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Summary and Results of Past Initiatives

Monroe County (2006) - Well Balanced

A partnership was developed between the University Of Rochester School Of Nursing and the New York Care Coordination Program to evaluate a nursing model for adults with both serious mental illness and diabetes mellitus. The Well Balanced program incorporated health promotion, disease management, nursing care management and evidence-based practice guidelines into 8 Steps to Wellness for a community-based mental health population.  During a 16-visit intervention period, psychiatric nurses worked with 74 individuals. As a result of the program, clients experienced improvements in health risk status and in their hemoglobin A1C as well as high satisfaction with the Well Balanced program. Article Link: Journal of Psychosocial Nursing

Wyoming County (2006) - Well Balanced / Wellness Coach

A partnership was developed between the University Of Rochester School Of Nursing and the New York Care Coordination Program to evaluate a nursing model for adults with both serious mental illness and moderate/high risk physical health issues. This program embedded a nurse wellness coach in an outpatient mental health clinic to work in tandem with mental health clinicians and care coordinators on client-determined physical health issues. Nurses worked with fifteen individuals with various health related conditions including obesity, hypertension, lipid disorder, GERD and diabetes. As a result of the program, individuals experienced change related to weight, smoking, exercise, cholesterol, blood pressure and relationships with their medical providers. Link to Power Point Presentation

Monroe Plan Pilot (2008)

A partnership has been developed between Monroe Plan, Monroe County Office of Mental Health and the New York Care Coordination Program to develop a model of care coordination for individuals with severe mental illness and high utilization of physical health care services. The model incorporates a behavioral health case manager into the Monroe Plan managed care team. Preliminary results have demonstrated a reduction in hospitalizations and emergency room visits among some enrollees.