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A front end system for wellness and population health Relationship-based coaches from the neighborhood Group-focused behavior change with tracker feedback.

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Presentation on theme: "A front end system for wellness and population health Relationship-based coaches from the neighborhood Group-focused behavior change with tracker feedback."— Presentation transcript:

1 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 Neighborhood Health Coach Model

2 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.

3 TRIPLE AIM Better Care Better Population Health Better Population Health Better Value




7 NEIGHBORHOOD HEALTH COACH MODEL 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)

8 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


10 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?” COACHING IS OFTEN CONFUSED WITH OTHER ROLES

11 We must go beyond our traditional, hierarchal and linear ways of learning, thinking, problem solving and acting! (One- way flow of information filling ignorant, passive, empty vessels)

12 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. WHAT IS THE CURRENT MODEL?

13 Expert knowledge does NOT translate readily or consistently into behavior change.

14 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.

15 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

16 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

17 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

18 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

19 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

20 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

21 Provide Health Coach Training Introduce Virtual Health Coach Track Critical Health Parameters Design System-Wide Expansion MODEL IMPLEMENTATION: FOUR PROCESSES

22 VIRTUAL COACH & TRACKER Give gift of Health for Children and Families.

23 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

24 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)

25 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.

26 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


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