Abstract 108: Unpacking the Black Box of Telehealth Communication Patterns in Heart Failure Self-Management
Authors: Pope Charlene A , Davis Boyd H , Distler Maureen M 
Published: July 2021

Background/Problem
Though a technological advance currently recommended for patients with heart failure, systematic reviews of telehealth services present mixed results for outcomes of care. Some telehealth services are automated with little human-to-human communication, while other telehealth interventions offer little insight into the black box of nurse-patient communication when prompted and shaped by technology. As a foundation for quality improvement and outcomes research, telehealth services that promote heart failure (HF) self-management rely on communication patterns of care between nurse care coordinators and patients that are rarely described beyond message content or tied to patient outcomes. The Veterans Affairs (VA) Home Telehealth (HT) Service uses a variety of telehealth technologies to promote HF self-management while reducing emergency room visits and avoidable hospitalization. This study report examines the nurse - patient communication specific practices and patterns of care with Veterans who have HF to identify the role of shared decision making and patient engagement as potential links to self-management and HF outcomes. Though HT has been shown effective, the communication patterns of care associated with effective implementation and improved outcomes remain to be identified. Evidence that supports best telehealth communication patterns associated with positive HF outcomes is needed to set evaluation standards and propose interventions for effective quality improvement. Currently there is very limited evidence-based research that identifies the actual speech practices and patterns of care that promote effective communication resulting in positive engagement.

Methods
This presentation reports on a discourse analysis and ratings of shared decision making for 50 Veteran-care coordinator recorded telephone conversations typical of telehealth services for HF monitoring. Transcriptions and recordings were decoded to study patterns of care for speech and word usage that engaged the patient, increased interaction and encouraged shared decision making between the nurse and patient. A team of three coded patterns associated with scores of shared decision making, using an adaptation of the Rochester Participatory Decision Making (RPAD) Scale.

Results
Interactions with higher scores of shared decision making were characterized with particular best practices in communication and patterns of care. Examples include: requesting the patient's agenda, asking open-ended questions, the use of silence, responding to patient's cues associated with heart failure self-management, paralinguistic prompts that build narratives about self-management, etc. Yet the overall rating of telehealth shared decision making was lower than expected for the cohort, with patterns shaped by the technology that can be changed with education.

Conclusions
The identification of evidence based communication patterns that promote patient-care coordinator engagement and shared decision making can be integrated in enhanced training and monitoring of telehealth services and will be tested for effectiveness with HF outcomes in a future study.