Wyoming County Nurse Wellness Coach Program Evaluation

1. 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

2. 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

3. Assessment and Enrollment Client interview Comprehensive Health Risk Assessment (HRA) yields numerical score and suggested areas for intervention (see sample) Home visit Laboratory

4. 2006 Client Participation – 20 client caseload