ACLM Program Certification Application

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Name *
Email *

Application Information

Program Certification Application

Thank you for your interest in the Lifestyle Medicine Program Certification from the American College of Lifestyle Medicine. The full application appears below these instructions. Please read the instructions carefully and answer the questions exactly as they are asked. Applications that do not comply with the instructions will not be considered. The save draft feature will work for you as long as your are using the same IP address (same wifi router). The save draft feature WILL NOT save attachments.

Instructions

Please answer as completely and accurately as possible. Please use the third-person voice, as portions of applications from Certified programs will be posted publicly with your profile, pending evaluation and designation. The more descriptive detail you can include with each answer the better in terms of our reviewer's understanding of your program and of the scores they assign to it. The save draft feature will work for you as long as your are using the same IP address (same wifi router). The save draft feature WILL NOT save attachments.

Contact Information

Please provide the business and point-of-contact information for your program.

Program Name *

Please provide the name of the program or business name.

Business Address *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Country *

Please provide the physical mailing address of the business.

Website *

Please provide the program or business website.

Contact Name *

Please provide the point of contact for communicating with ACLM about this application.

Contact Email *

Please provide the email address for the point of contact.

Contact Phone *

Please provide the phone number for the point of contact.

Business Phone *

This phone number will be the number listed publicly on your profile for your business, pending evaluation of your application.

Program Background

Please provide background information on your program. Some of this information is used in evaluating and certifying programs.

Year Established *

Please select the date this program was established with the first active treatment group. You can choose Jan 1 if you are not sure of the specific day.

Founders *

Please list the names of the program founder(s) or designer(s)

Founders - Training *

Please describe the training, experience, and credentials of the founder(s) that makes that individual(s) qualified to have designed this program. (150-300 words)

LM Domains *

ACLM promotes six domains of lifestyle medicine. While it is not necessary for a Certified program to address all of the domains of lifestyle medicine, Certification does require alignment with ACLM's position for those domains which are a focus of the program. Please describe the components of your program that address any of the following: (1) Whole food, plant-predominant dietary lifestyle, (2) Regular physical activity, (3) Restorative sleep, (4) Stress management, (5) Avoidance of risky substances, (6) Positive social connection (150 - 350 words)

Side Effects *

Are there any known side effects / negative sequelae from following the guidelines of this program? Such side effects of interest include chronic diseases and their recognized risk factors such as heart disease (blood cholesterol, blood pressure), diabetes (blood sugar), overweight/obesity, cancer, or other negative effects such as an increased need for medications.

Enrollments *

Please enter the total number of current and former participants to date. Please enter a value greater than or equal to 1.

Program Description

Most but not all of these questions are used in evaluating and certifying programs.

Target Population *

Please be as specific as possible in defining your target population based on demographics, disease condition(s), or other characteristics. (50-250 words)

Prerequisites *

Are there specific criteria a potential participant must meet before being accepted into the program? (i.e., specific disease status or conditions, based on age, or unrestricted). It is not required that you have prerequisities, please just be explicit. (50-250 words)

Research-Based Background *

Select File(s)

What evidence/premise was program founded upon? Please provide one document that is a succinct, 400-600 word research-based background with references. Be attentive to using proper language of attribution (i.e. Use language such as "Diet has been shown to be associated with cardiovascular mortality" if you are referencing an observational cohort study. Reserve language such as "The effects of diet on cardiovascular disease risk" or "Diet has a demonstrated effect blood lipids" or "The effects of dietary change on blood lipids have been shown to be...." when you are referencing intervention trials, preferably randomized controlled trials with at least two treatment arms.) Please provide supporting evidence for both (1) the behavioral intervention itself, and (2) your method of delivery/administration. Please upload only one PDF or Word document presenting the research-based background, with references in AMA (American Medical Association) format. Please do not upload copies of the papers cited. (400-600 words)

Unique Contribution *

Are there components of this program that differentiate it from other multiple health behavior change interventions currently available or that you feel are unique? It is not required that you take a unique approach, but if you do feel something distinguishes this program from other please describe it. (50-250 words)

Live Sessions *

How many sessions with live program staff is the active program comprised of, and what is the format? This might include a live group format, individual sessions, online, combination of above, etc.? A webinar/telehealth format is sufficient, provided the sessions are with live program staff. Though not required for Honorable Mention or Certification, please clarify whether your program sessions are 100% in person, 100% webinar/telemedicine, or a combination. If relevant, please indicate the delivery of each session by providing a high-level syllabus or session topic list and indicating the format for each. Please distinguish between required vs. optional or follow-up sessions. (100-300 words)

Staff *

Who leads/manages the treatment sessions (i.e. physician, dietician, community health worker, nurse, health coach, etc.) and what are their credentials/background/training? (50-250 words)

