Telehealth technology on CHF patients

Telehealth technology improves CHF patient’s quality of life

Telehealth technology on CHF patients

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

Telehealth technology on CHF patients
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

Telehealth technology on CHF patients

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

Telehealth technology on CHF patients
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

Telehealth technology on CHF patients
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.

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.

Telehealth technology on CHF patients
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

Telehealth technology on CHF patients
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.


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

Telehealth technology on CHF patients
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).


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

Telehealth technology on CHF patients
aimed at improving nurse’s clinical judgments, reducing nurse workloads; and to simultaneously,
improve CHF patient quality of life.

Telehealth technology on CHF patients


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American Psychological Association. (2010). Publication manual of the American Psychological
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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.
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A randomized controlled trial of telemonitoring in older adults with multiple chronic
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