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 clientdetermined 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 interview
Comprehensive Health Risk Assessment
(HRA) yields numerical score and
suggested areas for intervention (see
sample)
Home visit
Laboratory
Program Evaluation – 12-4-06
2006 Client Participation – 20 client caseload
Referred and Assessed
Total N=32
Did not enroll
•3/6 completed HRA
Dropped Out
Enrolled, completed
HRA, bloodwork and
individualized plan
N=26
n = 6;
n=7
•Decided to pursue on own 1
•Moved out of county 2
•To nursing home 1
•Client chose not to pursue 3
Completed Pre-toPost Analysis: N=15
10+ direct contacts plus
all tests and information
Program Evaluation – 12-4-06
Client Demographics
Age of Clients Upon Enrollment
M
SD
Range
Wyoming County
N = 15
Monroe County
N = 77
48
9.61
32 – 69 years
46
9.56
22 – 64 years
Program Evaluation – 12-4-06
Client Demographics
Characteristics
Gender
Female
Male
Race
African American
Caucasian
Hispanic/Latino
Asian
Native American
Wyoming County
N = 15
n
%
Monroe County
N = 77
n
%
13 87%
2 13%
52
25
68%
32%
0
15 100%
0
0
0
27
44
4
1
1
35%
58%
5%
1%
1%
Program Evaluation – 12-4-06
Client Demographics
Characteristics
Marital Status
Single
Divorced
Separated
Domestic Partner
Married
Widowed
Education Level
Grade School
Some High School
High School
Some College
College
Post-College
Wyoming County
N = 15
n
%
Monroe County
N = 77
n
%
5 33%
6 40%
40 52%
18 24%
5 6%
9 12%
5 6%
0
3 20%
1 7%
2 13%
6 40%
6 40%
1 7%
3
33
23
12
5
1
4%
43%
30%
16%
6%
1%
Program Evaluation – 12-4-06
Client Demographics
Characteristics
Residence
Rural
Urban (146xx)
Suburban
Case Manager Type
SCM
ICM
Other
Treatment Type
Ambulatory
CDTP
MICA
Other
Wyoming County
N = 15
n
%
Monroe County
N = 77
n
%
15 100%
70
7
91%
9%
8 53%
7 47%
18
49
10
23%
64%
13%
8 53%
7 47%
25
30
16
6
32%
39%
21%
8%
Program Evaluation – 12-4-06
Client Psychiatric Diagnoses Axis I
Wyoming County
N = 15
n
%
Monroe
County
N = 77
n
%
Substance Abuse
1 7%
51 66%
Episodic Mood Disorders
Depressive 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%
*% adds to > 100; clients may have more than 1 diagnosis
Program Evaluation – 12-4-06
Client Psychiatric Diagnoses Axis II
Diagnosis
Personality Disorder
Wyoming County
N = 15
n
%
Monroe
County
N = 77
n
%
2 13%
18 23%
Mental Retardation
Borderline Intellectual
Functioning
4 5%
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
Obesity
Hypertension, Essential
Lipid Disorder
Gastrointestinal Disorder (GERD = 5)
Diabetes Mellitus (Type 1 = 2, Type 2 = 2)
Pulmonary Disease (Asthma = 4)
Osteoarthritis, Back Pain
Pain Disorder
Hypothroidism
Cardiac Disease (CAD = 1, CHF = 1)
n
12
9
8
7
5
5
4
4
2
2
%*
80%
60%
53%
47%
33%
33%
27%
27%
13%
13%
*% adds to > 100; clients may have more than 1 diagnosis
Program Evaluation – 12-4-06
Health Status: Wyoming County
Measures
Entering
Program
M
SD
PostProgram
M
SD
HRA N = 15
62
15
67
15
Hb A1c n = 3
7.7
3.1
6.3
1.1
Fasting Blood 132
Glucose n = 12
46
116
25
t
df
p
-1.84
14
.09
2
1.99
11
.07
Program Evaluation – 12-4-06
Health Status: Wyoming County N = 15
Measures
Entering
Program
M
SD
PostProgram
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
Program Evaluation – 12-4-06
Consumer Health Status: Wyoming County N = 15
240
210
180
Cholesterol
HDL
LDL
Triglycerides
150
120
90
60
30
Mean Values
Entering
Mean Values
Completing
Program Evaluation – 12-4-06
Health Status: Wyoming County
Measures
Weight
N = 15
Weight
N = 12 --Only
those weighing
over 140 lbs on
entering
Entering
Program
M
SD
PostProgram
M
SD
t
df
p
218
76
211
75
2.70
14
.02
242
64
233
66
3.81
11
.00
Program Evaluation – 12-4-06
Health Status: Wyoming County
Measures
Weight
N = 15
Body Mass Index
N = 15
% Body Fat
n=9
Abdominal Girth
n = 10
Entering
Program
M
SD
218
76
PostProgram
M
SD
t
df
p
211
75
2.70
14
.02
35.9 11.1
35.0
10.4
1.79
14
.10
40.6
8.9
40.2
8.3
8
47
9
47
9
9
Program Evaluation – 12-4-06
Health Status: Wyoming County N = 15
Measures
Entering
Program
M SD
PostProgram
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
Program Evaluation – 12-4-06
Contacts: Locations
Wyoming County N = 15
Total Contacts = 222
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
Home
Clinic
Community
Tx
Program
Other
% of Total Contacts
Program Evaluation – 12-4-06
Nursing Interventions: Health Goals
Wyoming County N = 15
Function of
life
sustaining
processes
Maintain and promote
wellness, recovery,
and/or rehabilitation
4% 1%
Behavior,
communication,
relationships,
development
Total Health
Interventions
= 346
Behavioral
Environmental
Physiological
Psychological
95%
Program Evaluation – 12-4-06
Direct & Indirect Contact Times:
Wyoming County N = 15
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
Note. Mean is average; mode is most frequent.
Program Evaluation – 12-4-06
Client Service Utilization: Wyoming County N = 15
Service Use
Before
Program*
During
Program
Psychiatric Inpatient
Hospitalizations
3
(n = 14)
4
(n = 15)
Medical Inpatient
Hospitalizations
2
(n = 11)
2
(n = 11)
0
(n = 3)
0
(n = 3)
4
(n = 12)
7
(n = 12)
Psychiatric Emergency
Room Visits
Medical Emergency Room
Visits
Note: Pre-program data may be less reliable because it is recall data.
Program Evaluation – 12-4-06
Consumer Health Status: Wyoming County N = 15
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Entering
# Smoking
Completing
# Not Smoking
Entering: 1.25 packs/20 years (average)
Completing: 0.78 packs
1 Quit 4 months, 4 reduced >1/2 ppd
Program Evaluation – 12-4-06
Consumer Health Status:
Wyoming County N = 15
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Higher the score,
lower the risk
# Clients at High
Risk
# Clients at Moderate
Risk
# Clients at Lower
Risk
HRA Entering
HRA Completing
Program Evaluation – 12-4-06
Consumer Satisfaction: Wyoming County N = 15
4
3.5
3
2.5
Mean Ratings
2
Rating 1 – 4
(1 lowest to
4 highest)
1.5
8
7
6
5
4
3
2
1
To
t
al
Sc
al
e
1
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
Blood Pressure
Exercise
Cholesterol
Mammogram
Smoking
Weight
3
10
7
2
10
10
Client Selected Goals
2
7
5
0
6
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 involvement
Obtaining laboratory data is often difficult and time-consuming
HRA is a very useful tool for client, nurse and program; gives useful patientfriendly 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
Program Evaluation – 12-4-06
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