Speerin R. Needs C. Chua J. Implementing models of care for musculoskeletal conditions in health systems to support value-based care Best Pract Res Clin Rheumatol 34 5 2020 101548 10.1016/j.berh.2020.101548
13 Parikh P. Santaguida P. Macdermid J. Gross A. Eshtiagi A. Comparison of CPG’s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review BMC Musculoskelet Disord 20 1 2019 81 10.1186/s12891-019-2441-3 30764789
14 Gibbs A.J. Gray B. Wallis J.A. Recommendations for the management of hip and knee osteoarthritis: a systematic review of clinical practice guidelines Osteoarthritis Cartilage 31 10 2023 1280 1292 10.1016/j.joca.2023.05.015 37394226
15 Kreiner D.S. Matz P. Bono C.M. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain Spine J 20 7 2020 998 1024 10.1016/j.spinee.2020.04.006 Published correction appears in Spine J. 2021;21(4):726-727 32333996
16 Ernstzen D.V. Hillier S.L. Louw Q.A. Synthesis of clinical practice guideline recommendations for the primary health care of chronic musculoskeletal pain J Eval Clin Pract 28 3 2022 454 467 10.1111/jep.13644 34913219
17 Lin I. Wiles L. Waller R. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review Br J Sports Med 54 2 2020 79 86 10.1136/bjsports-2018-099878 30826805
18 Corp N. Mansell G. Stynes S. Evidence-based treatment recommendations for neck and low back pain across Europe: a systematic review of guidelines Eur J Pain 25 2 2021 275 295 10.1002/ejp.1679 33064878
19 Hurley M. Dickson K. Hallett R. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review Cochrane Database Syst Rev 4 4 2018 CD010842 10.1002/14651858.CD010842.pub2
20 Five emerging medical specialties you’ve never heard of— until now Association of American Medical Colleges https://www.aamc.org/news/five-emerging-medical-specialties-you-ve-never-heard-until-now
21 American College of Lifestyle Medicine https://lifestylemedicine.org/
22 Lippman D. Stump M. Veazey E. Foundations of lifestyle medicine and its evolution Mayo Clin Proc Innov Qual Outcomes 8 1 2024 97 111 10.1016/j.mayocpiqo.2023.11.004 38304165
23 Singh B. Olds T. Curtis R. Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews Br J Sports Med 57 18 2023 1203 1209 10.1136/bjsports-2022-106195 36796860
24 Neelapala Y.V.R. Mercuri D. Macedo L. Hanna S. Kobsar D. Carlesso L. Mechanisms hypothesized for pain-relieving effects of exercise in fibromyalgia: a scoping review Ther Adv Musculoskelet Dis 15 2023 1759720X231182894 10.1177/1759720X231182894
25 Prather H. Cheng J. Relationship of chronic systemic inflammation to both chronic lifestyle-related diseases and osteoarthritis: the case for lifestyle medicine for osteoarthritis HSS J 19 4 2023 459 466 10.1177/15563316231193753 37937092
26 Towery P. Guffey J.S. Doerflein C. Stroup K. Saucedo S. Taylor J. Chronic musculoskeletal pain and function improve with a plant-based diet Complement Ther Med 40 2018 64 69 10.1016/j.ctim.2018.08.001 30219471
27 Nimmo M.A. Leggate M. Viana J.L. King J.A. The effect of physical activity on mediators of inflammation Diabetes Obes Metab 15 Suppl 3 2013 51 60 10.1111/dom.12156 24003921
28 Villalba D.K. Lindsay E.K. Marsland A.L. Mindfulness training and systemic low-grade inflammation in stressed community adults: evidence from two randomized controlled trials PLoS One 14 7 2019 e0219120 10.1371/journal.pone.0219120
29 Smith M.T. Quartana P.J. Okonkwo R.M. Nasir A. Mechanisms by which sleep disturbance contributes to osteoarthritis pain: a conceptual model Curr Pain Headache Rep 13 6 2009 447 454 10.1007/s11916-009-0073-2 19889286
