Skip Navigation LinksHome > November/December 2011 - Volume 15 - Issue 6 > CLINICAL INTEGRATION AS A SUBVERSIVE ACTIVITY
ACSM'S Health & Fitness Journal:
doi: 10.1249/FIT.0b013e31823373b2


Jones, Don L. Ph.D., ACSM-CPT

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Author Information

Don L. Jones, Ph.D., ACSM-CPT, is the wellness center manager for Tri-City Wellness Center in Carlsbad, CA. He earned his Ph.D. from The Florida State University in 1985. His career in the medical fitness industry spans more than 25 years. Dr. Jones serves on the Editorial Board of ACSM’s Health & Fitness Journal®. Additionally, he is ACSM Certified Personal TrainerSM certified.

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LEARNING OBJECTIVE: • This article will provide the reader with insights to improve clinical integration efforts between wellness and fitness centers and physicians as well as clinicians.

There has been a lot of good dialogue and publications over the last few years regarding the need to establish relationships with the medical community to enhance physician referrals to medical wellness centers (1,4,5,8). In addition, articles have been published on sound practices to help secure physical therapy referrals (5,8).

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The purpose of this dialogue is to offer a different approach that has helped centers achieve more referrals — not only from physicians but from the clinical centers within the hospital.

It should be noted that, for the first time Clinical Integration and Medical Fitness made the Top Twenty (no. 18) for Worldwide Fitness Trends for 2011. In addition, Physician Referrals landed in the Top Ten for the first time. Educated and Experienced Fitness Professionals remained at no. 1 (7).

The above is very encouraging and gives rise to the need to seize the moment and look for new and different ways to enhance clinical referrals from all sources.

The approach we took at Florida Hospital Celebration Health was a little bit radical at the time in that we actually sat in on weekly meetings with the different clinical departments to offer our input into how we felt exercise could improve the patient care outcome — hence, the title, Clinical Integration as a Subversive Activity.

You might be asking how we were able to gain that type of access to patient care — at least I hope you are. That will be covered in this article. Suffice it to say for now that a different approach is needed to augment the Exercise is Medicine® initiative so that we, as exercise physiologists, can gain the respect of the physicians, physical therapists, and other clinicians, so they will feel comfortable and confident that their patients are being released to experts in the field.

It seems as though most medical fitness centers have gained access to physical therapy and cardiac rehabilitation patients as more and more hospitals and clinicians see the benefits of moving their patients through the continuum of care. In addition, managed care has reduced the number of physical therapy visits. The options for continuing self-care are either prescribing a home care program or referring their patient to a trainer at a local fitness center.

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With the continuing push for credentialed personal trainers and specialists, clinicians have more options for referrals than ever before. Medical fitness centers have much more to gain now provided they are encouraging their employees to get appropriate training and certifications that have undergone third-party accreditation, such as the National Commission for Certifying Agencies.

There is something for everyone depending on your area of interest and specialty. The medical community recognizes the value of these credentials and will take notice of those centers with credentialed staff.

As Amanda Harris, M.Ed., vice president of fitness and wellness for ACAC Fitness & Wellness Centers points out, “the marketing image of your facility has a lot to do with whether a physician will consider referring a diabetic, hypertensive, overweight, or otherwise challenging patient to your facility” (1).

Part of that marketing image is your Web site, Facebook page, blog, email blasts, and any other marketing materials that showcase the credentials of your staff. Social media is a new way to gain acceptance in the medical community, provided it is done with taste and offers education and information (blogging) to members and nonmembers.

Another part of that marketing image is your own internal campaign within your local hospital. Dr. Harris and Doug Ribley, M.S., director of Wellness and Administrative Services at Akron General Health and Wellness Center have previously addressed physician referrals and rehabilitative referrals, respectively (1,5).

In addressing the issue of physician referrals, Dr. Harris emphasizes the need to reach out to medical professionals and build relationships with them. One way to do this is to create a Medical Advisory Board: “Having a strong advisory board can bolster your facility’s professional image and build credibility among area hospitals, physicians, and patients” (1).

With regard to rehabilitation referrals, Ribley states that the key “is to develop a keen understanding and respect between those staff members who will be sharing space and exhibit wide ranging degrees, credentials, licenses, and expertise” (5). This mutual understanding and respect will aid the rehabilitation patient and/or fitness center client so that he or she will be referred to the appropriate professional. Everybody wins.

