Program Evaluation – 12-4-06 Wyoming County Nurse Wellness Coach Program Evaluation Wyoming County Department of Mental Health Stephen Snell, LCSW Wyoming County Mental Health Clinic Joyce Barker, RN Well-Balanced Program, University of Rochester, Consultants Eva Bellis, RN, BSN, CCM Donna Tortoretti, RNC, MS, CMAC Patricia Lindley, PhD, RN
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Program Evaluation – 12-4-06 Wyoming County Nurse Wellness Coach Program Evaluation Wyoming County Department of Mental Health Stephen Snell, LCSW Wyoming.
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Program Evaluation – 12-4-06
Wyoming County Nurse Wellness Coach Program Evaluation
Wyoming County Department of Mental Health
Stephen Snell, LCSW
Wyoming County Mental Health Clinic
Joyce Barker, RN
Well-Balanced Program, University of Rochester, Consultants
Eva Bellis, RN, BSN, CCM
Donna Tortoretti, RNC, MS, CMAC
Patricia Lindley, PhD, RN
Program Evaluation – 12-4-06
Program Design: 2006
“Embedded” nurse wellness coach (clinic employee) works in tandem with mental health clinicians and care coordinators on client-determined physical health issues
Caseload: 20 slots, revolving enrollment, attends SPOA Not time limited; pace/frequency of contacts vary Eligibility: Care coordination enrollees with moderate to high risk
physical health problems, by referral Program dovetails with Monroe’s Well Balanced Program, using same
assessment, documentation and planning tools Not disease-specific: interventions customized to individual health
problems, client wishes, capacities and readiness Maximize internet, disease-management protocols “best practices” for
education
Program Evaluation – 12-4-06
Assessment and Enrollment
Client interviewComprehensive Health Risk Assessment
(HRA) yields numerical score and suggested areas for intervention (see sample)
Home visitLaboratory
Program Evaluation – 12-4-06
2006 Client Participation – 20 client caseload
Referred and Assessed Total N=32
Enrolled, completed HRA, bloodwork and individualized plan
N=26
Completed Pre-to- Post Analysis: N=15
Dropped Out n = 7
•Decided to pursue on own 1
•Moved out of county 2
•To nursing home 1
•Client chose not to pursue 3
10+ direct contacts plus all tests and information
Did not enroll n = 6;
•3/6 completed HRA
Program Evaluation – 12-4-06
Age of Clients Upon Enrollment
Wyoming County N = 15
Monroe County N = 77
M SD Range
48
9.61 32 – 69 years
46
9.56 22 – 64 years
Client Demographics
Program Evaluation – 12-4-06
Client Demographics
Characteristics Wyoming County N = 15 n %
Monroe County N = 77 n %
Gender Female Male
13 87% 2 13%
52 68% 25 32%
Race African American Caucasian Hispanic/Latino Asian Native American
0
15 100% 0 0 0
27 35% 44 58% 4 5% 1 1% 1 1%
Program Evaluation – 12-4-06
Client Demographics
Characteristics Wyoming County N = 15 n %
Monroe County N = 77 n %
Marital Status Single Divorced Separated Domestic Partner Married Widowed
5 33% 6 40%
3 20% 1 7%
40 52% 18 24% 5 6% 9 12% 5 6%
0
Education Level Grade School Some High School High School Some College College Post-College
Two clients began attending Social Club regularly.
DIABETES MANAGEMENT
Two clients with diabetes who were not testing or using insulin began testing regularly and using insulin regularly
Three clients with diabetes who had not attended medical appointments began seeing their physical care provider.
Program Evaluation – 12-4-06
Wellness Areas of Change (cont’d)
NUTRITION - Eight clients made significant improvements in their diets, such as eating more fruits and vegetables, increasing low fat dairy products and lean meats, and decreasing sweets.- Three clients met with a dietitian for additional help in improving their diets.
EXERCISE- Eight clients increased their level of exercise by walking more or riding a bicycle more.
Program Evaluation – 12-4-06
Wellness Areas of Change (cont’d)
MEDICAL CARE-Five clients were accompanied to medical
care appointments resulting in improved communication with the provider, and additional diagnostic testing and treatment options.
-Three clients’ medical care was adjusted based on information provided by the Nurse Wellness Coach
Program Evaluation – 12-4-06
Other findings and lessons learned
“Wellness coach” P-C approach reduces client wariness of nurse involvementObtaining laboratory data is often difficult and time-consumingHRA is a very useful tool for client, nurse and program; gives useful patient-
friendly information key to starting change behaviors, tracks progress, encourages positive lifestyle shifts, provides aggregate data
Interventions must be adjusted to client situation, considering current mental status, learning styles, literacy;
Time, patience relationship-building often required; changes often start slowly, build on earlier steps; individual readiness often surprises
Individual support usually most effective; formal disease management protocols, written materials often minimally effective; many take well to charting progress (e.g. weight or exercise charts) especially if gains are being made
Medical practitioners build confidence in nurse over time, welcome help from useful data (lab, etc.), better follow-up, enhanced client education and support; improves medical attention to health problems
“Health assessment and referral” are required, Medicaid-reimbursable services under 14 NYCRR Parts 587 and 588