Telehealth technology in CHF’s care

Telehealth technology improves CHF patient’s quality of life

Your Name

Chamberlain College of Nursing

NR451 RN Capstone Course

Term and Year

Telehealth technology in CHF’s care

According to evidence based practice, hospitals are under pressure from public insurance to provide quality care to minimize readmissions 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 readmissions 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.

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.

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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Capstone Project Milestone #2:

Design for Change Proposal Guidelines

Purpose

You are to create a Design for Change proposal inclusive of your PICO and evidence appraisal information from your Capstone Project Milestone #1. Your plan is to convince your management team of a nursing problem you have uncovered and you feel is significant enough to change the way something is currently practiced. In the event you are not currently working as a nurse, please use a hypothetical clinical situation you experienced in nursing school, or nursing education issue you identified in your nursing program.

Course Outcomes

This assignment enables the student to meet the following course outcomes.

CO1: Applies the theories and principles of nursing and related disciplines to individuals, families, aggregates, and communities from entry to the healthcare system through long-term planning. (PO #1)

CO2: Proposes leadership and collaboration strategies for use with consumers and other healthcare providers in managing care and/or delegating responsibilities for health promotion, illness prevention, health restoration and maintenance, and rehabilitative activities. (PO #2)

Due Date

Milestone #2 consists of the proposal for your Design for Change Capstone Project. Submit this Milestone to the Dropbox by the end of Week 4.

Points

Milestone #2 is worth 225 points.

Directions

  1. Create a proposal for your Design for Change Capstone Project. Open the template in Doc Sharing. You will include the information from Milestone #1, your PICO question, and evidence appraisal, as you compose this proposal. Your plan is to convince your management team of a nursing problem you have uncovered and you feel is significant enough to change the way something is currently practiced.
  2. The format for this proposal will be a paper following the Publication manual of APA 6th edition.
  3. The paper is to be four- to six-pages excluding the Title page and Reference page.
  4. As you organize your information and evidence, include the following topics.
    1. Introduction: Write an introduction but do not use “Introduction” as a heading in accordance with the rules put forth in the Publication manual of the American Psychological Association (2010, p. 63). Introduce the reader to the plan with evidence-based problem identification and solution.
    1. Change Plan: Write an overview using the John Hopkins Nursing EBP Model and Guidelines (2012)
      1. Practice Question
      1. Evidence
      1. Translation
    1. Summary
  5. Citations and References must be included to support the information within each topic area. Refer to the APA manual, Chapter 7, for examples of proper reference format. In-text citations are to be noted for all information contained in your paper that is not your original idea or thought. Ask yourself, “How do I know this?” and then cite the source. Scholarly sources are expected, which means using peer-reviewed journals and credible websites.
  6. Tables and Figures may be added as appropriate to the project. They should be embedded within the body of the paper (see your APA manual for how to format and cite). Creating tables and figures offers visual aids to the reader and enhances understanding of your literature review and design for change.

Grading Criteria: Design for Change Capstone Project

CategoryPoints%Description
Introduction2511%Introduction to the plan is nursing focused, with evidence-based problem identification and potential solutions clearly identified.
Change Plan; Practice Question (Steps 1–5)5022%Activities to achieve the first steps of change are fully described in detail and are based on the first five steps of the John Hopkins EBP Process; Practice Question.
Change Plan; Evidence (Steps 6–10)5022%Activities to achieve steps six through ten of the John Hopkins EBP Process are fully described in detail; Evidence.
Change Plan; Translation (Steps 11–18)5022%Activities to achieve the final steps of change are fully described in detail and are based on steps 11 through 18 of the John Hopkins EBP Process; Practice Question.
Summary2511%Clear, solid summary summarizing the key points and steps of the change plan is included; ways to maintain the change plan are described. 
APA Format2511%Minimal errors.
Total225 points100% 

