Neighborhood Health Coach Model
• A front end system for wellness and
population health
• Relationship-based coaches from the
neighborhood
• Group-focused behavior change with tracker
feedback
Sheila Ryan, PhD, RN,FAAN
UNMC CON Omaha, NE
Complexity science: meta-theory quantum physics, math and
philosophy
patterns emerge; information forms us;
vision bonds, energizes;
relationship is the foundation
Complex adaptive systems: mid range; change is local, with
continuous feedback, benchmarking and trending the results, and
innovative collaboration by owning the results (not blaming nor
directing and/or controlling)
Quality Improvement: the operational level; form a team, set clear
aims and clear outcome measures of results to be achieved; pdsa
cycle of small scale trial, then learn from it and repeat into many
pdsa cycles.
TRIPLE AIM
Better Population Health
Better Care
Better Value
THE HUMAN HEALTH EXPERIENCE
The Human Health Experience
COMPLEX
Crisis Management
Risk Management
(Tertiary Care)
(Primary Care)
Hospital Setting
Acute Care
Multi-disciplinary Team
Ambulatory Care Center
Risk Reduction
Primary Care Providers
Health Management
Disease Management
(Self-Care)
(Specialist Care)
Home Setting
Lifestyle Awareness
Health Coach
Specialty Clinic/Care Setting
Disease Management
Specialist Physician/Team
SIMPLE
WELLNESS
ILLNESS
DISEASE
J Koerner & S Ryan
HUMAN HEALTH INDICATORS
Human Health Indicators
COMPLEX
Risk Management
Crisis Management
(Primary Care)
COMPLEX
(Tertiary Care)
Risk Management
Hypertension
(Primary Care)
BMI/A1C
Hypertension
Hyperlipidemia
BMI/A1C
Maternal-Child
Care
Crisis Management
Acute Illness
Episode
(Tertiary
Care)
Multi-Systems Crisis
Acute
Illness Episode
Trauma
Multi-Systems
End-of-Life Care Crisis
Hyperlipidemia
Maternal-Child Care
Trauma
End-of-Life Care
Health Management
SIMPLE
SIMPLE
Disease Management
(Self-Care)
Health
Management
(Specialist
Care)
Disease Management
(Self-Care)
(Specialist Care)
Stress Management
Stress
Management
Exercise
Exercise
Nutrition
Nutrition
Relationships
Relationships
WELLNESS
WELLNESS
Diabetes
Diabetes
Asthma/COPD
Asthma/COPD
Cardiovascular Disease
Cardiovascular Disease
Depression
Depression
ILLNESS
ILLNESS
DISEASE
DISEASE
J Koerner
J Koerner
& S Ryan& S Ryan
HUMAN HEALTH
EXPERIENCE GUIDES
Human Health Experience Guides
COMPLEX
Risk Management
Crisis Management
(Primary Care)
(Tertiary Care)
Clinic Personnel/RN Case Manager
Consultant for Health Coach
Assess & monitor health status
Integrate information
Make appropriate referral
SIMPLE
Hospital-based Care Team
Consultant for Specialty Providers
Stabilize a Crisis
Restore functional health patterns
Assist with chronic lifestyle planning
Health Management
Disease Management
(Self-Care)
(Specialist Care)
Health Coach
Consultant for Family
Lifestyle Coach
Monitor specific health parameters
Link to RN Case Manager
Specialty Team/APN
Consultant for Primary Care RN
Disease Educator
Disease Management Coach
Monitor disease process & refer
WELLNESS
ILLNESS
DISEASE
J Koerner & S Ryan
NEIGHBORHOOD HEALTH
COACH MODEL
Training in Relationships:
Coaching, Leadership, Empowerment, Relationships, Health
Promotion & Risk Reduction, Life Span Development, Safety,
Lifestyle Activities, Addictions, Group Management, Advocacy
Virtual Coaching:
Web-based Goal Setting, Health Education, Individual & Group
Challenges, Social Networking, Activity & Clinical Indicators
Tracking, Risk and Health Information monitoring with RN Mentor
Illness System Integration:
NHC/RN Mentor referral to PC
Nurse Managed Center/Faculty/Student Practice
Primary Care clinic (NP or MD)
RELATIONSHIP-BASED
PERSONAL HEALTH
Between all Health Coaches and RN mentors in the
program, sharing best-practices and innovations
Family members and community members, creating
real-time support groups
Students providing neighborhood assessment,
wellness/risk management education, small group
facilitation, creating a new health
Professionals in neighborhood-based primary care
environment
University Faculty/Health Researchers to evaluate
program performance and impact
NHC TRAINING MODULES
COACHING SKILLS
HEALTH, WELLNESS AND CHANGE
COMMUNITY HEALTH & SYSTEMS
INTEGRATION
COACHING IS OFTEN CONFUSED
WITH OTHER ROLES
• Supervision – “I know how. Do it this way.”
