Health Wellness ProgramHealth and Wellness Programs and Wellness Program Consulting

Counselors ought to follow up on workers at least every 6 months throughout the career of the employee at the worksite. The goals of follow-up are to:

• Involve staff members who have health risks in treatment and risk reduction programs.
• Involve all employees in health improvement programs and workplace-wide wellness activities.
• Support employees in carrying out the risk reduction or health improvement activities they have chosen.
• Help staff members comply with their treatment regimens.
• Prevent relapse.
• Prevent staff members from dropping out.
• Help employees maintain behavior changes.

Follow-up can be conducted in person, by phone, mail, and via computer if the technology is available. Most preferable is an in-person contact. Computer programs which can do case load management are available to help counselors track information and perform follow-up.

Priorities for Follow-Up

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

People who need a healthcare assessment for high Blood Pressure (BP) or blood lipids ought to also be targeted early. Many workers will have seen their doctors as a result of the assessment, but some will need more encouragement to do so. Those with no health risks can be followed up annually.

A follow-up counseling session can take 20 to 45 minutes. At minimum, follow-up must include those who were told to seek health care assessment for elevated Blood Pressure (BP) readings, elevated blood lipid readings, or borderline elevated blood cholesterol readings with 2 or more other risk factors.

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

Follow-Up With Physicians

A letter (see forms) should be sent to the physician or clinic of each employee who has elevated Blood Pressure (BP), elevated cholesterol, or is under a physician’s care.

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

Along with the letter, send a self-addressed return envelope. Follow-up with the physician ought to be repeated every 6 months until it is determined that the employee is under satisfactory control.

Contacting the physician is valuable for three reasons:

• The doctors receive workers’ health measurements taken at the worksite.
• You receive the Blood Pressure (BP) and blood lipid readings the doctor takes and information on the treatment the doctor prescribes. Many times the employee does not have this information or does not remember it. The information can be used when counseling the employee.
• Follow-up encourages physicians to pay closer attention to heart disease risk factors among their patients.

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

The four basic types of programs include:
• Classes
• Minigroups
• Guided self help
• Individual counseling

Classes

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

Many workers are under time constraints with after work commitments and although they may be interested they simply can’t take part because of their schedules.

employees may be very eager to begin a program but because of lack of participants to meet class quotas, the program is canceled. Many national corporations such as the American Heart Association, American Cancer Society, Weight Watchers, etc. offer classes; you should have little trouble in identifying a provider for class sort programs.

You may want to contact your local hospital, health department, or YMCA for possible options. For selecting a vendor to support a program you may want to review the section on program structure.

Minigroups

When there is not sufficient interest to create a class, those who are interested in a given health topic can 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 primary 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 backing, materials, and encouragement.

Meeting times can be arranged and contact can be made either in person, 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 better their health status is counseling (or coaching) on a one-on-one basis.

In published research 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 constructive.

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

• Review employee health risks
• Contact employees who have health risks.
• Counsel staff members on a one-on-one basis, helping them set goals and objectives, solve concerns, and get professional help when they need it.
• Help employees follow their treatment recommendations and make lifestyle and health behavior changes.
• Recruit staff members into health improvement programs, such as weight loss and tobacco cessation.
• Work with workers on a one-on-one basis using guided self-help.
• Conduct classes and minigroups if necessary.
• Work with Employee Health Promotion Program Committee participants to plan and conduct worksite-wide wellness activities.

Wellness counselors are health generalists; they must have basic knowledge about a wide range of health issues and health risks.

Counselors must be able to talk with employees about their medical concerns and the treatments prescribed by their doctors. They ought to have a good overview of diet, exercise physiology, pathophysiology of disease, pharmacology, psychology, and behavior modification skills.

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

Social, physical, and employer stressors must be explained and methods to ease or elevate stressors must 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 ought to support 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 beneficial
• Practical steps of incorporating stress reduction into lifestyle

Personnel conducting stress management programs must have training in psychology, behavioral sciences, or related disciplines such as mental health professionals, 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 diet education program should include a nutritional needs assessment, education counseling, and referral as essential.

Educational sessions and materials should include the following information:

• The relationship of diet and chronic diseases
• Improving eating patterns
• Relationship of nutrition and proper weight maintenance
• Exercise
• Stress
• Blood Pressure
• Cholesterol
• Diabetes and other chronic diseases.
• Nutritionally accurate 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 eating habits. Guidelines for working on eating habits ought to be based on or consistent with national recommendations such as The Food Guide Pyramid.

Instructor ought to be a registered dietitian, registered nurse, or have a baccalaureate degree or higher in health education with training in nutrition. If an allied health professional instructs the program, a consultation and review of the program design by a registered dietitian is recommended.

It is recommended that smoking cessation programs subscribe to the Code Of Practice for Smoking Cessation Programs.