Oversight *

What is the protocol, if any, for health professional oversight of medication/symptom management? Please describe oversight performed by program staff, affiliated healthcare professionals, or, in the case of oversight not being performed by programs staff, the instructions or referrals provided to participants. (50-250 words)

Duration *

Please describe the total duration of the active treatment program (days/weeks/months) from start to end of the program. Again, please distinguish between required vs. optional or follow-up sessions. (50-250 words)

Contact Hours *

Please describe the frequency and contact hours that participants have with live program staff, as well as how many total contact hours this adds up to over the course of the active program. The active program is administered during the delivery of the core curriculum/support of the intervention and does not include the optional follow-up sessions. (50-250 words)

Follow-Up *

Please describe any optional follow-up or maintenance component offered after completion of the required portion of the program. If some follow-up component exists, is there a cost to participate? If no follow-up exists, are participants provided with referrals or resources to outside programs? (50-250 words)

Metrics *

Please list metrics evaluated (i.e. height/weight, BMI, blood pressure, lipid panel, Hgb A1C, medication use/discontinuation of previous medications, etc.). How are metrics measured and by whom? If they are self-reported, what kind of instructions are given to participants? If no metrics are assessed, please explain why. (50-250 words)

Assessment Schedule *

How often are metrics assessed (i.e beginning, 3 months, 6 months, 12 months, 24 months, etc.)? Are there follow-up assessments post-program end date to demonstrate longer-term effects, and if so, have you been able to document lasting effects at the 12-month post-program mark? Ideally the same metrics will be assessed at baseline, end-of-program, and in follow-up. If available, please provide your assessment of long-term (12 month+) outcomes based on your own data. If you have published a report, white paper, or peer-reviewed journal article, please provide a link. (50-400 words)

Collaborations *

Are there organizations/institutions/corporations currently implementing the program or formally providing referrals to the program? If yes, can you provide examples, distinguish between implementation and referrals, and describe the length of time intervention has been utilized or referred to? Three or more examples are preferred.

References - Organizations *

Select File(s)

Please provide three or more reference letters from organizations endorsing your program. At least one should be from a company that has used your program. Please upload all documents as PDFs.

References - Professional Contacts *

Select File(s)

Please provide one or more reference letters from a professional contact (preferably a healthcare practitioner and if possible, one who is affiliated with ACLM) who is familiar with your intervention program. Please upload all documents as PDFs.

Languages *

Is program available in multiple languages? If so, which ones?

Evidence *

Select File(s)

What evidence exists that this program is effective? Have papers demonstrating program efficacy or effectiveness been published in peer-reviewed journals? Please upload a brief summary (200-400 words) of the research that has been published on your program, as well as copies of the original papers published on your program. If there are no peer-reviewed publications on this program, please outline your plans for future evaluation and research (200-400 words). Please upload all documents as PDFs.

Testimonials *

Select File(s)

Please upload two to five testimonials (at least four is preferred). Participants can remain anonymous. If you have not collected testimonials please explain why. Please upload all documents as PDFs.

Support *

How much support does/can program provided to participants and/or facilitators when questions/needs arise? How scalable are the support mechanisms is/when the program grows? (50-250 words)

Additional Information

These questions are for informational purposes only and are not used in evaluating or certifying programs.

Faith-Based *

Is program faith-based or affiliated with another specific group? If it is faith-based, is it denominational?

Cost to Individuals *

What is the cost of the program to individual participants?

Cost to Organizations *

What is the cost of the program to sponsoring organizations?

For Profit/Nonprofit

Is parent company a for-profit or nonprofit entity?

Financial Impact *

Have you evaluated any economic data (i.e. cost-effectiveness or return on investment) for the program? If yes, please describe your evaluation. If anything has been published in a peer-reviewed journal, be sure to submit the PDF in the "Evidence" field above. If you are interested in potentially publishing in the future, please describe your capacities or interest in collaborating with LMERC.

Comments

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Next Steps

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Certification Fees *

Lifestyle Medicine Program Certification - Initial Application Fee
Program status of Certified or Honorable Mention can be maintained for 24 months.
$1500 Program Status Extension Fee
Programs that have achieved Certified or Honorable Mention status can reconfirm previous application responses and maintain their listing and previous score. Program status can be extended for 24 months.
$500 Recertification Program Application Fee
Programs that previously achieved a status of Certified can submit a new application to be scored at a discounted rate once the 24-month period from their initial application expires. New program status of Certified or Honorable Mention can be maintained for 24 months.
$500 Rescoring for Certification Fee
Programs that previously applied but were not Certified can reapply within the 24 months following their initial submission to have their application rescored.
$1000

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