Best Practices for Telehealth in Nurse-Led Care Settings-A Qualitative Study

The COVID-19 pandemic in the US prompted a sudden shift to telehealth in nurse-led care sites which provide services to diverse geolocations. Using a lens of intersectionality, this study characterizes provider and patient-perceived best and promising practices emerging from geographical variation. The aim of this study was to identify best practices of implementing telehealth in nurse-led care models in Colorado through patient and provider experiences of the sudden implementation of telehealth that can enhance health equity. In this exploratory/descriptive qualitative study, a purposive sample of 18 providers and 30 patients were interviewed using a guide informed by the RE-AIM implementation and evaluation framework to capture the contextual experiences related to the sudden shift to telehealth. Textual theme analysis and reflexive team strategies guided the interpretation. Four primary themes of perceived best practices were identified: using multiple modalities, tailoring triage and scheduling, cultivating safety through boundaries and expectations, and differentiating established versus new patient relationships. The findings suggest that telehealth is a flexible and powerful tool to enhance the delivery of equitable care through nurse-led care models within diverse communities such as the one represented in this study. Nurse leaders are positioned to participate in innovative research and create policies and protocols to ensure telehealth is a viable resource to deliver equitable, safe, and accessible high-quality healthcare.

Perinatal Telehealth: Meeting Patients Where They Are

INTRODUCTION

Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities.

METHODS

This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context.

RESULTS

Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources.

DISCUSSION

This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service.

METHODS

We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors.

RESULTS

When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression.

DISCUSSION

No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

Patient and Provider Perceptions of COVID-19-Driven Telehealth Use From Nurse-Led Care Models in Rural, Frontier, and Urban Colorado Communities

The purpose of this study was to characterize the patient and provider engagement in the sudden telehealth implementation that occurred with the onset of the COVID-19 pandemic. Patients and providers from 3 nurse-led models of care (federally qualified health centers, nurse midwifery practices, and the Nurse-Family partnership program) in Colorado were surveyed. Data from the Patient Attitude toward Telehealth survey and Provider Perceptions about Telehealth were collected. Patient respondents (n = 308) who resided primarily in rural or frontier communities were female, white, and Hispanic. Patients in urban areas used telehealth more frequently than in rural or frontier areas (P < .001). Rural/Frontier patients had significantly lower attitude scores than urban patients across each of 5 domains assessed. Telehealth modality differed across location (P < .023), with video calls, used more frequently by urban providers, and phone calls used by rural/frontier providers. Our data highlight differences in telehealth access and attitudes across rurality. These findings may contribute to future policy while addressing barriers to telehealth access and delivery.

Contemporary Nurse-Midwifery Care in Colorado: A Survey of Certified Nurse-Midwife Practices in Hospital and Community Settings

Lack of access to birth facilities and maternity care providers has contributed to rising US maternal mortality and morbidity rates, especially among women in rural areas. Evidence supports the increased use of midwives as a potential solution for access-to-care issues. This observational survey was conducted to identify the practice environment for Certified Nurse-Midwives® in Colorado for the purpose of informing future workforce expansion. Study results indicate that midwives provide services aligned with the midwifery model of care and have mostly autonomous practice in hospitals where midwifery practices are already established. However, there is limited use of midwives, as fewer than half of Colorado's 69 birthing hospitals have midwifery practices, and financial constraint created by low Medicaid reimbursement could be a limiting factor in establishing new midwifery practices. Policy recommendations based on survey results include (a) support for midwifery education and workforce development, (b) removal of hospital-level restrictions for privileges of midwives, and (c) consideration for public payment models that promote expansion of midwifery practices.

Program implementation and outcomes from three cohorts of the nurse-family partnership nurse residency program

BACKGROUND

The purpose of this paper is to describe a Nurse-Family Partnership (NFP) Nurse Residency Program (NRP) and program outcomes.

METHODS

Dual methods were used to evaluate the first three cohorts of the NFP NRP. Participants were new NFP nurses, most working in Colorado. Pre-(n = 42) and post-program (n = 26) surveys were completed using the Individual Workplace Perception Scale (IWPS) and endorsement of program objectives; key informant interviews were done with the initial cohort. Descriptive statistics and unpaired t-tests (for the IWPS) were used to explain program effectiveness and efficacy.