Grading Rubric: Capstone Project Milestone #2

Assignment CriteriaOutstanding or Highest Level of Performance A (92–100%)Very Good or High Level of Performance B (84–91%)Competent or Satisfactory Level of Performance C (76–83%)Poor, Failing or Unsatisfactory Level of Performance F (0–75%)Total
Introduction 25 pointsIntroduction to the plan is nursing focused, with evidence-based problem identification and potential solutions clearly identified. 23–25 pointsIntroduction to the plan is nursing focused, with evidence to support the problem and potential solution identified but convincing areas are missing. 21–22 pointsIntroduction to the plan is provided; however, evidence to support the problem and potential solution is not convincing. 19–20 pointsIntroduction lacks evidence to support need for change and/or potential solution is not realistic. 0–18 points/25
Change Plan Practice Question (Steps 1–5) 50 pointsActivities to achieve the first five steps of change are fully described in detail and are based on the first section of the John Hopkins EBP Process: *Practice question is identified. *Scope of the problem discussed (including supportive statistics). *Stakeholders identified. *Team is identified. 46–50 pointsActivities to achieve the first five steps of change are fully described, not in detail but are based on the first section of the John Hopkins EBP Process: *Practice question is identified. *Scope of the problem discussed (including supportive statistics). *Stakeholders identified. *Team is identified. 42–45 pointsActivities to achieve the first five steps of change are vague. The first section of the John Hopkins EBP Process is not clearly identified. *Practice question is identified. *Scope of the problem does not contain statistics to support the problem. *Stakeholders are identified but not appropriate or missing key members. *Team members are identified but not appropriate or missing key members. 38–41 pointsActivities to address and support change are not specifically addressed. Portions of the first five steps are missing or absent. 0–37 points/50
Change Plan Evidence (Steps 6–10) 50 pointsActivities to achieve steps six through ten of change are fully described in detail and are based on the first section of the John Hopkins EBP Process: Evidence is identified. *At least four reliable sources are used, three of which are peer-reviewed. *Summary of evidence is thorough and detailed. *Strength of evidence is discussed. *Recommendation for change is based on evidence and is thorough. 46–50 pointsActivities to achieve steps six through ten of change are vague and are based on the first section of the John Hopkins EBP Process: Evidence is identified. *At least four reliable sources are used, three of which are peer-reviewed. *Summary of evidence is vague. *Strength of evidence is discussed. *Recommendation for change is based on evidence but connection is vague. 42–45 pointsActivities to achieve steps six through ten of change are vague and are based on the first section of the John Hopkins EBP Process: Evidence is identified. *At least four reliable sources are used but less than three are peer-reviewed. *Summary of evidence is vague. *Strength of evidence is not discussed. *Recommendation for change is present but not weak connection to the evidence. 38–41 pointsActivities to achieve steps six through ten of change may be missing or absent. *Less than four reliable sources are used. *Summary of evidence is not present or missing important elements. *Strength of evidence is missing. *Recommendation for change lacks support from evidence. 0–37 points/50
Change Plan Translation (Steps 11–18) 50 pointsActivities to achieve the last steps of change are fully described in detail and are based on the last steps of the John Hopkins EBP Process: Translation. *Action plan is well-developed with specific timeline in place to include all elements of the plan. *Measurable outcomes and way to report results are discussed in detail. *Plan for implementation is thoroughly discussed. *Ways to communicate findings (internally and externally) are discussed. 46–50 pointsActivities to achieve the last steps of change are described and are based on the last steps of the John Hopkins EBP Process: Translation. *Action plan is developed with specific timeline in but some elements of the timeline are missing. *Outcomes are present but not measurable. Ways to report results are discussed in detail. *Plan for implementation is discussed. *Communication of findings is present but does not address both internal and external ways. 42–45 pointsActivities to achieve the last steps of change are vague. *Action plan is developed but timeline is missing. *Outcomes are vague and not measurable. Ways to report results are discussed but not in detail. *Plan for implementation is vague. *Communication of findings is missing. 38–41 pointsActivities to achieve the last steps of change are vague or missing. *Action plan is not well-developed or missing. *Outcomes are vague or not present. Ways to report results are discussed but not in detail. *Plan for implementation is not present. *Communication of findings is missing. 0–37 points/50
Summary 25 pointsClear, solid summary of the key points and the change plan are included; ways to maintain the change plan are described. 23–25 pointsA clear summary of the key points and part of the change plan are provided; ways to maintain the change plan are mentioned, but not in detail. 21–22 pointsA summary is present but is vague; parts of the change plan are highlighted; ways to maintain the change plan are not clear. 19–20 pointsA summary is difficult to determine or absent. Key points of the change plan are not recapped or are absent. 0–18 points/25
APA formatting, scholarly writing 25 pointsAPA format  sixth edition: third person, grammar, sentence structure, punctuation, and spelling; sources correctly cited and referenced; title page, headers, and page numbers. No errors to one error. 23–25 pointsTwo to three errors. 21–22 pointsFour to five errors. 19–20 pointsMultiple errors 0–18 points/25
 Total Points /225

