TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation.
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ABSTRACT: Objective
To develop a conceptual model for effective use of telehealth in the management of chronic health conditions, and to use this to develop and evaluate an intervention for people with two exemplar conditions: raised cardiovascular disease risk and depression.Design
The model was based on several strands of evidence: a metareview and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions; a qualitative study of patients' and health professionals' experience of telehealth; a quantitative survey of patients' interest in using telehealth; and review of existing models of chronic condition management and evidence-based treatment guidelines. Based on these evidence strands, a model was developed and then refined at a stakeholder workshop. Then a telehealth intervention ('Healthlines') was designed by incorporating strategies to address each of the model components. The model also provided a framework for evaluation of this intervention within parallel randomised controlled trials in the two exemplar conditions, and the accompanying process evaluations and economic evaluations.Setting
Primary care.Results
The TElehealth in CHronic Disease (TECH) model proposes that attention to four components will offer interventions the best chance of success: (1) engagement of patients and health professionals, (2) effective chronic disease management (including subcomponents of self-management, optimisation of treatment, care coordination), (3) partnership between providers and (4) patient, social and health system context. Key intended outcomes are improved health, access to care, patient experience and cost-effective care.Conclusions
A conceptual model has been developed based on multiple sources of evidence which articulates how telehealth may best provide benefits for patients with chronic health conditions. It can be used to structure the design and evaluation of telehealth programmes which aim to be acceptable to patients and providers, and cost-effective.
SUBMITTER: Salisbury C
PROVIDER: S-EPMC4322202 | biostudies-literature | 2015 Feb
REPOSITORIES: biostudies-literature
Publications
TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation.
Salisbury Chris C Thomas Clare C O'Cathain Alicia A Rogers Anne A Pope Catherine C Yardley Lucy L Hollinghurst Sandra S Fahey Tom T Lewis Glyn G Large Shirley S Edwards Louisa L Rowsell Alison A Segar Julia J Brownsell Simon S Montgomery Alan A AA
BMJ open 20150206 2
<h4>Objective</h4>To develop a conceptual model for effective use of telehealth in the management of chronic health conditions, and to use this to develop and evaluate an intervention for people with two exemplar conditions: raised cardiovascular disease risk and depression.<h4>Design</h4>The model was based on several strands of evidence: a metareview and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions; a qualitative study of patients' and health ...[more]
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Project description:Background The COVID-19 pandemic forced Veterans Health Administration facilities to rapidly adopt and deploy telehealth alternatives to provide continuity of care to veterans while minimizing physical contact. The impact of moving to virtual visits on patients with congestive heart failure (HF) is unknown. The goal of this study was to understand how patients with HF and their providers experienced the shift to telehealth for managing a chronic condition, and to inform best practices for continued telehealth use. Methods and Results We identified Veterans Health Administration Medical Centers with high telehealth use before COVID-19 and sites that were forced to adopt telehealth in response to COVID-19, and interviewed cardiology providers and veterans with HF about their experiences using telehealth. Interviews were recorded, transcribed, and analyzed using team-based rapid content analysis. We identified 3 trajectory patterns for cardiology telehealth use before and during COVID-19. They were the low-use class (low to low), high-use class (relatively high to higher), and increased-use class (low to high). The high-use and increased-use classes fit the criteria for sites that had high telehealth use before COVID-19 and sites that rapidly adopted telehealth in response to COVID-19. There were 12 sites in the high-use class and 4 sites in the increased-use class. To match with the number of sites in the increased-use class, we selected the top 4 sites by looking at the months before COVID-19. We identified 3 themes related to telehealth use among patients with HF and cardiology providers: (1) technology was the primary barrier for both patients and providers; (2) infrastructural support was the primary facilitator for providers; and (3) both patients and providers had largely neutral opinions on how telehealth compares to in-person care but described situations in which telehealth is not appropriate. Conclusions Only 12 sites fit the criteria of high telehealth use in cardiology before COVID-19, and 4 fit the criteria of low use that increased in response to COVID-19. Patients and providers at both site types were largely satisfied using telehealth to manage HF. Understanding best practices for managing ambulatory care-sensitive conditions through virtual visits can help the Veterans Health Administration prepare for long-term impacts of COVID-19 on in-person visits, as well as improve access to care for veterans who live remotely or who have difficulty traveling to in-person appointments.
