For this essay, you will be addressing how leaders in your current

For this essay, you will be addressing how leaders in your
current or past organization handle motivation and
empowerment. If you do not have a workplace example, you can
use a civic, volunteer, or school experience as the basis for your
essay.
· Include background information on the organization you are
discussing.
· Describe how situational factors, such as the structure, size,
environment, and geographic location of the organization, may
affect the leaders’ success. [Unit Learning Outcome 3.2]
· Examine the tools and techniques the leaders are currently
using to motivate or empower individuals within their
organization. [Unit Learning Outcome 3.1]
· Address whether or not these tools and techniques are
successful in motivating both you and other employees. Be sure
to include examples. [Unit Learning Outcome 3.1]
· Conclude by suggesting improvements that could be made to
enhance the leaders’ abilities to motivate and empower. [Unit
Learning Outcome 3.1]
Your final essay must be a minimum of two pages, not counting
the title and reference pages that are required. Utilize and cite
your textbook for support, but you may also use outside
scholarly resources.. Your essay must follow APA 7th edition
format.
SM Gerontology
and Geriatric
Research
Gr upSM

How to cite this article Metzger LM. Are Patients Satisfied with
Telehealth in Home Health Care? A Quantitative Research
Study in Congestive Heart Failure
Patients. SM Gerontol Geriatr Res. 2017; 1(2): 1009.
https://dx.doi.org/10.36876/smggr.100 9
OPEN ACCESS
ISSN: 2576-5434
Research Article
Are Patients Satisfied with Telehealth
in Home Health Care? A Quantitative
Research Study in Congestive Heart
Failure Patients
Lori M Metzger
Department of Nursing, Bloomsburg University, USA
Article Information
Received date: Sep 29, 2017
Accepted date: Nov 01, 2017
Published date: Nov 06, 2017
Corresponding author
Lori M Metzger, Assistant Professor,
Department of Nursing, Bloomsburg
University, USA, Tel: 570-389-5121;
Email: [email protected]
Distributed under Creative Commons
CC-BY 4.0
Keywords Aging; Chronic disease; Heart

failure; Home health; Patient satisfaction;
Recidivism; Telehealth
Abbreviations ANCOVA: Analysis of
Covariance; HCSSI - R: Home Care
Client Satisfaction Survey; TELE:
Telehealth; UHH: Usual Home Health;
U.S: United States of America
Article DOI 10.36876/smggr.1009
Abstract
Study Background: The telehealth in home health care study
aimed to determine patients’ satisfaction
with or without the use of telehealth technology in home health
care. As the population continues to age and
manage chronic disease, the use of tools such as telehealth
assists the home health or visiting nurse to provide
the best care and education to patients. Understanding patients’
perceptions regarding telehealth technologies
in home care allows the practitioner to further understand one’s
health belief and facilitate cues to changes in
health behaviors toward management of chronic disease. The
results of this study provide strength for the use of
telehealth in home care and potentially contribute to the demand
for reimbursement of telehealth.
Methods: Patient satisfaction was examined in older adult
patients with heart failure in home health
care. Eighty-six participants ranging in ages 59-99 with a mean
age of 80.7 (sd = 8.9), voluntarily completed a
questionnaire (HCSSI-R) of fifteen items. A comparison was
made between and telehealth home health services
and usual home health care.

To answer the research question regarding the difference in
patient satisfaction for patients using either
telehealth vs. usual home health services in patients diagnosed
with heart failure; an analysis of covariance,
frequency distributions and descriptive statistics were
completed to answer the research question.
Results: The dependent variable, total patient satisfaction score,
was determined for the UHH group (n =
53), as 54.96 (sd = 5.2) and the TELE group (n = 33), as 56. 94
(sd = 3.8). Furthermore, an independent t-test
comparing the mean patient satisfaction scores of the UHH and
TELE groups found a statistically significant
difference between the two groups (t (81.469) = -1.991, p<0.05)
indicating that the telehealth home health group
was more satisfied. When controlling for the demographic
information of age, gender, prior home health services
and living alone status, there was no significant impact on the
patient satisfaction score.
Conclusion: It has been proven that telehealth in home care is
cost-effective and produces favorable
clinical outcomes in the management of chronic disease [1-3].
This study concludes that telehealth in home
health care provides for a highly satisfied home health client
managing chronic disease thereby contributing to
the call for use and reimbursement of telehealth in home health
care.
Introduction
In an increasingly aging population, the growing prevalence of
chronic disease is a consistent
concern in the healthcare industry [4,5]. As healthcare resources
are strained to encompass the
management of chronic care, the demand for greater efficiencies

