Posts from — June 2010

Information to evaluate your program comes from routinely accumulated screening and follow-up data of your program that look at process and outcomes of your program.

The Staff Member Medical Program has available a computerized case-management system which includes queries that allow easy assessment of process and outcome results at any point in time.

Process Evaluation

Process analysis looks at the program’s impact as seen at various points in time.

Information that is accumulated from the various forms that wellness employees fill out should supply you with the following –

• How many employees were screened?

• How many staff members who were referred to a physician went?

• How many workers who expressed interest in health improvement programs went?

• How many workers who were referred to health improvement programs went?

• How many workers who went to health improvement programs completed them?

• How many staff members are in follow-up caseload?

You can use this kind of process analysis to evaluate and learn about the health of your program.

Wellness Program Outcome Evaluation

A central objective of the program is to improve the health of workers. Information on how to judge how well your program is meeting this objective is called “outcome investigation” because you’re analyzing  the results or outcome of your program.

In wellness programs, goals are measured by specific (outcomes) behavior changes and reductions in health risk levels. Have workers lowered their blood pressure? Have they lost weight? Are they exercising more? is alcohol consumption at a safe level?

For example these are the kinds of questions you are able to ask to find out if you are reaching your goals –  

• for workers with high blood pressure (BP) (140 / 90 or higher or on medication) at screening, what percentage have it under control (below 140 / 90) a year later?

• What is the change in average blood pressure (BP) levels among all workers with high blood pressure (BP) 1 year after screening? Two years later?

• for employees with high blood cholesterol levels (above 240) at screening, what percentage has lowered their cholesterol to borderline-high levels (200-239)?

• for employees with borderline-high blood cholesterol levels, what percentages have decreased their cholesterol to the desirable range (below 200)?

• What is the change in average cholesterol levels among all employees with high and borderline-high blood cholesterol levels 1 year after screening? Two years later?

• for staff members who were overweight at screening, what percentage have lost 20 pounds or more a year later? Ten pounds or more? What is the typical weight loss?

• for workers who were smokers at screening, what percentages have quit smoking? for at least a year?

• for employees whose level of alcohol consumption put them at-risk at screening, what percentage have quit drinking alcohol? Are consuming alcohol at levels considered safe by CDC guidelines? Have decreased their drinking, but are still at-risk?

• for workers, what percentages are exercising at least three times a week for at least 20 minutes?

• If fitness levels were measured, what percentages have improved fitness?

Make sure to set a regular time like every 6 months to look at which workers your program is reaching and how effective it is at assisting them reduce their health risks. Use this information to make new decisions about how to direct your program efforts. Then make the change you need to improve your program.

Some might feel that investigation is a frill; it is not. Investigation is a necessary part of a wellness program. You’ll need to know what is working and what is not.

Decision-makers who fund the program need to be updated on the performance of the program. Evaluation will provide you with necessary data to maintain and expand the program and convince management to continue to support the program.

The keys to a successful wellness program are persistent one-on-one outreach and follow-up counseling to encourage health improvement, adherence to treatment programs, changes in lifestyle behaviors, and to prevent relapse.

Periodic outreach and follow-up procedures provide staff members with a safety net which keeps them involved in the program and prevents treatment dropout and relapse.

Counselors should follow up on workers at least every 6 months throughout the career of the staff member at the worksite. the goals of follow-up are to –  

• Involve workers who have health risks in treatment and risk reduction programs.

• Involve all workers in health betterment programs and worksite-wide wellness activities.

• Support staff members in carrying out the risk reduction or health betterment activities they have chosen.

• Make sure to help workers obey their treatment regimens.

• Prevent relapse.

• Prevent staff members from dropping out.

• Be certain to help employees maintain behavior changes.

Follow-up could be conducted in individuals, by phone, mail, and via computer when the technology is available. Most preferable is an in-person contact.

Computer programs which could do case load management are available to help counselors track information and perform follow-up.

Priorities for Follow-Up

People  with multiple health risks ought to be at the top of the list. People  in key positions like union leaders or department heads with health risks should also be contacted early so that they learn what the program is about and can share the information with others.

