Charlene Pope, PhD, MPHAssociate Nurse Executive for Research

Ralph H. Johnson VA Medical Center

&

Associate Professor, MUSC College of Nursing

Charleston, SC

Charlene Pope, PhD, MPHAssociate Nurse Executive for Research

Ralph H. Johnson VA Medical Center

&

Associate Professor, MUSC College of Nursing

Charleston, SC

Funding & Funding & AcknowledgementAcknowledgement

• VA Chronic Heart Failure (CHF) Quality

Enhancement Research Initiative (QUERI)

• Solicitation: Implementing Research into

Practice to Improve Care Delivery

(2009-2010)

• QUERI Grant RRP 09-151

• VA Chronic Heart Failure (CHF) Quality

Enhancement Research Initiative (QUERI)

• Solicitation: Implementing Research into

Practice to Improve Care Delivery

(2009-2010)

• QUERI Grant RRP 09-151

ObjectivesObjectives• Identify common approaches to

communication research in telehealth

• Summarize past communication research in heart failure & CCHT, especially in the VA

• Provide examples of communication research methods that expand interpretation of provider-patient communication in heart failure decision making and telehealth

• Identify common approaches to communication research in telehealth

• Summarize past communication research in heart failure & CCHT, especially in the VA

• Provide examples of communication research methods that expand interpretation of provider-patient communication in heart failure decision making and telehealth

VA Care Coordination: Home VA Care Coordination: Home Telehealth (CCHT)Telehealth (CCHT)

Taken from VA Services: http://www.carecoordination.va.gov/telehealth/ccht/index.asp

CCHT CCHT

• Not just technology

• Self-monitoring

• Nurse care coordination

• Access to electronic medical records

• Provider access & health system support

• Medication reconciliation

• Not just technology

• Self-monitoring

• Nurse care coordination

• Access to electronic medical records

• Provider access & health system support

• Medication reconciliation

Why Heart Failure & Communication?Why Heart Failure & Communication?

• Over 5.8 million people in the United States have heart failure.

• About 670,000 people are diagnosed with HF each year

• In 2010, HF will cost the United States $39.2 billion.

Ref: CDC, 2010

Almost 1/3 of HF patients are readmitted in 30 days

Defining Health CommunicationDefining Health Communication

Persuasion: Health

Behavior Change

Message Transmission: Health Facts

Therapeutic Communication: Health Advice

Relationship Building: Health Partnerships

Emotions

Power AttitudesSocial Contexts

Cultural habitusPreference

s

Speaking practices

Tone

Often Missing in Telehealth Research

Most Common Communication Research Most Common Communication Research Approaches in Health Care Approaches in Health Care (Kasch, 1984)(Kasch, 1984)

• Functional (Tasks: Intentional, asymmetric)

• Instructional (Content: Transmit information)

• Regulative (Manage patient behavior)

• Relational (Gain compliance, persuade)

• Identity management (Changing how people see themselves in relation to their disease or disability)

• Functional (Tasks: Intentional, asymmetric)

• Instructional (Content: Transmit information)

• Regulative (Manage patient behavior)

• Relational (Gain compliance, persuade)

• Identity management (Changing how people see themselves in relation to their disease or disability)

Common Health Communication Common Health Communication Research Methods Research Methods

• Functional = Content analysis (what is said & what people understood)

• Instructional = Rating scales, surveys

• Regulative = Participant observation & records

• Relational = Qualitative (Feelings, perceptions)

• Identity management = Satisfaction measures, health status assessments, attitudes, media campaigns

• Functional = Content analysis (what is said & what people understood)

• Instructional = Rating scales, surveys

• Regulative = Participant observation & records

• Relational = Qualitative (Feelings, perceptions)

• Identity management = Satisfaction measures, health status assessments, attitudes, media campaigns

Where is Patient-Centeredness & Where is Patient-Centeredness & Shared Decision Making in Common Shared Decision Making in Common

Telehealth Communication Telehealth Communication Approaches?Approaches?

• More than

.... activation

…. intentions

.... motivation

…. tactics

• More than

.... activation

…. intentions

.... motivation

…. tactics

Where is the Talk …the process of

communication ?

Usual Studies in CCHT: Usual Studies in CCHT: Assumes CommunicationAssumes Communication

• Chumbler et al. (2004, 2005): Outcomes, QOL

• Botsis et al. (2008): Satisfaction, costs, use of services, time

• Bowles (2007): Self-management, Length of stay, hospitalizations

• Arnaert, et al. (2007) Attitudes

• Mkanta et al. (2007). HRQOL

• Lutz et al. (2007) Qualitative analysis/ Stroke: effects of disease, roles, responsibilities

• Chumbler et al. (2004, 2005): Outcomes, QOL

• Botsis et al. (2008): Satisfaction, costs, use of services, time

• Bowles (2007): Self-management, Length of stay, hospitalizations

• Arnaert, et al. (2007) Attitudes

• Mkanta et al. (2007). HRQOL

• Lutz et al. (2007) Qualitative analysis/ Stroke: effects of disease, roles, responsibilities

Telemedicine & CCHT Telemedicine & CCHT Communication StudiesCommunication Studies

• Fincher et al (2009) Satisfaction scale• LaFramboise et al. (2009). Patient perceptions.• Agha/Roter (2009) Physician styles.

