In the VA, Chronic Heart Failure (CHF) accounts for 13% of all deaths and approximately $15,000 total costs per person with heart failure (HF) each year. Telehealth has been demonstrated to reduce hospital readmissions, emergency visits, and cost of care for patients with HF. Although Care Coordination Home Telehealth (CCHT) has been shown effective, the particular practices of communication associated with effective implementation that promotes patient participation and improved outcomes remain to be identified, a needed step to train staff in best practices, reduce readmission hospitalization rates, and set evaluation standards.
Aim 1: QUALITATIVE Question: In routine telehealth patient visits for problem-solving, what communicative practices and behavior change strategies characterize interactions with Veterans speaking with their Care Coordinators?
Aim 2: Exploratory QUANTITATIVE Hypothesis: Determine if specific communication patterns identified in Aim 1 are associated with bed days of care (BDC), readmission rates, and quality of life for veterans with CHF.
This mixed method study recruited 52 Veterans with HF enrolled in a CCHT program to study the quality of care they received including typical communication practices as part of implementation. In the purposive sample, complete data was collected for 50 veterans enrolled in CCHT, including recording of cognitive mapping interviews of a typical day with an independent interviewer and recordings of 1-2 problem-solving and decision-making phone calls with nurse care coordinators. Transcribed recordings were coded using linguistic analysis (Wmatrix and Stance Shift Analysis) to determine patterns of affect, agency, decision making, elaboration, and uncertainty. An adaptation of the Rochester Participation and Decision-making Scale (RPAD) was used to code and categorize decision making styles in telehealth for these Veterans and their care coordinators. Communication patterns and RPAD results were analyzed in comparison with CPRS compiled data on hospital admissions, bed days of care and for quality of life (Minnesota Living with Heart Failure Questionnaire, MLHFQ) for associations. The team also categorized patterns of communication for a taxonomy of practices to compare results with VA Office of Telehealth documentation of CCHT goals, current training content, and intended strategies.
In this relatively small sample, there were no statistically significant differences or racial disparities in 30 day hospital readmissions, bed days of care, or MLHFQ, a quality of life measure, associated with shared decision making. The research team found that the level of shared decision making overall for the cohort was lower than that identified previously in studies of provider-patient interaction in face-to-face primary care. Additionally, though best practices defined in previous patient-centered communication were present, most patterns did not support shared decision making or HF self-management. A review of national CCHT materials identifies opportunity to operationalize and enhance best practices in communication to improve services and the communication quality of care component in CCHT with Veterans who have HF, but that the lack of explicit attention to communication best practices and the effects of the mediation of technology and technological agenda setting restrict the CCHT process.
The lack of association between current patterns of communication and decision making and patient outcomes corroborate others who suggest that telehealth communication differs from face-to-face provider communication and requires more attention to particular communication practices that advance a patient-oriented agenda, engagement, and focused interaction. Findings support proposed intervention testing of materials for CCHT continuing improvement.
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- Pope CA. The Investigation of Communication in Heart Failure Care Coordination Home Telehealth. Paper presented at: University of Maryland School of Nursing / VA Maryland Health Care System Annual Evidence-Based Practice Conference; 2010 Apr 13; Baltimore, MD.