People  who need a medical evaluation for high blood pressure or cholesterol should also be targeted early. Many staff members will have seen their doctors then of the screening, but some will need more encouragement to do so. Those with no health risks could be followed up yearly.

A follow-up counseling session can take 20 to 45 minutes. at minimum, follow-up must include those who were told to seek medical examination for high blood pressure (BP) readings, high cholesterol readings, or borderline high blood cholesterol readings with 2 or more other risk factors.

It might include those who were identified as at-risk for one or more of the other major risk factors –  at-risk levels of alcohol consumption, being overweight, and having low HDL.

Follow-Up With Doctors

A letter (see forms) ought to be sent to the doctor or clinic of each employee who has high blood pressure, high cholesterol, or is under a doctor’s care.

The letter should explain the program and should include the employee’s relevant, current health measurements.

Along with the letter, send a self-addressed return envelope. Follow-up with the physician should be repeated every 6 months until it’s determined that the staff member is under satisfactory control.

Contacting the physician is important for three reasons –

• the physicians receive employees’ health measurements taken at the worksite.

• You receive the blood pressure and cholesterol readings the doctor takes and information on the treatment the doctor prescribes.

A lot of times the worker does not have this information or does not remember it. the information can be used when counseling the worker.

• Follow-up encourages doctors to pay closer attention to heart illness risk factors among their patients.

The menu approach offers employees a range of options to support lifestyle changes. It authorizes people  to choose the kind of help that suits their schedules and preferences.

The four basic kinds of programs include –

• Courses

• Minigroups

• Guided self help

• Individual counseling

Classes

Courses (8 or more) could be an effective means of providing education and social support for behavior change. the length of a class can vary depending on topic requirements. It is not sufficient to offer only classes at a worksite.

A lot of staff members are under time constraints with after work commitments and although they might be interested they simply cannot participate because of their schedules.

Staff Members might  be very eager to begin a program but because of lack of participants to meet class quotas, the program is canceled.

Many national organizations like the American Heart Association, American Cancer Society, Weight Watchers, etc. offer classes; you should’ve little trouble in identifying a provider for class kind programs.

You could want to contact your local hospital, health department, or YMCA for possible options. for choosing  a vendor to provide a program you could want to review the section on program structure.

Minigroups

When there isn’t enough interest to develop a class, those who are interested in a given health topic may be formed into a minigroup (2 to 7).

The minigroup can cover the same content as a class but do so in a less formal manner. Presentation of information and discussion is the major format of the minigroup.

Guided Self-Help

Most workers do not want formal help in making health changes; they prefer to do it on their own. In guided self-help, the wellness counselors provide support, materials, and encouragement.

Meeting times can be arranged and contact can be made either in individuals, by phone, or computer. Materials can be made available at the worksite, or mailed to the individual. Some worksites now make information available via intranets or the Internet.

Individual Counseling

One of the most successful ways to help individuals change and improve their health status is counseling (or coaching) on a one-on-one basis.

In published studies, wellness programs which incorporated individual counseling as part of the program process achieved significantly higher participation rates and achieved greater risk reduction/risk elimination than standard group programs. Studies have demonstrated that individual counseling is both cost effective and cost beneficial.

A wellness counselor should be trained in screening techniques, for in certain situations, they may be required to both screen person and counsel them. They ought to know how to do the following –  

• Review employee health risks

• Contact staff members who have health risks.

• Counsel staff members on a one-on-one basis, assisting them set objectives, solve problems, and get specialist help when they need it.

• Be certain to help employees follow their treatment recommendations and make lifestyle and health behavior changes.

• Recruit employees into health improvement programs, such as weight loss and use of tobacco cessation.

• Make sure to work with employees on a one-on-one basis using guided self-help.

• Conduct courses and minigroups if necessary.

• Make certain to work with wellness committee members to plan and conduct worksite-wide wellness activities.

Wellness counselors are health generalists; they must’ve basic knowledge about a broad range of health topics and health risks.

Counselors should be able to speak with workers about their medical problems and the treatments prescribed by their doctors.