| S-EPMC10111499 | biostudies-literature
Project description:BackgroundThe aged care system in Australia is under pressure. Residential aged care facilities (RACFs) and general practitioners (GPs) have difficulty providing the care needed by their residents, particularly after hours. Many residents are given ambulance support and transferred to hospital emergency departments (EDs) for care that could be provided at RACFs. The MyEmergencyDoctor (MED) service was commissioned in a 12-month program (February 2020-February 2021) using ED physicians to provide afterhours telehealth care in six RACFs.MethodsUsing the NASSS framework, we synthesised descriptive analyses of statistical data from the MED service, RACFs and the ambulance service and a thematic analysis of interview data collected from GPs, RACF and MED service staff, and family members of residents.ResultsMost calls to MED (179/209) were resolved with in-house treatment thereby reducing ambulance usage and hospital admissions. Interviews further revealed that MED enabled timely care for residents who were unwell but did not need hospital transfer. Technology, training, and rapid access to MED assisted RACF staff and complemented usual GP care. MED potentially reduced GP burnout. Refresher training was considered important especially in RACFs with high staff turnover, as was greater afterhours access to medications.ConclusionsThe afterhours telehealth model provided in-house care and reduced ambulance transfers, and GPs and RACF staff generally felt supported. The service was easy to use and fostered good communications with GPs and RACF staff. Some GPs preferred to provide their own care, commenting on the need for a good understanding of patient and family needs and of the local context. Other stakeholders suggested this model could be extended to palliative care settings and to normal business hours when GPs were unavailable. The reduced ambulance and hospital use suggested benefits to wider health systems, however policies and funding that remunerate GPs, support community-based care and provide additional staffing in RACFs are needed to sustain afterhours telehealth in RACFs. Use of the NASSS (non-adoption, abandonment, scale-up, spread, and sustainability) Framework provided a valuable explanatory lens for our analyses.
| S-EPMC10652444 | biostudies-literature
Project description:OBJECTIVE:To evaluate the feasibility and acceptability of a personalised telehealth intervention to support dietary self-management in adults with stage 3-4 chronic kidney disease (CKD). DESIGN:Mixed-methods process evaluation embedded in a randomised controlled trial. PARTICIPANTS:People with stage 3-4 CKD (estimated glomerular filtration rate [eGFR]15-60 mL/min/1.73 m2). SETTING:Participants were recruited from three hospitals in Australia and completed the intervention in ambulatory community settings. INTERVENTION:The intervention group received one telephone call per fortnight and 2-8 tailored text messages for 3 months, and then 4-12 tailored text messages for 3 months without telephone calls. The control group received usual care for 3 months then non-tailored education-only text messages for 3 months. MAIN OUTCOME MEASURES:Feasibility (recruitment, non-participation and retention rates, intervention fidelity and participant adherence) and acceptability (questionnaire and semistructured interviews). STATISTICAL ANALYSES PERFORMED:Descriptive statistics and qualitative content analysis. RESULTS:Overall, 80/230 (35%) eligible patients who were approached consented to participate (mean±SD age 61.5±12.6 years). Retention was 93% and 98% in the intervention and control groups, respectively, and 96% of all planned intervention calls were completed. All participants in the intervention arm identified the tailored text messages as useful in supporting dietary self-management. In the control group, 27 (69%) reported the non-tailored text messages were useful in supporting change. Intervention group participants reported that the telehealth programme delivery methods were practical and able to be integrated into their lifestyle. Participants viewed the intervention as an acceptable, personalised alternative to face-face clinic consultations, and were satisfied with the frequency of contact. CONCLUSIONS:This telehealth-delivered dietary coaching programme is an acceptable intervention which appears feasible for supporting dietary self-management in stage 3-4 CKD. A larger-scale randomised controlled trial is needed to evaluate the efficacy of the coaching programme on clinical and patient-reported outcomes. TRIAL REGISTRATION NUMBER:ACTRN12616001212448; Results.