Wendy A. Williamson, Ph.D., of Williamson Fitness Consulting, published an article on “Medical Exercise Positioning — A Business Tool Kit” (8) wherein she pointed out that “positioning exercise professionals to service medical conditions is gaining more attention.”

I would agree and add that because of the attention, fitness professionals need to be more assertive in how we introduce ourselves to the medical community — physicians and clinicians. Although I agree in principal with such initiatives as Medical Advisory Boards and professional certifications, I feel we need to get more involved with the medical community.

As a case in point, Edward Phillips, M.D., director of Outpatient Medical Service, Spaulding Rehabilitation Hospital, was asked by Brad A. Roy, Ph.D., FACSM, FACHE, and the then president of the Medical Fitness Association, “Are physicians comfortable referring patients to health/fitness clubs?” Dr. Phillips responded, “No, health clubs are not yet perceived to be part of the continuum of clinical care” (4).

When Dr. Phillips was asked what would convince them — physicians — to do so (refer patients to health/fitness clubs), Dr. Phillips referred to the need for the following:

* third-party accreditation

* medical fitness facility certification

* appropriate educational training and professional certification for exercise professionals

* demonstrated positive health outcomes for patients

* communication with physicians on the progress of their patients

* educational programs at health clubs or at the local hospital

* joining the Exercise is Medicine® initiative

This is a time of unprecedented opportunity. We now need to seize the moment and go with the momentum.

At the recent Medical Fitness Institute held at Vanderbilt University (June 22 to 25, 2011), I discussed clinical integration initiatives with Jay Groves, Ed.D, MMHC, administrative director for Vanderbilt’s Dayani Center for Health and Wellness (J. Groves, personal communication, June 2011).

Dr. Groves summarized three key questions that physicians — and I would add that this applies to other clinicians as well — want to know from health and fitness centers:

* What can you do for my patient?

* What are you doing with my patient?

* What are the results of your actions?

We need to send back a simple, clear message to the provider, physician, and/or clinician: “Your patient completed X program by doing Y, and this was the result” — a very simple but very powerful statement (J. Groves, personal communication, June 2011).

Dr. Groves goes on to say, “From my experience, it has not always been intuitive to our clinicians how their patients will specifically benefit from our services. In addition, in our zeal, we (medical fitness professionals) often promote our core services and modalities as if they will improve if not cure every symptom or condition that our patients and members present with. As a result, we stand the potential to lose our credibility, audience, and potential referral sources…the key here is to be specific in a practical and informative way. Anticipating or responding to simple what, where, and when questions can be of great value when communicating with a clinician.”

Dr. Groves gives this specific example to use when communicating with clinicians: “As a part of our Phase III Cardiac Rehabilitation program, your patient will be working with us 2 to 3 times/week. While here they will be completing 25 to 30 minutes of moderate treadmill walking to improve their stamina and endurance, strength training with their arms to become more functional and independent at home and spending 5 to 10 minutes in a breathing and meditation exercise to help them relax” (J. Groves, personal communication, June 2011).

Sharon M. Slowik, M.D., recently observed, “As the supervising physician at Tri-City Wellness Center’s Cardiac Rehabilitation program, I have witnessed patient’s becoming accountable for their health. Patients reduced medication use and report improved well-being after the program (cardiac rehabilitation). Concentrated risk factor modification during a time when a patient is most motivated to make lifestyle changes has been a critical role for a rehabilitation team, and the fitness professional plays an important part of that team whether it is cardiac rehabilitation, bariatric surgery patients, diabetes programs, total joint replacement, oncology, stroke, peripheral vascular diseases, the list is endless” (S. Slowik, personal communication, May 2011).

Besides the previously reviewed articles on physician referrals (1) and rehabilitation referrals (5), the strategy may assist in gaining access to the other patients: bariatric, oncology, adhesions, stroke, and joint replacement patients just to name a few.

While serving as the executive director of The Fitness Centre & Day Spa at Florida Hospital Celebration Health, we founded the CIA — no, not that one — the Clinical Integration Associates.

This group of individuals was composed of personal trainers and fitness professionals with a multi-varied level of interests and skill sets. For example, one of our personal trainers worked almost exclusively with bariatric patients.

He developed a program for preparing and transitioning bariatric patients. Another trainer worked almost exclusively with oncology and stroke patients.

What we decided to do, with the invaluable help of our vice president, Vickie White, was to “infiltrate” the various departments within the hospital, attend their bimonthly patient update meetings, present current literature reviews and research pertaining to their patients, and essentially “win the hearts and minds” of the physicians and clinicians.

