Attachment J.28 - Lifestyle Medicine SOP (Draft).pdf

CCE Lifestyle Medicine May 2022

Clinical Centers of Excellence Lifestyle Medicine

Published May 2022

Controlled Unclassified Information

Introduction The American College of Lifestyle Medicine (ACLM) defines lifestyle medicine (LM) as a collaborative clinical specialty that utilizes evidence-informed therapeutic lifestyle and behavioral interventions to treat chronic medical conditions, which may include certain World Trade Center (WTC)-related diseases. The interventions include nutrition, physical activity, restorative sleep, stress management, avoidance of risky substances, cognitive enhancement, and/or positive social engagement to optimally manage targeted chronic conditions.1

Purpose and Scope The purpose of this document is to provide clarification to the Clinical Centers of Excellence (CCE) on the expected scope of this new value-added LM component for eligible responders and survivors within the Program’s limited-care model. For the WTC CCE, a value-added LM component begins with member engagement to ascertain needs and therapeutic goals such that evidence-informed lifestyle and behavioral interventions integrate with other prescribed medical treatments to optimally manage the qualifying and certified chronic condition(s).

The CCE shall first identify whether eligible members are interested and willing to participate in a new LM component to address their qualifying, certified chronic condition(s). The CCE shall then conduct an assessment to determine member needs, establish which LM interventions are clinically appropriate for the member, and create a tailored plan of care (POC) that resides in the medical record and is available for audit. The CCE shall execute this LM POC including evidence-informed medical, lifestyle, and behavioral interventions. The CCE shall integrate the LM POC with case management and care coordination, if the member is receiving such services, to optimize the management of the qualifying (certified) chronic condition(s).

Process and Procedure – Lifestyle Medicine LM Model Team Structure

1. The CCE contractor shall provide the details of their core LM team structure, which will include a Lifestyle Medicine Champion (a practicing physician or other practitioners with specialized education and training in lifestyle medicine or other related specialties) and a nutritionist. These providers shall have demonstrated skills and abilities to identify referral sources and provide expertise for individual and/or group interventions and therapies related to lifestyle medicine. The core staffing plan and roles of the LM team should be cost-effective in terms of the tasks required.

2. The LM team may need to consult with additional CCE staff or refer to external providers via a fee-for-service model in accordance with a future WTC Health Program Lifestyle Medicine Technical Guidance Document (TGD) to provide the LM services deemed appropriate for eligible members based on the needs identified in their LM assessments.

1 See generally American College of Lifestyle Medicine at https://www.lifestylemedicine.org.

https://www.lifestylemedicine.org/

2022 CCE Lifestyle Medicine

a. The LM team can consult with and/or refer to providers with knowledge and/or training within the following areas, as clinically indicated:

i. WTC-related chronic illness/disease management

ii. Behavioral and psychological counseling/motivational interviewing

iii. Health and wellness coaching

iv. Exercise therapy

b. The LM Team shall be integrated with Case Management, as clinically indicated, to ensure alignment with and optimization of the member’s WTC-related certified condition(s). Case Management shall provide and integrate member information obtained from case management assessments to include:

i. Clinical status, diagnoses, and comorbidities

ii. Psychosocial status (to include available support systems as applicable)

iii. Functional/cognitive status

iv. Sociocultural needs

v. Nutritional/medication needs

vi. Barriers to accessing care

c. The LM Team shall be integrated with Care Coordinators, as administratively indicated, who will assist with support responsibilities to ensure smooth continuum of care, such as:

i. Scheduling of member appointments, follow-ups, authorizations, or coordination of phone calls

ii. Documenting treatment plans and obtaining records

iii. Benefits counseling and care navigation

Lifestyle Medicine Coverage

1. The Program views LM as a value-added professional service provided under the leadership of a qualified provider who assists in the planning, coordinating, monitoring, and evaluation of benefits and clinical services to match a member’s clinical needs with allowable Program benefits. Not every enrolled member of the WTC Health Program is eligible for LM services, nor does every eligible member need or desire LM services.

2. The LM team shall develop an LM Operations Plan describing the process that will be used to identify all eligible members interested in participating in lifestyle medicine therapies to improve outcomes of their certified WTC-related chronic conditions. The LM Operations Plan should be accessible to audit.

a. Eligible members include:

i. Members with Program-certified cancer that has been treated and is now in a chronic management phase (survivorship)2

ii. Members with Program-certified obstructive sleep apnea who have a

Body Mass Index (BMI) > 30

iii. Members with Program-certified severe respiratory disease who have a

BMI > 30

b. A process should be identified for periodically revisiting lifestyle medicine service availability for members known to be eligible but who are not ready for the commitment to lifestyle changes at a previous time in their clinical course, 2 See National Comprehensive Cancer Network “Clinical Practice Guidelines in Oncology: Survivorship” at www.nccn.org.

http://www.nccn.org/ assessment, and/or evaluation.

c. Should a member requiring LM services opt to seek treatment outside of the

WTC Provider Network with their private insurance, they can continue to receive general LM oversight based on their assessed needs.