| S-EPMC6352771 | biostudies-literature
Project description:BackgroundThe rise of digital methods and computational tools has opened up the possibility of collecting and analyzing data from novel sources, such as discussions on social media. At the same time, these methods and tools introduce a dependence on technology, often resulting in a need for technical skills and expertise. Researchers from various disciplines engage in empirical bioethics research, and software development and similar skills are not usually part of their background. Therefore, researchers often depend on technical experts to develop and apply digital methods, which can create a bottleneck and hinder the broad use of digital methods in empirical bioethics research.ObjectiveThis study aimed to develop a research platform that would offer researchers the means to better leverage implemented digital methods, and that would simplify the process of developing new methods.MethodsThis study used a mixed methods approach to design and develop a research platform prototype. I combined established methods from user-centered design, rapid prototyping, and agile software development to iteratively develop the platform prototype. In collaboration with two other researchers, I tested and extended the platform prototype in situ by carrying out a study using the prototype.ResultsThe resulting research platform prototype provides three digital methods, which are composed of functional components. This modular concept allows researchers to use existing methods for their own experiments and combine implemented components into new methods.ConclusionsThe platform prototype illustrates the potential of the modular concept and empowers researchers without advanced technical skills to carry out experiments using digital methods and develop new methods. However, more work is needed to bring the prototype to a production-ready state.
| S-EPMC9121222 | biostudies-literature
Project description:BackgroundThe burden of obesity is high among US veterans, yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE, a home-based, 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services.ObjectiveThe primary aim was to establish preliminary evidence for the program by comparing outcomes for TeleMOVE with standard, facility-based MOVE weight-management services (group, individual modalities) over the evaluation period based on the number of patients enrolled per site and the program's clinical effectiveness, as demonstrated by average weight lost per patient. The secondary aim was to understand factors influencing TeleMOVE implementation variability across demonstration sites to develop recommendations to improve national program dissemination.MethodsWe employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE at 9 demonstration sites and compare patient- and site-level measures of program uptake. Data were collected between October 1, 2009 and September 30, 2011. Patient-level program outcomes were extracted from VHA patient care databases to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared with outcomes for veterans enrolled in standard MOVE! at each demonstration site, as well as with national averages during the first 2 years of program implementation. For the secondary aim, we invited program stakeholders to participate in 2 rounds of semistructured interviews about aspects of TeleMOVE implementation processes, site-level contextual factors, and program delivery. Twenty-eight stakeholders participated in audio-recorded interviews.ResultsAlthough stakeholders at 3 sites declined to be interviewed, objective program uptake was high at 2 sites, delayed-high at 2 sites, and low at 5 sites. At 6 months post enrollment, the mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at -5.2 lb (SD 14.4) and -5.1 lb (SD 12.2), respectively (P=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements, whereas low-uptake sites reported less leadership support and effective communication among stakeholders.ConclusionsThis implementation evaluation of a clinical telehealth program demonstrated the value of partnership-based research in which researchers not only provided operational leaders with feedback regarding the effectiveness of a new program but also relevant feedback into contextual factors related to program implementation to enable adaptations for national deployment efforts.
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Project description:BackgroundTreatment and prevention guidelines highlight the key role of health information and evidence-based psychosocial interventions for adolescent depression. Digital health technologies and psychoeducational interventions have been recommended to help engage young people and to provide accurate health information, enhance self-management skills, and promote social support. However, few digital psychoeducational interventions for adolescent depression have been robustly developed and evaluated in line with research guidance.ObjectiveWe aimed to evaluate the feasibility, acceptability, and potential impact of a theory-informed, co-designed digital intervention program, MoodHwb.MethodsWe used a mixed methods (quantitative and qualitative) approach to evaluate the program and the assessment process. Adolescents with or at elevated risk of depression and their parents and carers were recruited from mental health services, school counselors and nurses, and participants from a previous study. They completed a range of questionnaires before and after the program (related to the feasibility and acceptability of the program and evaluation process, and changes in mood, knowledge, attitudes, and behavior), and their Web usage was monitored. A subsample was also interviewed. A focus group was conducted with professionals from health, education, social, and youth services and charities. Interview and focus group transcripts were analyzed using thematic analysis with NVivo 10 (QSR International Pty Ltd).ResultsA total of 44 young people and 31 parents or carers were recruited, of which 36 (82%) young people and 21 (68%) parents or carers completed follow-up questionnaires. In all, 19 young people and 12 parents or carers were interviewed. Overall, 13 professionals from a range of disciplines participated in the focus group. The key themes from the interviews and groups related to the design features, sections and content, and integration and context of the program in the young person's life. Overall, the participants found the intervention engaging, clear, user-friendly, and comprehensive, and stated that it could be integrated into existing services. Young people found the "Self help" section and "Mood monitor" particularly helpful. The findings provided initial support for the intervention program theory, for example, depression literacy improved after using the intervention (difference in mean literacy score: 1.7, 95% CI 0.8 to 2.6; P<.001 for young people; 1.3, 95% CI 0.4 to 2.2; P=.006 for parents and carers).ConclusionsFindings from this early stage evaluation suggest that MoodHwb and the assessment process were feasible and acceptable, and that the intervention has the potential to be helpful for young people, families and carers as an early intervention program in health, education, social, and youth services and charities. A randomized controlled trial is needed to further evaluate the digital program.