RESULTS

Forty-two NFP nurses participated in the program at the onset. There was consistent attendance (92% or more) among those who finished and modest individual attrition during the length of the program. Participants reported high levels of satisfaction with the content and meeting program objectives; there were no significant differences on pre- and post-program IWPS scores.

CONCLUSIONS

The program was well-received by program participants and has the potential to contribute to the professional development of new NFP nurses.

Meeting the Challenge of Perinatal Care in Rural Communities

The complexities of providing quality perinatal care within rural communities provide significant challenges to providers and policy makers. Provision of healthcare in rural communities is challenging on individual as well as community-based levels. A quality improvement lens is applied to consider key challenges that pertain to patients, providers, place, and policy. Potential solutions from a provider perspective include nurse-midwifery care and inclusion of advanced practice providers in a variety of specialties in addition to creating care models for registered nurses to practice at the top of their scope. To enhance access in the rural place, telehealth and coordination activities are recommended. Finally, policy approaches such as Perinatal Care Collaboratives, Area Health Education Centers, and enhanced financial resources to eliminate socioeconomic disparities will enhance perinatal care in rural communities.

Improving Access to Integrated Behavioral Health in a Nurse-Led Federally Qualified Health Center

BACKGROUND

The specific aims of this project were to create a fully integrated, nurse-led model of a psychiatric nurse practitioner and behavioral health care team within primary care to facilitate (1) patients receiving an appropriate level of care and (2) care team members performing at the top of their scope of practice.

METHOD

The guiding model for process implementation was Rapid Cycle Quality Improvement. Three task forces were established to develop interventions in the areas of Roles and Responsibilities, Training and Implementation, and the electronic health record.

INTERVENTION

The four interventions that emerged from these task forces were (1) the establishment of patient tiers based on diagnosis, medications, and risk assessment; (2) the creation of process maps to engage care team members; (3) just-in-time education regarding psychiatric medication management for primary care providers; and (4) use of a registry to track patients.

RESULTS

The process measures of referrals to the psychiatric care team and psychiatric assessment intakes performed as expected. Both measures were higher at the onset of the project and lower 1 year later. The outcome indicator, number of case reviews, increased dramatically over time.

CONCLUSIONS

For psychiatric nurse practitioners, this quality improvement effort provides evidence that a consultative role can be effective in supporting primary care providers. Through providing education, establishing patient tiers, and establishing an effective workflow, more patients may have access to psychiatric services.

A concept analysis of health literacy

AIM

To propose a conceptual definition of health literacy incorporating system demands, burdens, and complexities that are a critical part of patients' level of health literacy.

BACKGROUND

Health literacy is used frequently in health care and often is confused with patients' reading and comprehension levels.

DESIGN

Walker and Avant's concept analysis method was used.

DATA SOURCE

Cochrane Library, Cumulative Index of Nursing and Health Literature, OVID, PubMed, EBSCO Host databases, and Google Scholar.

REVIEW METHOD

The primary Search terms and MeSH terms used were health literacy, patient education, patient engagement, patient activation, health communication, health promotion, and nursing. Empirical and nonempirical articles published in English were reviewed. Ten systematic literature reviews were included.

RESULTS

A new definition of health literacy is provided based on four components that include: system demands, burdens, and complexities; measurable components, processes and outcomes; the dynamic nature of health literacy; and demonstration of the direct relationship of informed decisions to informed actions. Defining attributes, antecedents, and consequences are identified. Implications for nursing practice, education, and research are given.

CONCLUSIONS

Because health literacy is a dynamic and quickly changing concept, further exploration and evolution of the concept is warranted as empirical research and theoretical literature emerge.

Changes in the Helping Behaviors of Adult Children as Caregivers

This research uses data from the longitudinal file of the 1982-1984 National Long-Term Care Survey to (a) describe changes in the caregiving responsibilities of adult children over time and (b) estimate the effect of adult child, impaired elder, and sibling participation characteristics on changes in the participation of adult children as providers of ADL and IADL assistance. The results show that 5.2% of adult children who did not provide ADL help and 12.6% of those who did not provide IADL help at Time 1 were helping with these tasks at Time 2. Conversely, 50.7% of adult children who provided ADL assistance and 29.9% of those who provided IADL assistance at Time 1 had stopped providing such care by Time 2. Logit models used to predict changes in the helping behaviors of adult children indicate that there are both differences and similarities in the factors that affect the likelihood of becoming a caregiver and of discontinuing assistance over time.

