Equitable Access to Lifestyle Medicine: FQHCs, YMCAs, Trauma-Informed Health Coaching, and “Community as Medicine”

Abstract

Without intentional and collaborative input from stakeholders and members of the communities we serve, Lifestyle Medicine (LM) is at risk of evolving in ways that are inapplicable and even alienating to diverse and underserved populations. To mitigate this risk, this paper advocates for implementing transdiagnostic, culturally affirmative, trauma-informed, and integrative treatment frameworks that address mental, social, and physical health in tandem. It demonstrates how the Community as Medicine model can bridge the divide between clinical settings such as Federally Qualified Health Centers (FQHCs) and community settings, such as YMCAs, improving accessibility for diverse groups. It also shows how emerging professional identities—exemplified by health coaches—can be cultivated to expand the reach of care while simultaneously opening pathways to employment. By centering inclusivity, cultural affirmation, and interprofessional collaboration, LM can more effectively meet the needs of vulnerable communities and enhance overall public health outcomes.

“The CAM model fosters improved outcomes and offers socioeconomically disadvantaged individuals new career opportunities as certified health coaches.”

Introduction

Health outcomes are disproportionately worse for underrepresented racial and ethnic minorities, driven by longstanding inequities in access to care and the quality of that care, rooted in implicit bias and racism.^1-3 While this lack of access to medical and mental health care has been historically present, the COVID-19 pandemic amplified health disparities between predominantly White and minority communities due to a complex interaction of biological, structural, and social determinants of health (SDOH). ⁴ These include access to nutrient-dense meals, physical activities, social support, education, job opportunities, and safe housing.^4,5 A 2018 report from the W.K. Kellogg Foundation estimates that racial disparities create $93 billion in excess medical care costs, $175 billion in losses due to premature deaths, and $42 billion in lost productivity annually. ⁶ Notably, inadequate access to nutritious food and opportunities for physical activity fosters a self-reinforcing cycle of unhealthy behaviors and adverse health outcomes over the lifespan.^7-11

Lifestyle Medicine (LM) is recognized as a powerful approach to addressing SDOH and promoting health equity because of its emphasis on the link between lifestyle and chronic disease.^12,13 Studies suggest that clinical care accounts for only a small portion of the modifiable contributors to health outcomes, while the majority are attributed to SDOH.^14-16 If LM fails to account for the interconnected elements of a person’s social and physical environment, which directly affect their ability to reduce modifiable risk factors, LM may exacerbate, not improve, health inequities.^17-19 Take, for example, the “behavioral prescription” in which a physician tells a patient to “eat better, exercise more, and reduce your stress.” This advice falls flat for two reasons. First, there is a delivery system problem because giving verbal instructions doesn’t necessarily translate to effective intervention delivery. For example, the physical resources, health literacy, and structured support to make changes based on that intervention are dramatically varied and systematically lower in communities that have faced historical oppression. Just as a prescription with no pharmacy to fill it is useless, simply receiving a list of “shoulds” from a provider doesn’t equate to the actual support, education, troubleshooting, coaching, and ongoing community support needed to enact substantial and sustained behavioral change.

Second, there is an equity problem. If the patient has resources and privileges, there is a seven trillion dollar wellness industry waiting to serve them. ²⁰ For those living in a food desert or food swamp, without safe places to live or even go for a walk, or living with chronic nervous system activation due to personal trauma, this is a prescription to nowhere. Perhaps worse, this well-intentioned prescription leads to feelings of personal failure and shame as people without the ability to enact these changes struggle and fail, leading to depression and, ultimately, despair.^21-23 While despair looks like a personal problem, it quickly becomes a community problem because despair is psychologically upstream from violence, both to ourselves and to others.^24,25

To avoid unintentionally worsening health disparities through lifestyle medicine, healthcare professionals and public health educators are advocating for care models characterized by community engagement, cultural affirmation, and multilevel, multi-sector strategies to address the broader social and environmental factors contributing to health disparities.^12,17,18,26 One example of these care models is Community as Medicine^TM (CAM). This trauma-informed, transdiagnostic, and experiential group-based health coaching model delivers LM to diverse and underserved populations in clinical and community settings. ²⁷ The CAM model was developed by Open Source Wellness, a national nonprofit dedicated to generating health, well-being, and human connection in partnership with healthcare and communities. This paper describes the CAM model and five key elements that are vital to providing equitable access to LM for people with multiple chronic conditions, significant barriers to accessing care, and a much higher trauma burden than the average population. It also describes how CAM can be scaled through community partners, such as YMCAs, bringing more health coaching to populations that need it. Detailed findings on the CAM model’s effect on health behaviors, mental well-being, and clinical results appear in previously published work.^27-29