| S-EPMC7395255 | biostudies-literature
Project description:ObjectiveThe aim of this paper is to describe the stages undertaken to generate the items and conceptual framework of a new electronic personal assessment questionnaire for vascular conditions.DesignA mixed methods study: First a survey of vascular clinicians was completed to identify the most common conditions treated in vascular clinics and wards. Quantitative systematic reviews were done to identify validated patient-reported outcome measures (PROMs) for direct inclsuion in the new instrument. However, due to scarcity of validated PROMs, the items of the new instrument were mainly based on a large qualitative study of patients and systematic reviews of the qualitative evidence . This was followed by a quantitative clinicians' consensus study and, finally, a qualitative face validity study with patients.ParticipantsVascular patients participated in the primary qualitative study and the face validity study. In the qualitative study, 55 patients were interviewed, and for the face validity, 19 patients gave feedback. Twelve clinicians completed the survey and 13 completed two cycles of the clinicians' consensus study.ResultsThe items and scales in the electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS) were generated based on the results of five systematic reviews evaluating existing PROMs for possible inclusion in ePAQ-VAS, five systematic reviews of qualitative evidence, a primary qualitative study involving 55 patients and clinicians' input. One hundred and sixty-eight items were initially generated, of which 59 were eliminated by the expert panel due to repetition. The instrument was divided into one generic and three disease-specific sections (abdominal aortic aneurysm, carotid artery disease and lower limb vascular conditions). In each section, items were grouped together into putative scales. Fifty-five items were grouped across eight scales; the remaining items were kept as individual items, because of relevance to service users.ConclusionsThis multidimensional electronic questionnaire covers the most common vascular conditions. This is particularly important for patients presenting with mixed symptoms or multiple conditions. This tool captures symptomatology, health related quality of life (HRQoL) and other clinically relevant data, such as experience with services and comorbidities.
| S-EPMC7418769 | biostudies-literature
Project description:BackgroundThe role of technology in health care delivery has grown rapidly in the last decade. The potential of mobile telehealth (MTH) to support patient self-management is a key area of research. Providing patients with technological tools that allow for the recording and transmission of health parameters to health care professionals (HCPs) may promote behavior changes that result in improved health outcomes. Although for some conditions the evidence of the effectiveness of MTH is clear, to date the findings on the effects of MTH on diabetes management remain inconsistent.ObjectiveThis study aims to evaluate an MTH intervention among insulin-requiring adults with diabetes to establish whether supplementing standard care with MTH results in improved health outcomes-glycated hemoglobin (HbA1c), blood pressure (BP), health-related quality of life (HRQoL), diabetes self-management behaviors, diabetes health care utilization, and diabetes self-efficacy and illness beliefs. An additional objective was to explore the acceptability of MTH and patients' perceptions of, and experience, using it.MethodsA mixed-method design consisting of a 9-month, two-arm, parallel randomized controlled trial (RCT) was used in combination with exit qualitative interviews. Quantitative data was collected at baseline, 3 months, and 9 months. Additional intervention fidelity data, such as participants' MTH transmissions and contacts with the MTH nurse during the study, were also recorded.ResultsData collection for both the quantitative and qualitative components of this study has ended and data analysis is ongoing. A total of 86 participants were enrolled into the study. Out of 86 participants, 45 (52%) were randomized to the intervention group and 36 (42%) to the control group. Preliminary data on MTH training sessions and MTH usage by intervention participants are presented in this paper. We expect to publish complete study results in 2015.ConclusionsThe range of data collected in this study will allow for a comprehensive evaluation of processes and outcomes. The early results presented suggest that MTH usage decreases over time and that MTH participants would benefit from attending more than one training session.Trial registrationClinicalTrials.gov NCT00922376; http://clinicaltrials.gov/ct2/show/NCT00922376 (Archived by WebCite at http://www.webcitation.org/6Vu4nhLI6).