We wanted them to view our staff as the experts in the field. The only way to do this was to go “undercover.” To my knowledge, this type of integration is seldom tried or even allowed — hence the reference to the terms subversive activity and undercover.

It is vitally important to have an administrator lend support for such an initiative. The time has now come where this is more and more likely to happen — provided we are ready with the research and can present it in a cogent fashion to clinicians.

As mentioned earlier, clinical integration/medical fitness is now in the Top 20 as a Worldwide Fitness Trend, whereas Educated and Experienced Fitness Professionals remains no. 1. Let’s roll up our sleeves and show ‘em what we’ve got. It’s time to get involved at the departmental level.

To build the necessary intelligence before we went bounding off to department meetings, we held weekly CIA meetings wherein each staff member was responsible for presenting two current articles about their specialty from respected journals.

This enabled the staff to fully acquaint themselves with the literature, gain confidence in their presentation skills, and share knowledge with other professionals. It was almost like being back in college again — without the worry of a grade.

The standard “Lunch ‘n Learn,” although often treated as a cliché, also was a valuable tool for our staff to introduce concepts to hospital clinicians in a comfortable environment. We take the lead. We are seen as the experts in our field.

Here at Tri-City Wellness Center in Carlsbad, CA, where I am now the Wellness Center Manager, we call these Lunch ‘n Learn programs “Active Education.” Whatever you call them, at the very least provide them and “be the ball” — put your wellness staff front and center as the experts in the field. Showcase your staff’s talents. People — including physicians and clinicians — do take notice.

Holding workshops also builds cache with other clinicians. We held a Functional Movement Screen workshop at Celebration Health that was attended by two of the hospital’s physical therapists and the wife of a leading golf professional. Again, we were seen as the leaders, not the followers — and therefore, as experts in our field.

One of the most valuable ways to win the hearts and minds of clinicians is to present outcomes data. An excellent article by Paul Sorace, M.S., RCEP, CSCS, a clinical exercise physiologist for The Cardiac Prevention & Rehabilitation Program, and Tom LaFontaine, Ph.D., RCEP, FACSM, CSCS, NSCA-CPT of PREVENT Consulting Services, LLC, cites the “benefits of lifestyle intervention on overweight, stages 1 and 2 obesity, and associated risk factors and comorbidities” (6).

This is “just what the doctor ordered” — positive outcome measures for their patients. Of vital importance to note is that Mr. Sorace and Dr. LaFontaine point out, “The health and fitness professional’s role is not diminished with bariatric surgery but rather amplified.”

This is true with almost all medical conditions — the fitness professional’s role is amplified. There is ample evidence of the benefits of exercise in the literature. As fitness professionals, we need to be competent in reviewing it, putting it in context for our respective specialties, and presenting it in a cogent fashion to clinicians and physicians.

Amanda Harris points to the need to be a good community partner (1). She cites examples of partnering with the American Heart Association, Arthritis Foundation, and the American Diabetes Association just to name a few.

There are a number of other opportunities to win hearts and minds and build cache with the medical community. Think of your local Reservists, National Guard members, and their families — think of International Health, Racquet & Sportsclub Association’s (IHRSA’s) new “Joining Forces Network.” See for details on how your club can provide a valuable service to your community and be seen as the expert in the field.

The “Wounded Warrior Project,”, offers another service opportunity. “More than 40,000 service members have been injured in the current conflicts” and are in need of care (9). Many have already experienced the benefits of exercise.

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A recent article in USA Today reviewed the recent Warrior Games in Colorado Springs, CO, and how different the approach is now with injured soldiers. Col. Barbara Springer, a former chief of physical therapy services at Walter Reed Army Medical Center in Washington pointed out, “We used to try to set limits (on what they can do), because we didn’t want people to get discouraged. We don’t do that anymore” (3).

At Tri-City Wellness Center, we are fortunate enough to have a HydroWorx pool in our facility. We use this pool not only for physical therapy patients but also for personal training sessions and now for the “Wounded Warriors” program.

The HydroWorx pool is essentially an underwater treadmill 8 × 10 ft with jets that can be increased or decreased to move the water. In addition, there are underwater cameras, so a staff member can remain on the top level and view the client/patient’s gait from above.