The Community as Medicine Model

Community as Medicine (CAM) is a group health coaching model that offers an affordable, accessible system for promoting practices that improve human health and well-being. ²⁷ Developed within a lifestyle medicine framework, the CAM model addresses “behavioral prescriptions”—including physical activity, healthy eating, stress reduction, and social connection—through experiential group sessions and activities.^27,30 Each group consists of 15 to 25 participants who are prescribed a 12-week dose of CAM by their primary care providers. Programs are 60-120 minutes long, offered in-person or virtually, and in English or Spanish. All sessions are guided by trauma-informed and culturally affirmative health coaches and peer leaders, and some sessions are delivered as Group Medical Visits in integration with a primary care provider. This is especially relevant since the CAM model is frequently implemented as a partnership between a clinical system (typically a Federally Qualified Health Center) and a community-based delivery partner (such as a YMCA). The CAM model is designed to address physical, mental, and social health through four LM pillars: MOVE (physical activity), NOURISH (healthy nutrition), CONNECT (social engagement), and BE (stress reduction) (Figure 1).

Figure 1.

Community as medicine model.

Key Elements for Equitable Access to LM

The CAM model incorporates five key elements that ensure LM is delivered in a way that is appropriate, accessible, and meaningful to diverse and underserved populations. The design, facilitation, and coaching styles of CAM are (1) Experiential, (2) Transdiagnostic, (3) Trauma-informed, (4) Culturally Affirmative, and (5) Integrated with clinical partners.

Experiential

Experiential programming transforms lifestyle medicine by shifting the focus from delivering information to actively and joyfully practicing health behaviors in community settings. Rather than simply instructing patients on what they “should” do—a strategy that, as many experienced LM practitioners know, often fails to catalyze sustained behavior change—this approach immerses participants in shared, hands-on, and emotionally rewarding experiences. For example, instead of presenting a lecture on the benefits of physical activity, a group might engage in a playful interactive physical activity session together, allowing participants to feel the immediate physical and emotional rewards of exercise. By fostering a sense of accomplishment and social connection, experiential programming builds intrinsic motivation, reinforces positive habits, and helps participants internalize health-promoting behaviors.^31-34

Transdiagnostic

A transdiagnostic approach to group health coaching moves beyond diagnosis-specific frameworks, such as the Diabetes Prevention Program, ³⁵ Blood Pressure Self-Monitoring, ³⁶ or other single-issue groups, to embrace the holistic nature of human health. While a transdiagnostic approach is traditionally associated with mental health,^37,38 a fresh perspective is to consider it within the context of physical comorbidities that transcend singular diagnoses. ³⁹ The CAM model recognizes that individuals often face overlapping challenges and possess intersecting strengths that transcend singular diagnoses. By bringing together demographically and diagnostically diverse participants, transdiagnostic groups focus on universal pillars of health, such as physical activity, nutrition, stress reduction, and social connection. For example, a group might include individuals managing hypertension, depression, anxiety, chronic pain, or a combination of several disorders, each working toward shared and unique goals like improving functional fitness or fostering supportive relationships. This inclusive format eliminates restrictive eligibility criteria and fosters a rich exchange of perspectives, allowing participants to draw strength from shared experiences while learning from their differences. It also reduces the stigma that is, unfortunately, still common in mental health-focused groups. Transdiagnostic group formats promote holistic well-being and equity by addressing foundational health behaviors that benefit all, creating a space where diverse needs are collectively met. This transdiagnostic approach shows promise to promote holistic well-being, increase access to services, and create a space where diverse needs are met collectively. More research is needed to verify clinical outcomes from a transdiagnostic health coaching approach.