• Where are the studies of the interpersonal process or communication practices in telehealth?

• Where is the link between communication practices and patient outcomes?

• Fincher et al (2009) Satisfaction scale• LaFramboise et al. (2009). Patient perceptions.• Agha/Roter (2009) Physician styles.

• Where are the studies of the interpersonal process or communication practices in telehealth?

• Where is the link between communication practices and patient outcomes?

Alternative Communication Alternative Communication Process Research MethodsProcess Research Methods

• Narrative analysis: Explanatory models

• Speech acts: Meanings, practices

• Interaction analysis: RIAS (Roter)

• Discourse analysis (How things are said, variations, markers of intention, inference)

• Conversation analysis (sequences, turn-taking, interruptions)

• Stance analysis (positions people take in talk, agency, uncertainty, identities)

• Narrative analysis: Explanatory models

• Speech acts: Meanings, practices

• Interaction analysis: RIAS (Roter)

• Discourse analysis (How things are said, variations, markers of intention, inference)

• Conversation analysis (sequences, turn-taking, interruptions)

• Stance analysis (positions people take in talk, agency, uncertainty, identities)

Alternative Approaches ReportedAlternative Approaches Reported

• Wakefield et al. (2008)**. Communication Profiles in CCHT, comparing video and telephonic modes

• Sävenstedt et al. (2005). Conversation analysis; joint attention in talk

• Wakefield et al. (2008)**. Communication Profiles in CCHT, comparing video and telephonic modes

• Sävenstedt et al. (2005). Conversation analysis; joint attention in talk

Charleston REAP Charleston REAP

Research Team for Communication Studies: Charlene Pope, PI;

Co-Investigators:Boyd Davis, UNCC & Bonnie Wakefield, VA Missouri,

Maureen Distler, Ralph H. Johnson VA Medical Center; Bertha North-Lee & Clare Pittman, Study Coordinators

Ronald Epstein, MD, University of Rochester, Consultant

Communication in CHF Care Coordination in Home Telehealth

(CCHT) Implementation

Research Team for Communication Studies: Charlene Pope, PI;

Co-Investigators:Boyd Davis, UNCC & Bonnie Wakefield, VA Missouri,

Maureen Distler, Ralph H. Johnson VA Medical Center; Bertha North-Lee & Clare Pittman, Study Coordinators

Ronald Epstein, MD, University of Rochester, Consultant

Communication in CHF Care Coordination in Home Telehealth

(CCHT) Implementation

Study goals and objectivesStudy goals and objectives

• To categorize quality of communication and shared decision making that characterizes interactions between 50 Veterans with CHF and their nurse care coordinators

• To link communication patterns during typical problem-initiated, Veteran-nurse CCHT interactions with specific CHF quality of life and quality of care outcomes

• To categorize quality of communication and shared decision making that characterizes interactions between 50 Veterans with CHF and their nurse care coordinators

• To link communication patterns during typical problem-initiated, Veteran-nurse CCHT interactions with specific CHF quality of life and quality of care outcomes

Methodological Approach to Methodological Approach to Cognitive MappingCognitive Mapping

Application of CPIDR to spoken text discussion about the map for idea density, word frequency, & propositional density

Discourse Trends: Discourse Trends: Concurrent StudyConcurrent Study

• “I am a diabetic”

• “I have diabetes”

• “I suffer from diabetes”

• “I have a little sugar”

• “They say I have diabetes”

• “I am a diabetic”

• “I have diabetes”

• “I suffer from diabetes”

• “I have a little sugar”

• “They say I have diabetes”

Discourse Trends: Denial, Discourse Trends: Denial, Ownership, & Agency in HFOwnership, & Agency in HF

• Of 50 patients interviewed, few has said “I have congestive, chronic or heart failure”– What does it mean to not name the

disease? Or… “My heart condition…”

• “I have been living with heart failure”

• “They say I have congestive heart failure”

• Of 50 patients interviewed, few has said “I have congestive, chronic or heart failure”– What does it mean to not name the

disease? Or… “My heart condition…”

• “I have been living with heart failure”

• “They say I have congestive heart failure”

Stance AnalysisStance Analysis• Personalization & Agency• Elaboration & Affect• Opinions & Information• Rationale & Intentions

Co-investigator: Dr. Boyd Davis, University of North Carolina at Charlotte with Dr. Peyton Mason, Next Generation Marketing Insights

Teach Back

Patient Agenda

Uncertainties

Open-ended questions

Barriers

Re-Admissions in Target Year

12

3

Triangulating Talk with OutcomesTriangulating Talk with Outcomes

Implications for PracticeImplications for Practice• Patterns of best practices in

communication about chronic disease self-management

• Patient playback reflecting on recorded interactions

• Standards for Telehealth evaluation and communication training:

– Where are the Evidence-Based Communication courses, training & criteria for monitoring quality?

• Patterns of best practices in communication about chronic disease self-management

• Patient playback reflecting on recorded interactions

• Standards for Telehealth evaluation and communication training:

– Where are the Evidence-Based Communication courses, training & criteria for monitoring quality?