They should have a good overview of nutrition, exercise physiology, pathophysiology of illness, pharmacology, psychology, and behavior change skills.

The educational program should include approaches to stress awareness/reduction at the environmental level and at the individual level.

Social, physical, and organizational stressors ought to be explained and methods to ease or elevate stressors ought to be presented.

At the individual level how changes in attitudes and behaviors help one to cope with stressors; learning techniques to minimize stress response, such as meditation, relaxation response, and exercise.

Content of the program should provide the following –

• Identifying sources of stress

• Relationship of stress to health

• How the individual experiences stress, personal, family, work

• Solutions for coping and managing stress

• Techniques for reducing stress

• Value of stress, both negative and positive

• Practical steps of incorporating stress reduction into lifestyle

Personnel conducting stress management programs should’ve training in psychology, behavioral sciences, or related disciplines such as mental health specialists, counselors, health educators, psychologists, and psychiatrists.

Training in a reputable program on how to teach the stress management course including group process skills is a must.

A nutrition education program should include a nutritional needs assessment, education counseling, and referral as necessary.

Educational sessions and materials should include the following information –

• the relationship of nutrition and chronic diseases

• Improving eating patterns

• Relationship of nutrition and proper weight maintenance

• Exercise

• Stress

• Blood pressure (BP)

• Cholesterol

• Diabetes and other chronic illnesss.

• Nutritionally precise information regarding the relationship of health to diet, including cholesterol, fats, fiber, alcohol, carbohydrates, salt, sugar, and vitamin/mineral supplementation.

Methods for identifying healthier foods and incorporating low-calorie, high nutrient foods into consuming habits. Guidelines for improving consuming habits must be based on or consisitent with national recommendations such as the Food Guide Pyramid.

Instructor should be a registered dietitian, registered nurse, or have a baccalaureate degree or higher in health education with training in nutrition.

When an allied health professional instructs the program, a consultation and review of the program design by a registered dietitian is advised.

It is advised that use of tobacco cessation programs subscribe to the Code of Practice for Use of tobacco Cessation Programs.

Use of tobacco cessation programs must be multi-component with a focus on skills to build positive voluntary behavior change practices.

Useful techniques include establishing reasons for quitting, understanding the smoking habit, various techniques for stopping and remaining a non-smoker, overcoming the problems of quitting, short-term goal setting, weight control, stress management, importance of exercise, relationship of alcohol consumption to urges to smoke. Use no aversive or scare tactics.

In programs that use aids such as the “patch” or medications such as “Zyban” appropriate consultation ought to be available on the usage of these aids.

The instructor should’ve formal training in tobacco use cessation from a nationally recognized organization like American Heart Association, American Cancer Society, American Lung Association, or a nationally recognized commercial program like Smoke Enders.

Examination of success is sometimes very dubious in smoking cessation programs. Measurement of success ought to include participation rate, including the number starting the program, the number completing the program, and the average number per session.

Also included, number and percent who stopped smoking at the end of the program, and the number and percent who had not resumed smoking by the end of one year.

Participatory exercise plans ought to include education on benefits of regular exercise and risks of a sedentary lifestyle, its impact on cardiovascular health and illnesses, its relationship with weight control and stress management, and aerobic exercise choices.

Discussion and practice of safe principles of exercise – warm up, cool down, frequency, intensity, duration, flexibility and strength components. the program follows guidelines by the American College of Sports Medicine.

Safety precautions should include the following –

• Informed consent prior to starting exercise with clear and complete written and verbal instructions of possible risk, purpose of exercise, exercise format to be followed, opportunity for questions, and a signed informed consent with date.

• A screening/evaluation of participants to determine when medical analysis is necessary for exercise like the Exercise Readiness Questionnaire (PAR-Q, see forms).

• Measurements of blood pressure (BP) and resting heart rate are useful screening information to determine exercise readiness.

• Participants who fail screening are medically referred and should obtain a written clearance from their doctor to exercise.    