Lifestyle Medicine Assessment and Treatment

1. The CCE shall describe their process for assessing all eligible members for potential LM needs in the LM Operations Plan. The initial assessment shall occur at enrollment or another appropriate clinical visit, with follow-up assessments as clinically indicated to ensure continued member engagement and compliance. A comprehensive LM assessment completed with validated lifestyle medicine assessment tools shall be included in the member’s medical record and address the following LM domains:3

a. Nutrition

b. Physical activity

c. Stress/wellbeing

d. Sleep

e. Social support

f. Substance use

2. A Plan of Care (POC) is required for all members receiving LM treatments and services.

The LM POC must be easily identified within the clinical files of the member record and updated as member clinical status or needs change. It should also be integrated with any other POC established for the member, such as Case Management. The CCE shall review the LM POC on an annual basis, or more frequently as clinically indicated, to ensure member satisfaction and adherence, identify any gaps in care, and determine overall LM intervention effectiveness. The POC shall include:

a. Member lifestyle medicine needs

b. Case management and care coordination components

c. Results of applicable lifestyle medicine assessments

d. Barriers to care

e. Member goals and goal tracking

f. Implementation plan to reach goals

g. Interventions or actions (education, coordination, referrals, and/or consultation) needed to meet the lifestyle medicine needs

h. Impact (sustainability and compliance, achievement of goals, effect on needs and

WTC certified disease management)

i. Criteria for downgrading service intensity and transitioning off LM services when they are no longer necessary, desirable, or beneficial.

Lifestyle Medicine Program Evaluation

1. The LM Operations Plan shall also develop an evaluation protocol to ensure the LM services are authorized based on medical necessity as related to the member’s certified condition and are being utilized appropriately and cost-effectively. Reports on LM are due semi-annually. Access to member files for quality review purposes is required upon request by NIOSH either in-person or remotely, as applicable. The LM Program Evaluation should address all the following:

3 See ACLM “Introduction to Lifestyle Medicine” at ACLM Home (lifestylemedicine.org).

https://www.lifestylemedicine.org/ACLM/Education/Introduction-to-Lifestyle-Medicine/Info-for-Validated-Assessment-Tools-and-Resources.aspx?WebsiteKey=5bd6714c-c023-412c-adcf-a68f63dd5607

a. The use of intervention services ought to be limited to those with scientific potential to limit disease progression and improve health outcomes, overall member well-being, quality of life, and member satisfaction with the Program.

b. The use of intervention services is subject to service limitations and authorization requirements, as will be described in a future Lifestyle Medicine

TGD.

c. Process and tools (such as certifications, prior authorizations, claims, and medical summary reports) that enable the LM team to verify that treatment is within the scope of a member’s benefit plan.

d. Medical quality assurance and member satisfaction with services.

e. The treatment plan review should be performed by qualified CCE staff independent of the LM clinical team annually as part of quality assurance processes.

Roles and Responsibilities

Role Responsibility Case Management (CM) Team

CCE staff designated to the CM Team who provide assessment, planning, facilitation, and care coordination to address member needs.

Lifestyle Medicine (LM) Champion

A CCE staff member designated to the LM Team who performs functions which assess, diagnose, educate, implement, treat, and evaluate member lifestyle medicine care to optimize WTC certified disease.

LM Team CCE staff members of the LM team who consist of the LM Champion and Nutritionist.

Nutritionist CCE staff member who evaluates dietary needs and behaviors of members, counsels on the value of nutrients in improving overall health and WTC-certified disease management, and prescribes changes in nutrition to optimize WTC-certified chronic medical conditions.

Responder Workers or volunteers who provided rescue, recovery, debris cleanup, and related support services on or in the aftermath of the September 11, 2001 attacks for certain amounts of time during the period between September 11, 2001 and July 31, 3002. There are three groups of Responders who may be eligible for the WTC Health Program. These groups are:

• FDNY Responders and Family Members

• NYC General Responders (including NYPD)

• Pentagon and Shanksville, PA Responders

Survivor Also known as NYC Survivors; Includes individuals who were present in NYC Disaster Area in the dust or dust cloud on September 11, 2001; individuals who lived, worked or went to school or childcare, or adult child care in the NYC Disaster area for a certain amount of time during the period between September 11, 2001 and July 31, 2002; certain cleanup and maintenance workers; and certain individuals eligible (or whose place of employment was eligible) to receive certain grants from the Lower Manhattan Development Corporation.

Acronyms and Definitions

Role Responsibility American College of Lifestyle Medicine (ACLM)

A medical professional society that provides quality education and certification to those dedicated to clinical and worksite practice of lifestyle medicine as the foundation of a transformed and sustainable health care system.

Case Management (CM) A collaborative process of assessment, planning, facilitation, and care coordination to address member needs.

Clinical Center of Excellence

(CCE)

A medical center under contract with the WTC Health Program to provide WTC-related health services to members.

Lifestyle Medicine (LM) A collaborative clinical specialty that utilizes evidence-based therapeutic lifestyle and behavioral interventions to treat chronic medical conditions, and focuses on nutrition, physical activity, restorative sleep, stress management, avoidance of risky substances, cognitive enhancement, and positive social engagement as both prescriptive treatment for chronic conditions and prevention of additional chronic disease.

Plan of Care (POC) A care plan developed for each eligible member based on individual member needs.

Technical Guidance Document (TGD)

A document published within the Program outlining contractual requirements.