Trauma-informed

Trauma-informed care recognizes the influence of adverse or traumatic experiences on a person’s beliefs, behaviors, and sense of self. It shifts the approach from “what’s wrong with you?” to consider “what happened to you?” ⁴⁰ Trauma-informed health and wellness coaching prioritizes safety, trust, collaboration, choice, and empowerment to minimize the risk of recreating harmful interpersonal dynamics in the helping relationship.^41,42 A key to this approach is self-directed change, which means the coaches are not presenting as “the experts.” ⁴⁰ Instead, they provide the tools and techniques to help people figure out what they want and how they will get it for themselves. For example, a CAM participant might come to the program because “my doctor wants me to lose weight,” but the CAM health coach, while supporting this goal, will probe for genuine desire: “what’s important to you?” Slowly, the coach may discover that the individual “just wants to be able to play with my grandkids again.” This identification of desire, values, and intrinsic motivation is consistent with self-determination theory (SDT), which shows that behaviors propelled by autonomy and personal fulfillment are more durable, sustainable, and psychologically beneficial than those primarily driven by external rewards. ³¹

Language plays a pivotal role in coaching by facilitating trust, clarifying goals, and fostering reflective insight. ⁴³ In contrast to directive or command-based language, often exemplified in healthcare, Invitational Language helps individuals explore their preferences, notice what feels right for them, and stay attuned to their bodies, all while providing options and consistently honoring choices (see Figure 2).

Figure 2.

Examples of Invitational language.

Culturally affirmative

Culturally affirmative health coaching embraces cultural humility and proactive cultural affirmation to honor individuals’ unique identities and practices while promoting wellness strategies that resonate with their lived experiences.^44-46 Cultural humility requires a health coach to continuously reflect on their own biases and avoid imposing dominant cultural norms. For example, instead of recommending kale or quinoa—foods commonly associated with Western wellness trends—a coach might explore what cultural foods the client values, enjoys, or has access to. Culturally affirmative coaching builds on this by affirming the value of these traditional practices, celebrating their cultural significance, and co-creating health strategies around them. This might involve helping clients incorporate family recipes with healthier cooking methods or exploring culturally relevant ways to increase plant-based meals. Centering wellness practices within the client’s cultural context fosters deeper engagement, trust, and participation in health-promoting activities.^47,48

Integrated with Clinical Partners

The Community as Medicine model exemplifies deep clinic-community integration by partnering with Federally Qualified Health Centers (FQHCs). These community-based health organizations deliver prevention and primary care services in an outpatient clinic setting to underserved populations regardless of their ability to pay. ⁴⁹ Partnering with FQHCs and other clinical providers expands access to care beyond traditional “health-seekers” and plays a critical role in reducing health disparities. By embedding equity-centered, experiential group health coaching within these settings, both in-person and virtually, the model ensures that underserved populations can engage in meaningful health promotion interventions that may be beyond the scope of what an FQHC can provide. One key strategy is incorporating Group Medical Visits (GMVs)^50,51 into the CAM health coaching model. GMVs are clinic-based interventions delivered to multiple patients at one visit, integrating clinical care, health education, and peer support. ⁵⁰ Within the CAM model, the GMVs are predominantly facilitated by a team of health coaches, with one primary care provider pulling patients aside for top-of-scope and billable individual medical visits. These visits allow participants to receive evidence-based medical guidance alongside culturally resonant health coaching in areas such as physical activity, nutrition, stress management, and social connection. This integrated approach fosters accessibility, reduces provider burnout, increases provider morale, and builds community by meeting patients where they are—both physically and culturally—within the healthcare system.^51-53 It also supports sustainability since GMVs are reimbursable.^50,51

Scaling Community as Medicine through Community-Based Organizations

This paper has identified key aspects of the CAM health coaching model to ensure LM is delivered in a way that is appropriate, accessible, and meaningful to diverse and underserved populations, including its emphasis on experiential, transdiagnostic, trauma-informed, and culturally relevant experiences that integrate community health coaching with clinical partners. Results of the CAM model, including improvements in clinical outcomes, fruit and vegetable consumption, minutes of exercise, depression, anxiety, and loneliness, can be found in previously published works.^27–29 However, lifestyle medicine’s capacity to broadly drive behavior change on a large enough scale to significantly impact population health and extend its benefits to underserved populations will require approaches that are both scalable and flexible in their implementation.^17,19 Researchers and clinicians stress the importance of community-level interventions that can reach populations who do not possess the wealth, health, or racial equity needed to be served solely by traditional health systems.^12,18,26