30 Thomas S. Browne H. Mobasheri A. Rayman M.P. What is the evidence for a role for diet and nutrition in osteoarthritis? Rheumatol (Oxf Engl) 57 suppl_4 2018 iv61 iv74 10.1093/rheumatology/key011
31 Raja S.N. Carr D.B. Cohen M. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises Pain 161 9 2020 1976 1982 10.1097/j.pain.0000000000001939 32694387
32 Goesling J. Clauw D.J. Hassett A.L. Pain and depression: an integrative review of neurobiological and psychological factors Curr Psychiatry Rep 15 12 2013 421 10.1007/s11920-013-0421-0 24214740
33 Favretti M. Iannuccelli C. Di Franco M. Pain biomarkers in fibromyalgia syndrome: current understanding and future directions Int J Mol Sci 24 13 2023 10443 10.3390/ijms241310443
34 Saxer F. Hollinger A. Bjurström M.F. Pain-phenotyping in osteoarthritis: current concepts, evidence, and considerations towards a comprehensive framework for assessment and treatment Osteoarthr Cartil Open 6 1 2024 100433 10.1016/j.ocarto.2023.100433
35 Xiong H.Y. Hendrix J. Schabrun S. The role of the brain-derived neurotrophic factor in chronic pain: links to central sensitization and neuroinflammation Biomolecules 14 1 2024 71 10.3390/biom14010071 38254671
36 Zhuo Q. Yang W. Chen J. Wang Y. Metabolic syndrome meets osteoarthritis Nat Rev Rheumatol 8 12 2012 729 737 10.1038/nrrheum.2012.135 22907293
37 Stilwell P. Harman K. An enactive approach to pain: beyond the biopsychosocial model Phenom Cogn Sci 18 4 2019 637 665 10.1007/s11097-019-09624-7
38 Vaz D.V. Stilwell P. Coninx S. Low M. Liebenson C. Affordance-based practice: an ecological-enactive approach to chronic musculoskeletal pain management Braz J Phys Ther 27 5 2023 100554 10.1016/j.bjpt.2023.100554
39 McCarberg B. Peppin J. Pain pathways and nervous system plasticity: learning and memory in pain Pain Med 20 12 2019 2421 2437 10.1093/pm/pnz017 30865778
40 Greenwald J.D. Shafritz K.M. An integrative neuroscience framework for the treatment of chronic pain: from cellular alterations to behavior Front Integr Neurosci 12 2018 18 10.3389/fnint.2018.00018 29875641
41 Párraga J.P. Castellanos A. A manifesto in defense of pain complexity: a critical review of essential insights in pain neuroscience J Clin Med 12 22 2023 7080 10.3390/jcm12227080 38002692
42 Eller-Smith O.C. Nicol A.L. Christianson J.A. Potential mechanisms underlying centralized pain and emerging therapeutic interventions Front Cell Neurosci 12 2018 35 10.3389/fncel.2018.00035 29487504
43 Jang K. Garraway S.M. A review of dorsal root ganglia and primary sensory neuron plasticity mediating inflammatory and chronic neuropathic pain Neurobiol Pain 15 2024 100151 10.1016/j.ynpai.2024.100151
44 Williams D.A. Phenotypic features of central sensitization J Appl Biobehav Res 23 2 2018 e12135 10.1111/jabr.12135
45 Kurek A.A. Shah R. Inman E.E. Quiroga A. Primary care redesign for value-based care NEJM Catal 4 12 2023 10.1056/CAT.22.0285
46 Keswani A. Koenig K.M. Bozic K.J. Value-based healthcare: part 1—designing and implementing integrated practice units for the management of musculoskeletal disease Clin Orthop Relat Res 474 10 2016 2100 2103 10.1007/s11999-016-4999-5 27457622
47 Porter M.E. Lee T.H. The strategy that will fix health care. Harvard Business Review https://hbr.org/2013/10/the-strategy-that-will-fix-health-care October 2013
48 Porter M.E. Lee T.H. Integrated practice units: a playbook for health care leaders NEJM Catal 2 1 2021 10.1056/CAT.20.0237
