wyoming county nurse wellness coach program evaluation

Program Evaluation – 12-4-06

Wyoming County Nurse Wellness Coach Program Evaluation

Wyoming County Department of Mental HealthStephen Snell, LCSW

Wyoming County Mental Health ClinicJoyce Barker, RN

Well-Balanced Program, University of Rochester, Consultants Eva Bellis, RN, BSN, CCM

Donna Tortoretti, RNC, MS, CMACPatricia Lindley, PhD, RN


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


Assessment and Enrollment

Client interviewComprehensive Health Risk Assessment

(HRA) yields numerical score and suggested areas for intervention (see sample)

Home visitLaboratory


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


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


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%


Client Demographics

Characteristics Wyoming County N = 15 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%


Client Demographics

Characteristics Wyoming County N = 15 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%


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


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%


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


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


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


306090

120150180210240

Mean ValuesEntering

Mean ValuesCompleting

CholesterolHDLLDLTriglycerides

Consumer Health Status: Wyoming County N = 15



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



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


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


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


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


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.


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


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


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


Consumer Satisfaction: Wyoming County N = 15

11.5

22.5

33.5

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


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


Wellness Areas of Change

SOCIALIZATION Two clients began attending Social Club regularly.

DIABETES MANAGEMENTTwo clients with diabetes who were not testing or using insulin began testing regularly and using insulin regularlyThree clients with diabetes who had not attended medical appointments began seeing their physical care provider.


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.


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


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

wyoming county nurse wellness coach program evaluation

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