• the basic content of an group exercise program should include –     

Warm up   5 – 10 minutes

Aerobic exercise   20 – 40 minutes

Cool down   5 – 10 minutes

Exercise instructors should have education and training in exercise physiology, physical education, physical therapy or comparable discipline, or possess a current certification by a nationally recognized sports medicine or exercise association, and be CPR certified.   

Program offered is consisitent with scientific and medical recommendations for weight loss, reflects a multi-disciplinary approach which offers four components –  behavioral, exercise, nutrition, and maintenance, and is in accordance with the document Guidance for Treatment of Adult Obesity. It includes –    

• Screening to verify that the participant lacks medical or psychological conditions which would make weight loss inappropriate, and to identify the participant’s level of health risk, classifying participants not only on excess body weight, but also on the basis of associated health conditions and overall heath risk.

• Referral for participants who are morbidly obese who’d require medical guidance for weight loss.

• Informed consent, explanation of potential physical and psychological risk from weight loss and regain, likely long-term success of program, full cost of the program, credentials of the staff.

• Identification of factors to participant’s weight status, serving as the basis for an individualized weight loss plan which includes the weight goal and plans for nutrition, exercise, and behavioral components.

• Weight goal of participant is reasonable based on personal and family weight history not solely on height and weight charts; initial weight loss goal doesn’t exceed loss of 10% of body weight, 1-2 pounds per week.

• Explanation of unsafe weight loss methods.

• Daily calorie level is modified to meet each participant’s recommended rate of weight loss.

• Daily caloric intake isn’t less than 1,000 calories; when less, doctor monitoring is required.

• Food plan designed so participants can select foods which meet 100 percent of all the Recommended Daily Allowance (RDA) except for calories. Nutritional supplementation can be used to achieve RDAs, nevertheless should not greatly exceed RDAs.    

• Nutrition education encouraging permanent healthful consuming habits based on the Food Guide Pyramid.    

• Participant involved in meal planning and food selection.    

The protein, fat, carbohydrate, and fluid content of the food plan meet safety recommendations –     

Protein   Between 0.8 and 1.5 grams of protein per kilogram of goal body weight, but no more than 100 grams of protein a day.

Fat   10 – 30 percent calories as fat.

Carbohydrate   At least 100 grams per day.

Fluid   At least one liter of water daily.

• Exercise component must be a significant portion of the program and be both didactic and experiential.

• Participant is appropriately screened for exercise using a screening questionnaire like the Par-Q Readiness Assessment (see forms). Instruction on recognizing untoward responses to exercise.

• Participants work towards 30-60 minutes of exercise 5-7 days per week.

• No appetite suppressant drugs.

• Maintenance plan offered for continued support.

• Weight control programs should be conducted by a registered dietitian or by degreed health specialists with training in nutrition with consultation by a registered dietitian.

• Trained lay leaders may assist if supervised by nutrition specialist.

Note –  There’s an interactive version of Guidance for the Treatment of Adult Obesity at e-Guidance for the Treatment of Adult Obesity.

Program is required to provide appropriate interpretation of cholesterol screening results, including a caution that a single measurement neither excludes nor establishes a diagnosis of their blood cholesterol.

Follow national guidelines –

Total Cholesterol

Desirable cholesterol   < 200 mg/dl

Borderline cholesterol   200 – 239 mg/dl

High cholesterol   > 240 mg/dl

HDL   

Desirable HDL    > 35 mg/dl

Low HDL    < 35 mg/dl

Refer cholesterol screening participants to medical care as follows –    

Total Cholesterol   

< 200 mg/dl    Recheck cholesterol in five years, if history of coronary heart illness or if two or more CHD risk factors are detected refers to risk reduction program or health specialists, as appropriate.

200 - 239 mg/dl    When history of CHD or when two or more other risk factors are detected, refer to medical care or risk reduction service within two months; when no announced history of CVD or less than two other risk factors, reassess cholesterol status within 1-2 years.

> 240mg/dl    Refer to medical care within two months.

HDL   

> 35 mg/dl   If fewer than 2 risk factors and borderline total cholesterol, refer to risk reduction service, as appropriate. Reassess HDL in 1-2 years.