Tracking Outcomes in Community-Based Care

The Public Health Nursing Outreach for New Americans (PHNONA) faculty practice serves refugee and immigrant populations in the Denver metropolitan area. The practice provides health education and home visits for children within the Head Start program and their families. Nursing students in the baccalaureate program have the opportunity to rotate through this practice during their Public Health Nursing course. The Omaha System is used as a tool to facilitate student documentation. Data from 27 closed cases were analyzed. Common problems in the environmental domain were income and residence; in the physiological domain, dentition; in the psychosocial domain, communication with community resources; and in the health-related behaviors domain, health care supervision and nutrition. The majority of interventions were in the Case Management and Health Teaching, Guidance, and Counseling categories. The Problem Rating Scale for Outcomes showed statistically significant improvement from admission to discharge in the areas of knowledge, behavior, and status.

Preparing the Next Generation of Advanced Practice Nurses for Connected Care

The health care delivery system in the United States is transforming at a rapid pace. Several trends, including the emergence of a Connected Health care system, will require advanced nurse practitioners to have new knowledge, skills and competencies to practice in the future. This paper describes the redesign of coursework and the development of a Connected Care Framework to guide the learning needs of nurse practitioners. A Connected Care Quotient consisting of ten relevant questions and learning activities will serve as a guide for the future development of competencies for advanced practice nurses.

Infusing informatics into interprofessional education: the iTEAM (Interprofessional Technology Enhanced Advanced practice Model) project

The iTEAM goal is to prepare advanced practice nurses, physicians and pharmacists with the interprofessional (IP) core competencies (informatics, patient centric, quality-focused, evidence based care) to provide technology enhanced collaborative care by: offering technology enhanced learning opportunities through a required informatics course, advanced practice courses (team based experiences with both standardized and virtual patients) and team based clinical experiences including e-health experiences. The innovative features of iTEAM project will be achieved through use of social media strategies, a web accessible Electronic Health Records (EHRs) system, a Virtual Clinic/Hospital in Second Life, various e-health applications including traditional telehealth tools and consumer oriented tools such as patient portals, social media consumer groups and mobile health (m-health) applications for health and wellness functions. It builds upon the schools' rich history of IP education and includes clinical partners, such as the VA and other clinical sites focused on care for underserved patient populations.

Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning

Improvements in health care are slow, in part because doctors and nurses lack skills in quality improvement, patient safety, and interprofessional teamwork. This article reports on the Retooling for Quality and Safety initiative of the Josiah Macy Jr. Foundation and the Institute for Healthcare Improvement, which sought to integrate improvement and patient safety into medical and nursing school curricula. In one academic year, 2009-10, the initiative supported new learning activities (87 percent of which were interprofessional, involving both medical and nursing students) in classrooms, simulation centers, and clinical care settings that involved 1,374 student encounters at six universities. The work generated insights-described in this article-into which learning goals require interprofessional education; how to create clinically based improvement learning for all students; and how to demonstrate the effects on students' behavior, organizational practice, and benefits to patients. A commonly encountered limiting factor for the programs was the lack of a critical mass of clinically based faculty members who were ready to teach about the improvement of care. What's more, the paucity of robust evaluation strategies for such programs suggests a future research agenda that deserves to be funded.

Creating social media policies for education and practice

The use of social media in society and healthcare has become pervasive. This paper reviews uses of social media within health care and higher education along with its concomitant risks and benefits. Challenges rooted in the blurring of boundaries between personal and professional experiences provide the rationale for policy development. Guidelines to enhance the use of social media to enhance organizational reputation and patient privacy are proposed.

The regulation of mobile health applications

In July 2011, the United States Food and Drug Administration issued draft guidance concerning the regulation of mobile medical applications (applications on a wireless device that are used as accessories to medical devices or to convert a mobile platform to a medical device). While the suggestion of regulation is rooted in patient safety, concerns about limits on innovation and discovery as well as the evolving nature of both mobile health and current healthcare delivery have emerged. This article discusses the prevalence of mobile health, the context of regulation concerning mobile medical applications, and implications for the future.