Reference: Dearholt, S. L., & Dang, D. (2012).Johns Hopkins Nursing Evidence Based Practice: Model and Guidelines (2nd ed.).Indianapolis, IN: Sigma Theta Tau International

Title

Your Name

Chamberlain College of Nursing

NR451 RN Capstone Course

Term and Year

Your title here

This paragraph(s) is to introduce the paper. State the problem and potential solutions backed by evidence. Briefly, introduce the nursing focused plan. Remember this is a scholarly APA assignment so you cannot use first person.

Change Model Overview

In this first paragraph, provide an overview of the John Hopkins Nursing Evidence-Based Practice Process. Feel free to state why nurses should use this model as a guide to facilitate change. Under each of the second level headers listed below, you now link your identified topic to the John Hopkins EBP Process.

Practice Question

Step 1: Identify an EBP question

Restate your question. Include the PICOT elements but make sure you write them in paragraph form and not in list format.

Step 2: Scope of practice question

Why is this a problem? Give statistics and information to back the scope of the problem. How does this problem impact healthcare on a broader scale?

Steps 3, 4, and 5: Team

You will be the leader of the team since this is your project. Who will you also include in your team? Make sure you choose relevant stakeholders. You should have no more than eight members. Why are the members chosen important to your project?

Evidence

Steps 6 and 7: Internal and external search for evidence

What type of evidence did you find? EBP guidelines? Quality improvement data? Position statements? Qualitative research? Quantitative research? Briefly discuss the strength of this research.

Steps 8 and 9: Summarize the evidence

Synthesize the information that you obtained from your sources. You will need at least four sources. Of these four sources, three must be from peer-reviewed articles. The other source can be from a reputable source. See page 44 of your text for examples of sources you can use.

In this section, you need to synthesize the information from the articles. Feel free to cite multiple articles within one sentence. You should avoid one paragraph for each of the sources.

Step 10: Recommendations for change

What is your recommendation based on the research? Ideally, you will have found enough support in your evidence to proceed with implementing your pilot program.

Translation

Steps 11, 12, and 13: Action plan

You have not implemented your project yet, therefore, this section will be hypothetical. Develop your plan for implementation. What are the specific steps you will take to implement your pilot study?  What is the timeline for your plan? Make sure you include a plan for evaluation of outcomes and method to report the results.

Steps 14 and 15: Evaluating outcomes

What are the desired outcomes? How will they be measured? How will you report the results to the key stakeholders?

Steps 16, 17, and 18: Implementation

How will you implement the plan on a larger scale? Will this be applicable to other units or the facility as a whole? What will you do to ensure that the implementation becomes permanent? How will you communicate your findings internally (within your organization) and externally (to others outside of your organization)?

Conclusion

Provide a clear and concise summary. Review the key aspects of the problem as well as the change model. Be sure to include important aspects of the three levels of change for the John Hopkins EBP process.

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