Smoking cessation programs must be multi-component with a focus on skills to build positive voluntary behavior change practices. Useful techniques include instituting reasons for stopping, understanding the smoking habit, various techniques for stopping and remaining a non-smoker, overcoming the concerns of stopping, short-term intention setting, weight control, stress management, importance of exercise, relationship of alcohol consumption to urges to use tobacco. Use no aversive or scare tactics.

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

The instructor ought to have formal training in tobacco cessation from a nationally recognized employer such as American Heart Association, American Cancer Society, American Lung Association, or a nationally recognized commercial program such as Smoke Enders.

Evaluation of success is at times very dubious in tobacco cessation programs. Measurement of success should include participation rate, including the number implementing 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 physical activity programs should include education on benefits of regular exercise and risks of a sedentary lifestyle, its impact on cardiovascular health and diseases, its relationship with weight control and stress management, and aerobic exercise options. 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 must include the following:

• Informed consent prior to beginning exercise with clear and complete written and verbal ground rules 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 if medical evaluation is crucial for exercise such as the Physical Activity Readiness Questionnaire (PAR-Q, see forms).
• Measurements of Blood Pressure (BP) and resting heart rate are useful evaluation information to determine exercise readiness.
• Members who fail screening are medically referred and ought to obtain a written clearance from their physician to exercise.
• The basic content of an aerobic physical activity program must include:

Warm up   5 – 10 minutes
Aerobic exercise   20 – 40 minutes
Cool down   5 – 10 minutes

Exercise instructors must 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 consistent with scientific and medical recommendations for weight loss, reflects a multi-disciplinary approach which offers four components: behavioral, exercise, diet, and maintenance, and is in accordance with the document Guidance For Treatment Of Adult Obesity. It includes:

• Screening to verify that the colleague has no medical or psychological conditions which would make weight loss inappropriate, and to identify the colleague’s level of health risk, classifying participants not only on excess body weight, but also on the basis of associated medical conditions and central heath risk.
• Referral for participants who are morbidly obese who would 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 employee.
• Identification of contributing factors to colleague’s weight status, serving as the basis for an individualized weight loss plan which includes the weight goal and plans for diet, exercise, and behavioral components.
• Weight objective of attendant is reasonable based on personal and family weight history not solely on height and weight charts; initial weight loss objective does not exceed loss of 10 percent of body weight, 1-2 pounds per week.
• Explanation of unsafe weight loss methods.
• Daily calorie level is adjusted to meet each participant’s recommended rate of weight loss.
• Daily caloric intake is not less than 1,000 calories; if less, physician monitoring is required.
• Food plan designed so participants can choose foods which meet 100 percent of all the Recommended Daily Allowance (RDA) except for calories. Nutritional supplementation can be used to achieve RDAs, however ought to not greatly exceed RDAs.
• Nutrition education encouraging permanent healthful eating habits based on The Food Guide Pyramid.
• Participant involved in meal planning and meal selection.

The protein, fat, carbohydrate, and fluid content of the meal plan meet safety recommendations:

Protein   Between 0.8 and 1.5 grams of protein per kilogram of objective body weight, but no more than 100 grams of protein a day.
Fat   10 – 30% calories as fat.
Carbohydrate   At least 100 grams per day.
Fluid   At least one liter of water daily.

• Exercise component must be a valuable portion of the program and be both didactic and experiential.
• Participant is appropriately screened for exercise using a assessment questionnaire such as 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 prescription drugs.
• Maintenance plan offered for continued support.
• Weight control programs ought to be conducted by a registered dietitian or by degreed health professionals with training in nutrition with consultation by a registered dietitian.
• Trained lay leaders may assist  if supervised by nutrition professional.

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

A program is necessitated to support appropriate interpretation of cholesterol evaluation 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 evaluation participants to healthcare as follows:

Total Cholesterol
< 200 mg/dl    Recheck cholesterol in five years, if history of coronary heart disease or if two or more CHD risk factors are detected refers to risk reduction program or health professionals, as appropriate.
200 - 239 mg/dl    If history of CHD or if two or more other risk factors are detected, refer to medical care or risk reduction service within two months; if no published history of CVD or less than two other risk factors, reassess blood lipid 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.

Offer the following:
• The relationship of blood cholesterol, elevated Blood Pressure, and other risk factors.
   o Risk factors include: high Blood Pressure 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, smoking, high fat or other unhealthy diet, and lack 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., significance 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 attendant delivering Blood Pressure programs. These programs are necessitated to follow national standard procedures.

• National instructions for Blood Pressure protocols:
   o Calibration of Blood Pressure quantifying equipment
   be done at least each year.
   o Two or more measurements of attendant’s Blood Pressure should be taken.
   o Referral of participants with high Blood Pressure readings to personal physician for further evaluation.

• Systolic/Diastolic Follow-Up:
   o Normal:   <130 / <85
      Action: Recheck in 2 years
   o High Normal:   130-139 / 85-90
      Action: Recheck in 1 year

• Hypertension:
   o Stage 1 (Mild):   140-159 / 90-99
      Action: Confirm within 2 Months.
   o Stage 2 (Moderate):   160-179 / 100-109
      Action: Refer to source of care within 1 month.
   o Stage 3 (Severe):   180-209 / 110-119
      Action: Refer to source of care within 1 week.
   o Stage 4 (Very Severe):   >210 / >120
      Action: Refer to source of care immediately.