49 Fong M. Kaner E. Rowland M. The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: a systematic review and meta-analyses PLoS One 18 7 2023 e0286757 10.1371/journal.pone.0286757
50 Jayakumar P. Mills Z. Triana B. A model for evaluating total costs of care and cost savings of specialty condition-based care for hip and knee osteoarthritis in an integrated practice unit Value Health 26 9 2023 1363 1371 10.1016/j.jval.2023.05.009 37236394
51 Standaert C.J. Li J.W. Glassman S.J. Costs associated with the treatment of low back disorders: a comparison of surgeons and physiatrists PM R 12 6 2020 551 562 10.1002/pmrj.12266 31628773
52 MacLean C.H. Titmuss M. Lee J. Russell L. Padgett D. The clinical, operational, and financial components of a successful bundled payment program for lower extremity total joint replacement NEJM Catal 2 10 2021 10.1056/CAT.21.0240
53 Yanamadala V. Kim Y. Buchlak Q.D. Multidisciplinary evaluation leads to the decreased utilization of lumbar spine fusion: an observational cohort pilot study Spine 42 17 2017 E1016 E1023 10.1097/BRS.0000000000002065 28067696
54 Fuhrmans V. A novel plan helps hospital wean itself off pricey tests. Wall Street Journal Published January. 12, 2007. A1 https://www.wsj.com/articles/SB116857143155174786
55 Baker P.N. van der Meulen J.H. Lewsey J. Gregg P.J. National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales J Bone Joint Surg Br 89 7 2007 893 900 10.1302/0301-620X.89B7.19091 17673581
56 Bourne R.B. Chesworth B.M. Davis A.M. Mahomed N.N. Charron K.D. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 468 1 2010 57 63 10.1007/s11999-009-1119-9 19844772
57 Scott C.E. Howie C.R. MacDonald D. Biant L.C. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients J Bone Joint Surg Br 92 9 2010 1253 1258 10.1302/0301-620X.92B9.24394 20798443
58 Jain D. Nguyen L.L. Bendich I. Higher patient expectations predict higher patient-reported outcomes, but not satisfaction, in total knee arthroplasty patients: a prospective multicenter study J Arthroplasty 32 9S 2017 S166 S170 10.1016/j.arth.2017.01.008 28258830
59 Elsamadicy A.A. Kemeny H. Adogwa O. Influence of racial disparities on patient-reported satisfaction and short- and long-term perception of health status after elective lumbar spine surgery J Neurosurg Spine 29 1 2018 40 45 10.3171/2017.12.SPINE171079 29701564
60 Garcia A.N. Cook C.E. Gottfried O. Psychological, mobility, and satisfaction variables mediate the relationship between baseline back pain intensity and long-term outcomes in individuals who underwent lumbar spine surgery Musculoskelet Sci Pract 55 2021 102424 10.1016/j.msksp.2021.102424
61 Rampersaud Y.R. Canizares M. Perruccio A.V. Fulfillment of patient expectations after spine surgery is critical to patient satisfaction: a cohort study of spine surgery patients Neurosurgery 91 1 2022 173 181 10.1227/neu.0000000000001981 35442936
62 Campbell P. Hill J.C. Protheroe J. Keele Aches and Pains Study protocol: validity, acceptability, and feasibility of the Keele STarT MSK tool for subgrouping musculoskeletal patients in primary care J Pain Res 9 2016 807 818 10.2147/JPR.S116614 27789972
63 Dunn K.M. Campbell P. Lewis M. Refinement and validation of a tool for stratifying patients with musculoskeletal pain Eur J Pain 25 10 2021 2081 2093 10.1002/ejp.1821 34101299
64 Mayer T.G. Neblett R. Cohen H. The development and psychometric validation of the central sensitization inventory Pain Pract 12 4 2012 276 285 10.1111/j.1533-2500.2011.00493.x 21951710