Our personal trainers volunteer their time every Friday morning to work with up to 15 injured combat veterans from Camp Pendleton. As one soldier stated, it was “by far the best overall 50 minute workout/therapeutic session I have experienced. Since my injury in 2006, I have not been able to run, but while submerged mid to upper torso I was able to open my stride, bound, and align my right foot in a toe/heel step all with no or mild difficulty or discomfort” (A. Siebert, personal communication, May 2011).

When we first started working with the “Wounded Warriors” project and the soldiers from Camp Pendleton, there were only three participants and one personal trainer. Now, we have up to 15 soldiers and 3 personal trainers.

These veterans have all commented on how much these sessions have improved their morale — in addition to their level of fitness. This is just another way your club can be a good community partner and provide essential services for a deserving group of people who otherwise may not have this type of outlet.

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To truly capture the hearts and minds of physicians and clinicians and to seize on the Worldwide Trends of 2011, we, as fitness professionals, need to do the following:

* We must be aggressively friendly — community service offers many chances to meet individuals and offer assistance.

* Divide and conquer — infiltrate the clinical departments and help them help their patients.

* Find a champion for our cause — preferably a VP or hospital administrator.

* “Publish or perish” — provide outcomes data for our physicians and clinicians.

* Get certified — the options are numerous.

* Host workshops at your site — help educate your staff and other clinicians.

* Grand rounds — offer to present outcomes data.

* Lunch ‘n Learns — “active education” — whatever you call them, provide them — weekly.

* Work with physicians and clinicians — help them help their patients get better and communicate what you are doing along with the results.

* Speak their language — know the literature inside and out — become the Rosetta Stone of the fitness language.

A recent article in Club Industry, June 2011, points to the trend of increasing medical fitness center operations despite the recession (2). The Affordable Care Act may very well be responsible for driving this growth. As Doug Ribley points out, “It (Affordable Care Act) will compel more health care organizations to assume the risks of their community…keeping people in the community around each hospital out of the health system by keeping them healthy is the solution to the whole health care cost crisis” (2).

As fitness professionals, we must be prepared now more than ever to work with physicians and clinicians. We cannot wait for patients to come to us. We cannot wait for referrals. We have to infiltrate the various clinical departments. We have to be the experts on exercise. We have to publish our results. We have to set the bar higher.

We can seize the moment and drive initiatives such as ACSM’s Exercise is Medicine®, IHRSA’s Joining Forces Network, and the Wounded Warrior Project.

It’s an exciting time to be a fitness professional. The barriers to entry into the clinical world are now coming down. According to the ACSM’s Health & Fitness Journal®; we’re now in the Top Twenty Worldwide (Clinical Integration and Medical Fitness)!

It’s time to get to work and expand on our fields of expertise — and show the clinicians and physicians that we are willing and able to help their patients with their transition and truly establish a continuum of care once and for all.

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Clinical integration is a strategic imperative for medical wellness centers. It is one of the key initiatives that set these centers apart from their competitors. Today, more and more wellness center members are coming via direct referrals from cardiac rehabilitation and physical therapy departments. The Exercise is Medicine® initiative is expected to improve physician referrals as well. This article describes additional ways to augment the above approaches and involve other hospital clinical departments such as oncology, bariatrics, joint replacement, diabetes, and stroke to provide a true continuum of care.

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1. Harris A. Is your facility linked to the health-care community? ACSM’s Health & Fitness Journal. 11(6):26–8, November/December 2007.

2. Kufahl P. Prescription for fitness. Club Industry. 28–37, June 2011.

3. Michaelis V. Sports help wounded vets heal. USA Today, May 25, 2011.

4. Phillips EM, Roy BA. Exercise is MedicineTM: partnering with physicians. ACSM Health Fitness J. 2009;13(6):28–30.

5. Ribley D. Integrating rehabilitation services and medical fitness: what are you waiting for? ACSM Health Fitness J. 2006;10(3):27–8.

6. Sorace P, LaFontaine T. Lifestyle intervention: a priority for long-term success in bariatric patients. ACSM’s Health Fitness J. 2007;11(6):19–25.

7. Thompson W. Worldwide survey of fitness trends for 2011. ACSM’s Health Fitness J. 2010;14(6):8–17.

8. Williamson W. Medical exercise positioning: a business tool kit. ACSM’s Health Fitness J. 2010;14(1):30–3.

9. Wounded Warrior Project Web site [Internet]. Available from: Accessed September 23, 2011.


Clinical Integration Associates; Affordable Care Act; HydroWorx; “Wounded Warriors”; Social Media; Exercise is Medicine®

© 2011 American College of Sports Medicine


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