• Appropriate educational messages:
   o Normal:   <130 systolic and <85 diastolic
      Action: No referral. If on treatment, then inform attendant that Blood Pressure is under great control today and should continue seeing and following treatment program.
   o 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 one of the most effective means to reduce Blood Pressure (BP) is to bring weight into normal range and to exercise.
   o High:   >140 systolic and/or >90 diastolic
      Action: Refer to physician for further assessment within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. If already on treatment, advise participant of readings and need to get Blood Pressure (BP) to a goal of 140/90 or less.
   o Isolated Systolic Hypertension:   140-159 systolic and < 90 diastolic in a participant 65 years of age or older.
      Action: Advise participant to inform physician of readings at next visit and consider advice regarding weight loss and exercise if appropriate.
   o Urgent:   180-209 systolic and/or 110-119 diastolic
      Action: Recommend obtaining medical assessment within 1 week.
   o Emergency:   >210 systolic and/or >120 diastolic
      Action: Get immediate healthcare attention.

• Provides the following:
   o Written results, referral guidelines, and an explanation of Blood Pressure (BP) levels given to each attendant with individualized counseling, including advice about the interval of time recommended when the attendant must be checked again.
   o Utilizes the recommendations in The Fifth Report Of The Joint National Committee on Detection, Assessment and Treatment of High Blood Pressure (BP), March 1994.
   o Written and audiovisual materials that are informative, simple to know, and useful while containing scientifically accurate information.
   o Relationship of elevated Blood Pressure and other risk factors, such as family history, smoking, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular disease, including stroke, kidney disease, heart attack, and other diseases.
   o Definition and causes of elevated Blood Pressure (BP).
   o Importance of following prescribed treatment.

Health risk assessment programs ought to be carried out on a one-on-one basis by trained healthcare professionals. Health risk measures ought to include the following:

• Blood Pressure measurements – at least two Blood Pressure measurements taken during the assessment episode, using a mercury sphygmomanometers or regularly calibrated aneroids.
• Blood Pressure treatment status – ascertain whether the colleague is under a doctor’s care, on any medication, on a prescribed diet, or any other sort of treatment for hypertension.
• Blood cholesterol measurement – total cholesterol and HDL-cholesterol taken either using a properly tested and maintained table top blood analyzer offering immediate feedback to the client, or sending blood to a laboratory offering feedback using a method that is as effective as immediate feedback.
• Cholesterol treatment status – ascertain whether the client is under a doctor’s care, on any medication, on a prescribed diet, or any other sort of treatment for high cholesterol.
• Obesity – utilize an accepted method for estimating obesity. For example evaluate participants height and weight and use the 1959 Metropolitan Life Height/Weight charts or use Body Mass Index.
   o Identify people 20% or more above their ideal weight.
• Smoking status – evaluate whether the participant currently smokes cigarettes, whether the client has quit or never smoked, and the number of cigarettes smoked/day.
• Exercise habits – screening questions may be limited to frequency and duration exercise. Do participants exercise in a moderately vigorous fashion at least three times per week for 30 minutes or more.
• Diabetes – whether the client has diabetes, and whether or not it is currently under control. A blood glucose may be also done via finger stick and desk top analyzer. Several manufactures make available cassettes which include blood lipid and glucose measurements.
• Cerebrovascular disease or occlusive PVD – ascertain if the client has had a stroke or other kind of blood vessel disease.
• Family history of cardiovascular disease – ascertain whether any of the participants’ parents or siblings had a heart attack or sudden death due to heart disease before age 55.
• Coronary heart disease – determine if the client has had a heart attack or other type of coronary heart disease.
• Stress – colleague’s assessment of stress in work and/or personal life. A series of well-tested and validated questions assessing levels of stress are available from the Worker Health Program.
• Participant release form (see forms) – A release form is necessitated in which the colleague authorizes the program to draw blood for testing to send information to the colleague’s medical provider if medical risks are identified, and to obtain information from the provider about diagnosis and prescribed treatment.
• Participant interest survey – if an assessment of interest has not been collected previously, the screening activity must assess levels of interest in programs such as: weight management, smoking cessation, fitness or exercise, stress management, diet, self-care, cholesterol control.
• Health education messages – the screener must review with the attendant his/her identified health risks and what they mean to the attendant’s central health, and give the attendant a written record of the Blood Pressure (BP), total cholesterol, and any other physiological measures taken.
• Referral of participants for treatment – participants with elevated risks must be referred to appropriate sources of diagnosis and possible treatment following nationally or locally recognized standard procedures for such referral.

Demographic information ought to include location of the screening, worksite, client’s name, address, social security number, home and work phone number, sex, race, birthdate, relevant job information (e.g., hourly or salaried), department number, and work shift.