Analysis of Communication Best Practices in Telehealth Charlene Pope, PhD, MPH Associate Nurse...
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Transcript of Analysis of Communication Best Practices in Telehealth Charlene Pope, PhD, MPH Associate Nurse...
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?