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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
2 13%
6 40% 6 40% 1 7%
3 4%
33 43% 23 30% 12 16% 5 6% 1 1%
Program Evaluation – 12-4-06
Client Demographics
Characteristics Wyoming County N = 15 n %
Monroe County N = 77 n %
Residence Rural Urban (146xx) Suburban
15 100%
70 91% 7 9%
Case Manager Type SCM ICM Other
8 53% 7 47%
18 23% 49 64% 10 13%
Treatment Type Ambulatory CDTP MICA Other
8 53% 7 47%
25 32% 30 39% 16 21% 6 8%
Program Evaluation – 12-4-06
Wyoming CountyN = 15n %
Monroe CountyN = 77n %
Substance Abuse 1 7% 51 66%
Episodic Mood DisordersDepressive Disorder NOS
7 47%4 27%
38 49%
Schizophrenic Disorders 4 27% 38 49%
Anxiety, Dissociative, & Somatoform Disorders
1 7% 9 12%
Stress Disorder 1 7% 3 4%
Anorexia, Hyperkinetic Disorder, Non-Organic Psychosis
2 14% 1 1%
Client Psychiatric Diagnoses Axis I
*% adds to > 100; clients may have more than 1 diagnosis
Program Evaluation – 12-4-06
Client Psychiatric Diagnoses Axis II
Diagnosis Wyoming CountyN = 15n %
Monroe CountyN = 77n %
Personality Disorder 2 13% 18 23%
Mental Retardation 4 5%
Borderline Intellectual Functioning
1 7% 3 4%
Obsessive-Compulsive Disorder
3 3%
Developmental Delay (Reading)
2 3%
Post-Traumatic Stress Disorder
1 1%
Program Evaluation – 12-4-06
Client Medical Diagnoses Axis III: Wyoming County N = 15
Diagnosis n % *
Obesity 12 80% Hypertension, Essential 9 60% Lipid Disorder 8 53% Gastrointestinal Disorder (GERD = 5) 7 47% Diabetes Mellitus (Type 1 = 2, Type 2 = 2) 5 33% Pulmonary Disease (Asthma = 4) 5 33% Osteoarthritis, Back Pain 4 27% Pain Disorder 4 27% Hypothroidism 2 13% Cardiac Disease (CAD = 1, CHF = 1) 2 13%
*% adds to > 100; clients may have more than 1 diagnosis
Program Evaluation – 12-4-06
Measures Entering Program M SD
Post-Program M SD
t df p
HRA N = 15 62 15 67 15 -1.84 14 .09
Hb A1c n = 3 7.7 3.1 6.3 1.1 2
Fasting Blood Glucose n = 12
132 46 116 25 1.99 11 .07
Health Status: Wyoming County
Program Evaluation – 12-4-06
Measures Entering Program M SD
Post-Program M SD
t df p
Cholesterol 208 51 186 44 2.00 14 .07
HDL 51 16 44 10 2.38 14 .03
LDL 123 43 110 42 1.75 14 .10
Triglycerides 216 159 201 105 0.70 14 ns
Health Status: Wyoming County N = 15
Program Evaluation – 12-4-06
30
60
90
120
150
180
210
240
Mean ValuesEntering
Mean ValuesCompleting
CholesterolHDLLDLTriglycerides
Consumer Health Status: Wyoming County N = 15
Program Evaluation – 12-4-06
Health Status: Wyoming County
Measures Entering Program M SD
Post- Program M SD
t df p
Weight N = 15
218 76 211 75 2.70 14 .02
Weight N = 12 --Only those weighing over 140 lbs on entering
242 64 233 66 3.81 11 .00
Program Evaluation – 12-4-06
Health Status: Wyoming County
Measures Entering Program M SD
Post- Program M SD
t df p
Weight N = 15
218 76 211 75 2.70 14 .02
Body Mass Index N = 15
35.9 11.1 35.0 10.4 1.79 14 .10
% Body Fat n = 9
40.6 8.9 40.2 8.3 8
Abdominal Girth n = 10
47 9 47 9 9
Program Evaluation – 12-4-06
Measures Entering Program M SD
Post-Program M SD
t df p
Systolic BP 123 20 114 15 1.86 14 .08
Diastolic BP 81 15 74 11 1.78 14 .10
Health Status: Wyoming County N = 15
Program Evaluation – 12-4-06
Contacts: LocationsWyoming County N = 15
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Home Clinic Community TxProgram
Other
% of Total Contacts
Total Contacts = 222
Program Evaluation – 12-4-06
95%
4% 1%
BehavioralEnvironmentalPhysiologicalPsychological
Nursing Interventions: Health GoalsWyoming County N = 15 Total Health
Interventions = 346
Function of life sustaining processes
Behavior, communication, relationships, development
Maintain and promote wellness, recovery, and/or rehabilitation
Program Evaluation – 12-4-06
Direct Time
Indirect Time
Per Program Mean Mode
SD
40 min 40 min 13.00
15 min 10 min 14.62
Per Client Mean Mode
SD
65 min 50, 60 19.50
26 min 10 min 17.67
Direct & Indirect Contact Times: Wyoming County N = 15
Note. Mean is average; mode is most frequent.
Program Evaluation – 12-4-06
Service Use Before Program*
During Program
Psychiatric Inpatient Hospitalizations
3(n = 14)
4(n = 15)
Medical Inpatient Hospitalizations
2(n = 11)
2(n = 11)
Psychiatric Emergency Room Visits
0(n = 3)
0(n = 3)
Medical Emergency Room Visits
4(n = 12)
7(n = 12)
Note: Pre-program data may be less reliable because it is recall data.
Client Service Utilization: Wyoming County N = 15
Program Evaluation – 12-4-06
Consumer Health Status: Wyoming County N = 15
0123456789
101112131415
Entering Completing
# Smoking # Not Smoking
Entering: 1.25 packs/20 years (average)Completing: 0.78 packs1 Quit 4 months, 4 reduced >1/2 ppd
Program Evaluation – 12-4-06
0123456789
101112131415
HRA Entering HRA Completing
# Clients at HighRisk
# Clients at ModerateRisk
# Clients at LowerRisk
Higher the score, lower the riskConsumer Health Status:
Wyoming County N = 15
Program Evaluation – 12-4-06
Consumer Satisfaction: Wyoming County N = 15
1
1.5
2
2.5
3
3.5
4
Mean Ratings
Rating 1 – 4 (1 lowest to 4
highest)
1 = Quality Service 2 = Got Service 3 = Met Goals
4 = Recommend 5 = Satisfied Help 6 = Helped Problems
7 = Satisfied Overall 8 = Come Back
Program Evaluation – 12-4-06
Client Goals Recommended and Selected
HRA Recommended Goals Client Selected Goals
Blood Pressure 3 2Exercise 10 7Cholesterol 7 5Mammogram 2 0Smoking 10 6Weight 10 8
Program Evaluation – 12-4-06
Wellness Areas of Change
SOCIALIZATION
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
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