Telehealth technology in CHF’s care
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Telehealth technology in CHF’s care
According to evidence based practice, hospitals are under pressure from public insurance to provide quality care to minimize re admissions especially for patients suffering from Congestive Heart Failure (CHF). This calls for proper utilization of telehealth technology to improve patient’s outcome. CHF, a cardiovascular complication arises when the heart is unable to pump enough blood as demanded by the body. This results to irregular heartbeat, fluid retention and shortness of breath. The conditions are usually fatal especially among the elderly. With the new trend of telehealth systems, CHF patient will become empowered to manage their symptoms better and improve the quality of life. This is one of the strategies which are aimed at improving smooth transitional processes of hospital care to home care. The move is aimed at reducing the rate of re admissions and emergency department visits by the CHF patients (American Nurses Association, 2010).
Despite the innumerable advantages, there is reduced acceptance of the new technology, which has become the road block for successful implementation of the programs. There are concerns that integration of telehealth systems will interfere with the nurse-patient relationship. This indicates the need to implement a strategy/ action plan which is tailored made for this particular health care facility to ensure that collaborative involvement is achieved. The change model that will be utilized to implement the nursing changes is the John Hopkins Nursing Evidence based practice (JHNEBP).
Change Model Overview
The Johns Hopkins Nursing evidence based practice model was chosen due to its ability to effectively guide the translation of healthcare evidences into practice. The model is characterized by three cornerstones of nursing including practice, education and research. The model also integrates the internal and external factors during transition.
Source: http://www.medscape.com/viewarticle/773058_4
JHNEBP model has three phases commonly referred to as the PET processes; (a) identification of the problem question; b) systematic review of the problem question and research evidence and c) Translation process which includes implementation processes, pilot study, outcomes evaluation and monitoring of the findings. The model provides examples of EBP projects which have been successful, and guides step by step the process for planning and implementing the program.
Source: http://www.medscape.com/viewarticle/773058_
Practice Question
Step 1: EBP question identification
Telehealth are the best intervention to manage and improve CHF quality of life. However, the use of Telehealth has not developed at the anticipated scale and pace. There are increased organizational, resources/financial, technological barriers and mixed perceptions and evidence of the telehealth have hindered implementation of the system. The research question is “why nursing care interventions coupled with telehealth technology is is increasingly being resisted, even with the increased evidence that it improves CHF patient’s quality of life?”
The Problem in this case is the resistance to care management change by nurses who provide care for CHF patients. The intervention being considered is to establish a tailor made implementation action to reverse the resistance into acceptance of telehealth technology. This is because the technology will empower the patient and simultaneously provide workload relief to the nurses. The intervention will be compared with the conventional standard care. The desired outcome includes reduction of re-hospitalization, ER visits and considerable reduction of CHF care costs. The overall outcome expected is improved CHF patient quality of life and reduction of nurses care workload; thereby increasing quality service delivery.
Step 2: Scope of practice question
Among the non-communicable diseases, CHF is reported to be the leading cause for mortality and morbidity in the industrialized countries. Additionally, it is the leading cause for hospitalization and emergency department visits. Despite the advances in pharmacology and medical care trends, nurses who provide care for CHF are faced with increased workloads (62%) due to the increased rates of re-hospitalization. With no exception, the CHF trend (prevalence and increased medical resource consumption) is projected to increase by five folds if no intervention is put in place (Dearholt &Dang, 2012).
According to literature, effective disease management requires the patient to be actively involved in disease management and decision making processes. Unfortunately, patient empowerment has been lagging in CHF disease management system for a long period of time; thus the increased re-hospitalization incidences. The introduction of telehealth technology is important because it facilitates frequent communication between the patient and the care provider; the ability to monitor health at home increases patient’s health outcome (American Nurses Association, 2010).
Steps 3, 4, and 5: Team
For a study to have an impact on the health policy, communication with the relevant stake holders (who are directly affected by the transition) is very important. In this context, the stake holder’s participants include; Advanced community nurse, Nurse CHF service managers semi-clinical staff (includes telehealth installers), General practitioner, and Organizational commissioning managers.
The varying stakeholders were chosen because each group has values which seem important. For example, the physician is concerned with patient safety and quality care delivery; whereas organizational commissioning managers are concerned with system efficiencies at a low cost of operational cost. By involving the stakeholders, the negative perceptions and doubts about telehealth technology will be addressed; and could result to changes of ideas position from negative grounds to a neutral one.
Evidence
Steps 6 and 7: Internal and external search for evidence
Four patterns of nursing research evidence influenced the internal search for evidence. This includes empirical evidence which is based on scientific research; ethical evidence based on nurse’s perception, cultural competency and preferences; personal evidence and aesthetic evidence. Empirical evidence indicates that two thirds of the healthcare providers are not willing to integrate telehealth care due to uncertainty on assessing patient’s suitability, and the difficulty in prediction of the patient’s response to the technology (concerns of depression and anxiety). Again, there is limited data which is relevant to telehealth patient outcomes coupled with the mixed published evidence reduced the acceptance of the new trend. Ethical evidence is discerned through limited referral, implying that only the patients of certain economic status can enjoy the privileges. There are also concerns on impact of the technology on nurse’s roles especially with the sharing of care delivery with the patient. These evidences highlight the absence of shared visions and telehealth rationale, thus the heightened resistance among the CHF care providers (American Nurses Association, 2010).