• Mentoring – “My experience is… This is how I would
do it.”
• Consulting – “I know how. That is what you are
paying me to tell you. This is how you do it.”
• Coaching – “How can I help you learn? What have
you tried? How has that worked? What else can you
try?”
We must go beyond our traditional,
hierarchal and linear ways of learning,
thinking, problem solving and acting! (Oneway flow of information filling ignorant,
passive, empty vessels)
WHAT IS THE CURRENT MODEL?
• You don’t know what I’m about to expect you
to do and you must do it all…(we are the
best, we are the experts, there is little room
for improvement)
»OR
• Effective learning requires reflection and
validation which requires interaction.
Expert knowledge does NOT translate
readily or consistently into behavior
change.
WELLNESS WHEEL
The Wellness Wheel includes six dimensions of wellness that
encompass all aspects of a person’s life with the goal of promoting a
healthy, well-rounded, individual. These dimensions are connected
and work together to maintain a health balance in your life.
PHYSICAL WELLNESS: Taking care of your body for optimal
functioning.
•Exercising regularly (30 minutes most days)
•Eating healthy foods
•Getting adequate sleep (7 to 9 hours)
•Getting regular physical check-ups
•Avoiding the use of tobacco or illicit drugs
Social Wellness: Your ability to interact with the people around you.
•Understanding and appreciating people of different cultures, ethnicities,
backgrounds, ages
•Respecting yourself and others
•Developing meaningful relationships
•Having a good support system
•Giving back to the community
•Communicating effectively
Environmental Wellness: Your perception of the environment you work and
live in.
•Finding satisfaction and worth in your work
•Making the best use of your skills and experience
•Being aware of the impact your decisions have on the environment and
others
•Choosing lifestyle practices that are respectful of the environment
Emotional Wellness: The extent to which you feel positive and enthusiastic about
yourself and life.
•Having a positive attitude and sense of self
•Acknowledging and accepting your feelings and the feelings of others
•Expressing and managing your feelings maturely
•Learning to cope with stress
•Taking responsibility for your own behavior
•Viewing challenges as opportunities, not obstacles
•Functioning independently but knowing when you need to ask for help
Spiritual Wellness: The set of values and beliefs that provide meaning and
purpose in your life.
•Defining personal values, beliefs, and ethics and using them to guide your
decisions
•Making sense of life’s meaning, purpose, and direction through everyday
experiences.
•Connecting with self, others, or a higher power
•Spending time alone in personal reflection
•Participating in spiritual activities
•Caring about the welfare of others and acting out of that care
Intellectual Wellness: Engaging your mind in creative and
stimulating activities
•Seeking personal growth and lifelong learning
•Learning new concepts and skills
•Staying current with news and world affairs
•Exposing yourself to new experiences
•Being open to new ideas and the views of others
MODEL IMPLEMENTATION:
FOUR PROCESSES
• Provide Health Coach Training
• Introduce Virtual Health Coach
• Track Critical Health Parameters
• Design System-Wide Expansion
VIRTUAL COACH & TRACKER
Give gift
of
Health
for
Children
and
Families.
SCALE UP AND SPREAD
Train cohort of 10 NHCs for 2500-5000 population/site
• Repeat every 6 months
• Nurture relationships between NHC & their RN Mentor
• Refer to NHC/PCP (Primary Care Provider)
• Analyze high risk users
• Examine categories
• Provide on-going support to NHC & Mentor
• Decide on appropriate ratio of NHC to members
• On-going clinical/economic impact research to guide
•
model development & deepen impact
DISTINCTIVE MODEL FEATURES
• Community based and owned health information and data
• Family & NHCs ‘healthy’ modules on computer/I-pad
• Family and individual goal setting with weekly tracking
• Family & health focused activities with group interventions
• Educational & support groups for chronic care mgt: i.e., elderly
walking, diabetes mgt., etc.
• Utilization review of acute care services
• Salaried coaching jobs (1:50 families)
FACULTY-BASED
PRACTICE OUTCOMES
• Demonstrate innovative patient-centered models of nursing
practice and health care
• Lead efforts to translate research into practice
• Support nursing education across the health care continuum,
preparing nurses for the diversity of experiences that will be
needed in the future.
• Improve information continuity across the patient, provider, and
system level
• Help develop public policy to improve health care quality and
eliminate health care disparities.
Learning organizations anticipate change and
use adaptive, generative learning to enhance
capacity to create, innovate that allow people
to do things they were never able to do before,
to view their world from a new perspective,
and become a genuine part of the new
learning, new behavior, new life, new heart of
the organization.
Senge, 1990