Silva et al. Respond

Hopkins offers two reasonable suggestions to improve participation in an open model for exercise access. Establishing a gym-buddy system may facilitate healthy socialization and create a mutual support mechanism for physical activity goals and improved health. Gym-buddy networks could be created using group visits and organized by a coordinator who would suggest individual and group goals. Trainers or staff can be used to encourage personal goal setting and facilitate patient groups. Scheduled phone calls could also be used for coaching and follow-up when individuals miss sessions. These interventions may be scaled to fit the partnership and budget for this work. We established budgets for trainer services, including patient intake, goal setting, follow-up calls, personal training sessions, and group visits in several early pilot studies. We planned consistent, regular follow-up that was initiated by trainers. Our experience was that cancellation rates were too high to justify continued funding. Trainer time was budgeted by the hour and paid whether patients attended or not. We then switched to patient-initiated contact and scheduling. All new patients received access, a facility tour, and orientation, and we found that there were too many cancellations with one-on-one tours and orientations. Group orientation was then used as we adapted to patient preference and patterns. We called patients who did not keep appointments and used those conversations to learn what patients wanted or what did not work for them in the process. Many small changes were made, and we learned that individuals who were interested were the most consistent. Group visits are an important part of our plans, although attendance for trainer-scheduled groups was also low. Providers and fitness staff encouraged patients to create their own support networks, and patients began to meet at the facility for group exercise classes. The medical visits and kept fitness center visits were used to learn patient preferences and build on personal goal-setting practices while encouraging behaviors that were making exercise possible. Our later work was funded with fewer resources, so we met the main objectives of open access and the referral mechanism to fitness centers. We relied on follow-up visits to review individual progress, encourage regular visits to the fitness center, and track visits because resources were so limited. Funding was insufficient to have a full-time paid coordinator, although we followed up on select patients as needed. Gym buddies and follow-up calls from a project coordinator may be a more cost-effective way to create patient-level support systems than our experience with hourly trainers and may be sustainable in the long run. We agree that further work on exercise access should explore motivational approaches including accountability partners and other individualized strategies while budgeting for a project coordinator.