65 Martin J.R. Coronado R.A. Wilson J.M. Polkowski G.G. Shinar A.A. Bruehl S.P. Central sensitization: the missing link between psychological distress and poor outcome following primary total knee arthroplasty J Arthroplasty 39 5 2024 1201 1206 10.1016/j.arth.2023.12.026 38128626
66 Kim M.S. Kim J.J. Kang K.H. Lee J.H. In Y. Central sensitization and neuropathic pain cumulatively affect patients reporting inferior outcomes following total knee arthroplasty J Bone Joint Surg Am 106 2 2024 102 109 10.2106/JBJS.23.00399 37943951
67 Bennett E.E. Walsh K.M. Thompson N.R. Krishnaney A.A. Central sensitization inventory as a predictor of worse quality of life measures and increased length of stay following spinal fusion World Neurosurg 104 2017 594 600 10.1016/j.wneu.2017.04.166 28479522
68 Akeda K. Yamada J. Takegami N. Central sensitization as a predictive factor for the surgical outcome in patients with lumbar spinal stenosis: a multicenter prospective study Eur Spine J 32 12 2023 4200 4209 10.1007/s00586-023-07687-4 37010610
69 Imagama T. Okazaki T. Matsuki Y. Negative correlation between central sensitization and forgotten joint score-12 after total hip arthroplasty J Orthop Surg Res 18 1 2023 691 10.1186/s13018-023-04175-9 37715174
70 Lyman S. Lee Y.Y. Franklin P.D. Li W. Cross M.B. Padgett D.E. Validation of the KOOS, JR: a short-form knee arthroplasty outcomes survey Clin Orthop Relat Res 474 6 2016 1461 1471 10.1007/s11999-016-4719-1 26926773
71 Lyman S. Lee Y.Y. Franklin P.D. Li W. Mayman D.J. Padgett D.E. Validation of the HOOS, JR: a short-form hip replacement survey Clin Orthop Relat Res 474 6 2016 1472 1482 10.1007/s11999-016-4718-2 26926772
72 Hays R.D. Bjorner J.B. Revicki D.A. Spritzer K.L. Cella D. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items Qual Life Res 18 7 2009 873 880 10.1007/s11136-009-9496-9 19543809
73 Schalet B.D. Kaat A. Vrahas M. Buckenmaier I.I.I.C.T. Barnhill R. Gershon R.C. Extending the ceiling of an item bank: development of above-average physical function items for PROMIS Qual Life Res 25 2016 109
74 Amtmann D. Cook K.F. Jensen M.P. Development of a PROMIS item bank to measure pain interference Pain 150 1 2010 173 182 10.1016/j.pain.2010.04.025 20554116
75 Rose M. Bjorner J.B. Gandek B. Bruce B. Fries J.F. Ware J.E. Jr. The PROMIS Physical Function item bank was calibrated to a standardized metric and shown to improve measurement efficiency J Clin Epidemiol 67 5 2014 516 526 10.1016/j.jclinepi.2013.10.024 24698295
76 Principles of Collaborative Care AIMS Center University of Washington Department of Psychiatry and Behavioral Sciences https://aims.uw.edu/principles-of-collaborative-care/
77 Reist C. Petiwala I. Latimer J. Collaborative mental health care: a narrative review Medicine (Baltimore) 101 52 2022 e32554 10.1097/MD.0000000000032554
78 Behavioral Health Integration (BHI) Overcoming Obstacles Webinar Series American Medical Association https://www.ama-assn.org/delivering-care/public-health/behavioral-health-integration-bhi-overcoming-obstacles-webinar-series
79 Gilbody S. Richards D. Brealey S. Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis J Gen Intern Med 22 11 2007 1596 1602 10.1007/s11606-007-0333-y 17874169
80 Plummer F. Manea L. Trepel D. McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis Gen Hosp Psychiatry 39 2016 24 31 10.1016/j.genhosppsych.2015.11.005 26719105
81 Kotter J.P. Leading change: why transformation efforts fail. Harvard Business Review https://hbr.org/1995/05/leading-change-why-transformation-efforts-fail-2 October 2013