| S-EPMC4376177 | biostudies-literature
Project description:BackgroundDelivery of comprehensive care for persons with human immunodeficiency virus (HIV) infection in rural and low prevalence settings presents many challenges. We developed and evaluated a telehealth collaborative care (TCC) program for persons with HIV in a rural area.ObjectiveTo determine the feasibility of TCC, and identify factors influencing implementation in rural settings.DesignMixed methods evaluation of a quality improvement program with pre-measures and post-measures.PatientsVeterans with HIV infection in Iowa and Illinois.InterventionTCC integrated HIV specialty care delivered by clinical video telehealth, with primary care delivered by generalist providers, in seven Community Based Outpatient Clinics (CBOCs) serving rural areas. Principles guiding TCC design were: 1) clear delineation of specialty and primary care clinic roles in co-managed care; 2) creation of processes to improve care coordination between specialty and primary care teams; and 3) use of a patient registry for population management across sites.MeasuresVeterans Affairs (VA) healthcare system performance measures for care for HIV infection and common comorbidities, patient travel time to obtain care, and patient satisfaction. Qualitative evaluation involved semi-structured telephone interviews with patients.Key resultsThirty of 32 eligible patients chose TCC over traveling to the HIV clinic for all care. Among 24 patients in TCC during the June 2011-May 2012 evaluation period, median age was 54 (range, 40-79), most (96 %) were men, and median CD4 count was 707 cells/cm(3) (range, 233-1307). VA performance measures were met for > 90 % of TCC patients. Median yearly travel time decreased from 320 min per patient prior to TCC to 170 min during TCC (p?<?0.001). Interview themes included: 1) overcoming privacy concerns during care in local primary care clinics; 2) tradeoffs between access, continuity, and care coordination; and 3) the role of specialist involvement in collaborative care.DiscussionTelehealth Collaborative Care is a feasible approach to providing accessible and comprehensive care for persons with HIV in rural settings.
| S-EPMC3744312 | biostudies-literature
Project description:BackgroundWhen the US Department of Health and Human Services instituted a State of Public Health Emergency (PHE) during the COVID-19 pandemic, many telehealth flexibilities were fast-tracked to allow state Medicaid agencies to reimburse new specialty services, sites of care, and mediums such as FaceTime to communicate with patients.. This resulted in expanded access to care for financially vulnerable Medicaid patients, as evidenced by an uptick in telehealth use. Research has mostly focused on telehealth reimbursement for limited use cases such as rural primary care, without broader consideration for how telehealth can be appropriately mainstreamed and maintained.ObjectiveThis study sought to (1) evaluate the continuation of flexible telehealth reimbursement broadly, beyond the COVID-19 pandemic; (2) analyze the clinical effectiveness of the new telehealth services; and (3) offer code-by-code reimbursement guidance to state Medicaid leaders.MethodsWe surveyed 10 state Medicaid medical directors (MMDs) who are responsible for the scientific and clinical appropriateness of Medicaid policies in their respective states. Participants were asked to complete an internet-based survey with a list of medical billing codes, grouped by service type, and asked if they believed they should be reimbursed by Medicaid on a permanent basis. Additional questions covered more detailed recommendations, such as reimbursing video with audio versus audio-only, guardrails for certain specialty services, and motivations behind responses.ResultsThe MMDs felt that the majority of services should be reimbursed via some modality of telehealth after the PHE, with the most support for video combined with audio compared to audio-only. There were exceptions on both ends of the spectrum, where services such as pulmonary diagnostics were not recommended to be reimbursed in any form and services such as psychotherapy for mental health had the most support for audio-only. The vast majority of MMDs were supportive of reimbursement for remote monitoring services, but some preferred to have some reimbursement guardrails. We found that 90% (n=9) of MMDs were supportive of reimbursement for telehealth interprofessional services, while half (n=5) of the respondents felt that there should be continued guardrails for reimbursement. Motivations for continuing reimbursement flexibility were largely attributed to improving access to care, improving outcomes, and improving equity among the Medicaid patient population.ConclusionsThere is a strong clinical endorsement to continue the telehealth flexibility enabled by the PHE, primarily for video combined with audio telehealth, with caution against audio-only telehealth in situations where hands-on intervention is necessary for diagnosis or treatment. There is also support for reimbursing remote monitoring services and telehealth interprofessional services, albeit with guardrails. These results are primarily from a perspective of improving access, outcomes, and equity; other state-specific factors such as fiscal impact and technical implementation may need to be taken into account when considering reimbursement decisions on telehealth.
| S-EPMC11009844 | biostudies-literature