Increasing Adherence and Self-Care Knowledge: Implementing a Telecoaching Protocol with Medicaid/Medicare Recipients with Congestive Heart Failure

Purpose and Background

Congestive heart failure (CHF) affects nearly six million Americans. Readmission rates following CHF hospitalization are high; more than half of patients return to the hospital within six months of discharge. Among Medicare fee-for-service patients, CHF is the leading cause of hospital readmission.

The purpose of this study was to assess adherence to a new telehealth protocol intervention, implemented by social workers, designed to increase self-care knowledge for patients with CHF. An established standardized CHF self-care protocol was transformed to a telehealth platform that allowed for daily real-time reporting of health status and video conferencing with trained social workers.

Methods

Forty-five patients with congestive heart failure were recruited from a regional Managed Care Organization. All patients were provided with a touchscreen personal computer tablet with software designed specifically for a high-risk patient base with poor health literacy. The software application allowed for real-time reporting of patient-supplied health status; an interface designed to engage patients in CHF self-care; and educational information. Patients used the software on the tablet to report on their health symptoms daily (i.e. ankle swelling, breathing difficulty, and dizziness).

Adherence was defined as the percentage of days of the 120-day protocol on which the patient successfully completed the intervention. At baseline and at a 30-day follow-up, social workers administered the 13-item Member Confidence Measure © to measure patients’ understanding of CHF and related symptoms, knowledge of the disease, and the behaviors necessary to prevent their symptoms from getting worse.

Mann-Whitney U tests were used to compare adherence scores between demographic characteristics and various assessment information collected during the study. Rates of adherence to the protocol were divided into 30-day increments over a 120-day period in order to assess level of adherence over time. Scores for self-care knowledge based on the Member Confidence Measure were calculated by dividing the z-statistic by the square root of the number of observations over the 120 day period.

 

Results

Median adherence for over the full 120-day period was 96% (IQR=92-98%). Adherence was not significantly different across sex, race, age, living situation, depression, cognitive ability, or risk for readmission. Adherence did not significantly change across each 30-day increment over the 120-day study period.

The median Member Confidence Measure scores assessed by social workers at baseline and 30-day follow-up revealed a statically significant improvement in the total Member Confidence Measure score after the telecoaching, Z = 5.17, p < .001, with a large effect size (r = .544). Wilcoxon Sign Tests found comparable improvements in knowledge the five subscales: congestive heart failure symptoms (Z = .514), healthy behaviors (Z = .498), seeking medical attention (Z = .335), safety (Z = .320), and medications (Z = .285).

 

Implications

These findings suggest that telehealth programs combining technologies with best practices for at-risk populations can maintain excellent adherence. This protocol was notable in its use of social workers as specialized clinician-health coaches. The overall change in self-care knowledge also suggests that social workers can play a key role in educating high-risk CHF patients.