Charlene Pope, PhD, MPH Associate Nurse Executive for

Charlene Pope, PhD, MPH Associate Nurse Executive for

Charlene Pope, PhD, MPH Associate Nurse Executive for Research Ralph H. Johnson VA Medical Center & Associate Professor, MUSC College of Nursing Charleston, SC Funding & Acknowledgement 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 Objectives 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 Telehealth (CCHT) Taken from VA Services: http://www.carecoordination.va.gov/telehealth/ccht/index.asp CCHT

Not just technology Self-monitoring Nurse care coordination Access to electronic medical records Provider access & health system support Medication reconciliation Why Heart Failure & Communication? Over 5.8 million people in the United States have heart failure.

Almost 1/3 of HF patients are readmitted in 30 days About 670,000 people are diagnosed with HF each year In 2010, HF will cost the United States $39.2 billion. Ref: CDC, 2010

Defining Health Communication Message Transmission: Health Facts Therapeutic Communication: Health Advice Persuasion: Health Behavior

Change Relationship Building: Health Partnerships Preference s Emotion s Power

Speakin g practice s Attitudes Often Missing in Telehealth Cultural habitus Tone Social

Contexts Most Common Communication Research Approaches in Health Care (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)

Common Health Communication 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

Where is Patient-Centeredness & Shared Decision Making in Common Telehealth Communication Approaches? More than .... activation . intentions .... motivation . tactics Where is the Talk the process of communication ?

Usual Studies in CCHT: Assumes 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 Telemedicine & CCHT

Communication 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? Alternative Communication Process 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, turntaking, interruptions) Stance analysis (positions people take in talk, agency, uncertainty, identities)

Alternative Approaches Reported Wakefield et al. (2008)**. Communication Profiles in CCHT, comparing video and telephonic modes Svenstedt et al. (2005). Conversation analysis; joint attention in talk 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 Study 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 Methodological Approach to Cognitive Mapping Application of CPIDR to spoken text discussion about the map for idea density, word frequency, & propositional density

Discourse Trends: Concurrent Study I am a diabetic I have diabetes I suffer from diabetes I have a little sugar They say I have diabetes Discourse Trends: Denial, Ownership, & 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 Stance 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 Triangulating Talk with Outcomes 2 1 Patient Agenda

Uncertainties Barriers Teach Back Open-ended questions 3 Re-Admissions in Target Year Implications 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?

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