The external evidence search includes the legislation and standards. For instance, the public health insurance policies are emphasizing hospital to minimize the rates or re-admission and re-hospitalization. Again, World Health Organization has outlined standards for telemedicine. The importance of telemedicine in ensuring that patient’s safety and quality of care is delivered.
Steps 8 and 9: Summarize the evidence
Analysis of data generated from Veterans Health Administration (VHA) on Home Telehealth program indicated a 25% reduction in length of hospitalization days and 19% less re-admissions. Data generated from the Center for Connected Health (CCH) program which has been offering cardiovascular patients care intervention indicates 84.7% success in CHF management while undertaking the program. Another remote monitoring program I Ontario Telemedicine Network which had 800 patients with CHF indicated 65% reduction in hospital admission and 72% reduction on emergency visits (American Psychological Association, 2010).
Lawton (2010) acknowledges the importance of telehealth technology. However, the prevailing barriers impede successful integration of new trend in the healthcare sector. Paul and colleagues (2010) evaluations produces comparable results. This includes 27.1% readmission reduction and reduction of ER visits by 38.3%. The study concludes by pinpointing cost effectiveness as the key challenge for the program implementation in most healthcare settings.
Baker and Colleagues (2010) evaluations on the role of telehealth in managing CHF disease indicated a 15% mortality rate reduction, and 18% ER visits reduction. Brewster and colleagues found out that increased staff resistance as the main barrier for integration of telehealth system. The paper recommends future research on cost effectiveness and nurse workload reduction.
Step 10: Recommendations for change
The largest challenge in the implementation of telehealth is staff resistance to change. The results indicated that staff acceptance is critical for telehealth to be integrated; and is a research area which has been largely neglected. Until the innovation is viewed as better than or superior than conventional care, challenges on implementation will persist. In this case, it is not a question of replacing the technology face to face with the conventional approach, but rather according the staff support demand which ensure that their skills are improved, which will further change judgment and knowledge.
Further translational research to ascertain the benefits of the innovation would be effective in overcoming the barriers. Where most of them focus on training; the training scope should be expanded to include ways to retain and to refine strong staff-patient interaction and training on equipment use. These processes will empower staff; that in turn will empower the patients. The computer based hybrid models should entail staff training, lessons on home monitoring, and access to specialist and in person patient care which will change nurse’s perception on telehealth.
Translation
Steps 11, 12, and 13: Action plan
A computer based training module will be implemented. This module will contain all the hospital policies and protocols regarding evidence based practice. The exact model is the Continuous Quality model; FOCUS-PDSA. The action steps include (Dearholt &Dang, 2012):
Step 1: Find the underlying root for telehealth resistance by the staff
Step 2: Organizing committee and relevant stake holders to preside over the identified barriers
Step 3: Analysis and clarification of the underlying concepts
Step 4: Understanding the barriers and analyzing the discrepancies
Step 5: Recommendation of solution: Computerized training model
Step 6: Implementation of the solution recommended
Step 7: Evaluation of the outcome.
Steps 14 and 15: Evaluating outcomes
The outcomes evaluation will be conducted after 12 months. Evaluation will not be limited to this stipulated period. This is because interventions outcomes may not be immediately realized within the short term duration (Dearholt &Dang, 2012). Evaluation will include measuring the percentage or re-hospitalization, emergency department visits rates, and the mortality rates in two groups, the intervention group and control group. Additionally, evaluation tools such as 4 Likert scale will be used to evaluate nurses and patients responses.
Steps 16, 17, and 18: Implementation
Implementation of the action plan entails integration of online computer based practice. The first part of the module will have the prevalence rates of telehealth resistance and its clinical implications. The second part will highlight the procedures for telehealth, including the risky behaviors associated with poor telehealth practices. The implementation of this strategy is necessary because it will ensure that the novice’s nurses and new employees learn about safe telehealth process. If the strategy is found to be successful, it will be integrated in other departments. This model is chosen due to its efficacy, it is time conscious, easily accessible and can be retrieved on demand and at any location (Dearholt &Dang, 2012).
Conclusion
As indicated from the study, growing number of systematic reviews indicates a range of improved outcomes of normal care. The practice question was on how to address the increased resistance of integrating telehealth technology in management of CHF patients. The research evidence indicates reduced re-hospitalization rates, reduced mortality, reduced ER visits, which results to reduced quality of care. The study translation includes the implementation of nurse led computerized coaching on the approaches to manage the telehealth procedures. This strategy is aimed at improving nurse’s clinical judgments, reducing nurse workloads; and to simultaneously, improve CHF patient quality of life.
References
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring.
American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC:
Baker, LC. Macaulay, D S., Sort, A., Diner, M., Johnson, G., Birnbaum, G. (2012). Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data. Journal of the American Geriatrics Society 1: 1560–1567
Brewster, L., Gail M., Wessels, B., Kelly, C., & Hawley, M.(2013) Factors affecting frontline staff acceptance of telehealth technologies: a mixed-method systematic review. Journal of Advanced Nursing 1: 660–667
Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International Lawton, G. (2010). Telehealth Delivers many benefits, but concerns linger. PTin motion journal.
Paul, YT. , Gregory, Pecina, J., Stroebel, R., Chaudhry, R., Shah, N.D., & Naessens, JM. (2010). A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study. BMC Health Services Research 10: 255
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