Give the following –    

• the relationship of blood cholesterol, high blood pressure, and other risk factors.    

   o Risk factors include –  high blood pressure (BP) 140/90 or higher or on hypertension medication; current cigarette smoking; family history of premature CHD; diabetes mellitus; age – male > 45 years, female > 55 years or premature menopause without estrogen replacement therapy.

   o Negative risk factor –  high HDL 60 mg/dl or greater (subtract one risk factor).

   o Risk factors such as family history, use of tobacco, high fat or other unhealthful diet, andlack of exercise lead to the development of cardiovascular disease (CVD).

• Definitions and causes of high blood cholesterol and HDL, desirable levels, the meaning and limitations of a single measurement, the cause of variability, and the need for multiple measurements prior to diagnosis.    

• Wide range of treatment options, including diet (e.g., importance of controlling fat intake less than 30 percent of total calories from fat, less 10 percent saturated fats), less than 300 mg. of cholesterol per day, well-balanced diet, weight maintenance or reduction, exercise, and medication.    

• Importance of following prescribed treatment and professional advice.    

Appropriate medical or allied health professional trained in measurement of blood pressure, referral protocols, and delivering educational messages to participant conducting blood pressure programs. These programs are required to follow national guidelines.

National guidelines for blood pressure (BP) protocols –  

• Calibration of blood pressure measuring equipment ought to be done at least each year.

• Two or more measurements of participant’s blood pressure must be taken.

• Referral of participants with high blood pressure readings to personal doctor for further analysis.   

Systolic / Diastolic Follow-Up –     

• Normal –    <130 / <85   

   Action –  Recheck in 2 years

• High Normal –    130-139 / 85-90   

   Action –  Recheck in 1 year

Hypertension –     

• Stage 1 (Mild) –    140-159 / 90-99    

   Action –  Confirm within 2 Months.

• Stage 2 (Moderate) –    160-179 / 100-109    

   Action –  Refer to source of care within 1 month.

• Stage 3 (Severe) –    180-209 / 110-119    

   Action –  Refer to source of care within 1 week.

• Stage 4 (Very Severe) –    >210 / >120    

   Action –  Refer to source of care immediately.

Appropriate educational messages –     

• Normal –    <130 systolic and <85 diastolic   

   Action -  No referral. If on treatment, then inform participant that blood pressure is under good control today and should continue seeing and following treatment program.

• High Normal -    130-139 systolic and/or 85-89 diastolic   

   Action -  Recommend that participant have blood pressure (BP) rechecked within 1 year unless under treatment. Advise participant that the readings are in a high normal range that needs rechecking. In the interim, suggest that among the most effective means to lower blood pressure (BP) is to bring weight into normal range and to exercise.

• High -    >140 systolic and/or >90 diastolic   

   Action –  Refer to doctor for further evaluation within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. When already on treatment, advise participant of readings and need to get blood pressure to a goal of 140/90 or less.

• Isolated Systolic Hypertension –    140-159 systolic and < 90 diastolic in a participant 65 years of age or older.   

   Action -  Advise participant to inform doctor of readings at next visit and consider advice regarding weight loss and exercise when appropriate.

• Urgent -    180-209 systolic and/or 110-119 diastolic   

   Action -  Recommend obtaining medical analysis within 1 week.

• Emergency -    >210 systolic and/or >120 diastolic   

   Action –  Obtain immediate medical attention.

Provides the following –     

• Written results, referral instructions, and an explanation of blood pressure (BP) levels given to each participant with individualized counseling, including advice about the interval of time advised when the participant ought to be checked again.    

• Utilizes the recommendations in the Fifth Report of the Joint National Committee on Detection, Examination and Treatment of High Blood Pressure, March 1994.    

• Written and audiovisual materials that are informative, easy to understand, and useful while containing scientifically accurate information.    

• Relationship of high blood pressure (BP) and other risk factors, like family history, tobacco use, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular illness, including stroke, kidney illness, heart attack, and other illnesses.

• Definition and causes of high blood pressure.

• Importance of following prescribed treatment.