To build capacity for implementing the CAM model at scale via a dispersed network of local organizations, the Community as Medicine Learning Collaborative was established in 2024 with funding from the Ardmore Institute of Health https://www.ardmoreinstituteofhealth.org/, accessed March 7, 2025. The American Heart Association Social Impact Funds, Unlikely Collaborators, and other philanthropic funders are supporting this work, as well https://www.unlikely.foundation/, accessed March 7, 2025. ⁵⁴ The purpose of the CAM Learning Collaborative is to support clinical and community-based organizations (including YMCAs) in developing and implementing Community as Medicine programs in their communities. This includes training staff as NBHWC-certified health coaches, ⁵⁵ building or strengthening relationships with local clinical partners (predominantly FQHCs), and developing financial sustainability pathways leveraging Group Medical Visits, payor partnerships, and other innovative billing strategies, including Community Health Worker benefits. ⁵⁶ One participant in the 2024 Community as Medicine Learning Collaborative was the YMCA of the North, the second-largest YMCA system in the country. ⁵⁷ YMCA of the North engages more than 370,000 men, women, and children of all ages, income levels, and backgrounds through 29 Y branches and program sites, as well as eight overnight camps, 10-day camps, and more than 90 childcare locations. ⁵⁷ The YMCA of the North partnership with Open Source Wellness (OSW) was funded, in part, by an $8 million grant from Penny and Bill George and the George Family Foundation to increase access to whole-person health and well-being. ⁵⁸ Moving beyond the “swim and gym” model of the past, the YMCA of the North and other Ys are focusing on whole-person care, which sits at the intersection of conventional care and community care (see Figure 3). Whole-person care includes the CAM health and wellness group-based coaching alongside other health and wellness professionals, including massage therapists, chiropractors, physical therapists, acupuncturists, mindfulness instructors, nutritionists, chefs, gardeners, energy workers, and teaching kitchens, to achieve well-being, including spirit, mind, and body in a way that is accessible, affordable, and equitable. ⁵⁷

Figure 3.

YMCA of the north whole-person well-being model.

Extending the reach of conventional care through community-based group health coaching is crucial, as research indicates that clinical care accounts for only 20% of health outcomes in the US. ⁵⁹ YMCA of the North has a strong legacy of delivering group-based well-being programs focused on physical activity and behavior change, such as the LIVESTRONG® community-based exercise program. ⁶⁰ Building on this foundation, the CAM health coaching model has the potential to go beyond the YMCA’s traditional fitness-focused operations by addressing a broader spectrum of health behaviors that contribute to holistic well-being while also recognizing the critical role of social determinants of health.

Pathways to Employment

Beyond demonstrated improvements in health behaviors and mental well-being,^27-29 the CAM model provides novel pathways to employment for its participants. Past participants have the opportunity to serve as peer leaders. They may subsequently enroll in the Open Source Wellness Community as Medicine Health Coach Training Program, followed by a practicum designed to fulfill the clinical hours required to become licensed by the National Board for Health & Wellness Coaching (NBHWC) and earn the NBC-HWC credential. ⁵⁵ Obtaining this credential demonstrates to clients, collaborators, and employers that a health coach possesses the requisite skills, training, and practical experience for professional practice. ⁵⁵ As a result, several former participants have trained as health coaches, become NBHWC-certified, and been hired as staff members, while others have secured coaching positions outside the organization. In this way, the CAM model fosters improved outcomes and offers socioeconomically disadvantaged individuals new career opportunities as certified health coaches. This also provides an entry-level position in a career ladder that includes many in-demand allied health careers with family-sustaining wages and offers access to careers such as CNA, RN, and others.

Conclusion

Disparities in access to healthcare and resources that promote healthy lifestyles continue to undermine the health and well-being of underserved racial and ethnic communities. Lifestyle medicine has the potential to address social determinants of health, treat chronic disease and promote health and well-being, yet it must be delivered equitably to avoid unintentionally deepening those disparities. The CAM model offers one promising solution by focusing on group-based, trauma-informed, culturally affirmative, and experiential approaches integrated with clinical care. Through partnerships with community-based organizations like YMCAs and Federally Qualified Health Centers, CAM expands access for underserved populations while supporting healthcare providers through coordinated group medical visits. Early evidence suggests this model can improve health behaviors, mental health, and clinical outcomes in diverse settings. It can also open new pathways to employment for socioeconomically disadvantaged individuals. In addition, scaling efforts, such as the Community as Medicine Learning Collaborative, a year-long training and technical assistance program that helps community-based organizations implement the CAM model, are poised to broaden its reach. This represents an important step toward bridging the gap between individual-level care and population-level transformation.

ORCID iD

Sally C. Duplantier https://orcid.org/0009-0006-8218-3657