also grows. As earlier hospital
discharges are prompted, home health care is quietly bearing the
burden of chronic disease and
the elderly in the health care system. For the purposes of this
study telehealth is defined as using an
interactive device to transmit patient information such as blood
pressure, pulse oximetry, heart rate
and weight. Telehealth provides an efficient means for the home
health agency to manage patient
care in the presence of chronic disease. Empirical data for
telehealth and the effect of chronic disease
management relative to healthcare cost effectiveness
demonstrates the promise of a positive impact
[1,6].
It is estimated that by 2030, people over the age of 65 will
comprise over 20% of the total United
States (U.S.) population. The growth of this population affects
all aspects of our society, and this
issue of global aging significantly challenges policy makers and
health care providers. Since more
than 70% of these persons continue to live in the community,
the provision of health care can
be effectively accomplished through home health care [4,7].
Additionally, chronic conditions are
considered the leading causes of illness, disability and death,
accounting for much of the healthcare
resources used today [4,7-9]. In the U.S. over 75% of persons
over the age of 65 have at least one
chronic condition [4,7]. Additionally, over 12,000 home health
agencies are caring for more than
5 million patients in the U. S., contributing to the demand for
efficient and effective home health
care [4,7,10]. In managing chronic conditions, the delivery of
care in home health recognizes that
congestive heart failure is the leading cause of recidivism. The

cost of re-hospitalization for geriatric
https://creativecommons.org/licenses/by/4.0/
https://creativecommons.org/licenses/by/4.0/
https://dx.doi.org/10.36876/smggr.1009
Citation: Metzger LM. Are Patients Satisfied with Telehealth in
Home Health Care? A Quantitative Research Study in
Congestive Heart Failure Patients. SM
Gerontol Geriatr Res. 2017; 1(2): 1009.
Page 2/6
patients continues to burden the health care system and
contribute
to unfavorable health outcomes for patients. This begs the
question,
how do medical and nursing professional’s best care for patients
with
co-morbidities in the community setting?
Research relevant specific to heart failure and telehealth found
that cost-effectiveness can be achieved in heart failure patients
with
the use of telehealth when compared to usual home health visits.
[1]. DelliFraine and Dansky further completed a meta-analysis
to
determine that twenty-nine studies over the course of six years
(2001-
2007) demonstrated that telehealth positively affected the
clinical
outcome(s) of clients across different a variety of patient

populations
[11]. Additionally, systematic reviews specific to patients with
heart
failure to determine that telemonitoring is a promising strategy
to
provide improved clinical outcomes and cost reduction. [12,13].
Historically health care is a late adopter of information
technology.
Overcoming resistance to combine health information
technology
with medical care has been a challenge in the healthcare
industry
as the literature consistently demonstrates. [5,11,14-16].
Although,
not currently reimbursed to home health agencies, telehealth
care in
home health is rewarded through improved clinical outcomes
such
as reduced hospitalizations and improved functional status of
the
patient. In the use of telehealth, the nurse is able to remotely
assess
critical information to monitor patients and their chronic
conditions
through an interactive device, thus allowing the nurse to care
for
more patients in the same amount of time [14].
Through the concepts of telehealth, the nurse is able to increase
the number of contacts made with a single patient and increase
the
number of patients per day having contact with a professional
nurse
[2,3,17]. This is especially true of patients living in rural or
remote

areas, thereby improving overall home health care access. The
value
added service of telehealth continues to be examined in the
literature,
although patient satisfaction has had little attention.
The literature supports the notion that home telehealth when
used as a part of coordinated, comprehensive care has
demonstrated
quality improvement in care, provision of care that is equal or
superior to traditional home health care [1,3]. Traditionally,
home
health services have consisted only of part-time, intermittent
home
health visits to the home by a registered or licensed practical
nurse.
These visits consist of skilled nursing observation, assessment,
implementation and evaluation of the patient’s response to a
medical
or surgical illness or injury and this is known as Usual Home
Health
Care (UHH). The application of Telehealth (TELE) in home
health
care is considered to be a newer component of home health
technology,
allowing healthcare providers in a central office to monitor a
patient’s
vital signs, medication administration and pulse oximetry
[14,16].
Thus, telehealth has begun to address the issue of promoting
self-care
and efficiently managing life-threatening, chronic illnesses.
Use of telehealth in the home care setting is proving to be an
effective method in managing resources in an aging population
with a shortage of health care workers. By the nature of the

service
provided, home health care is consistently more cost-effective
when compared to hospital care, making it a viable and efficient
option. These beginning steps provide the industry of home
health
care the opportunity to be an active voice in the restructuring of
a
struggling healthcare system. As newer technologies emerge, it
is the
responsibility of the health care industry to ensure these
applications
are not ignored for the maximum benefit of the patient and the
health
care provider. As home health care continues to provide care for
a
greater percentage of the population than in decades past, this
unique
and valued health care delivery system of telehealth care will
need to
lead the way instead of inheriting a “trickle-down” effect of a
broken
system.
Theoretical and Conceptual Framework
Originally introduced by the discipline of psychology in the
1950’s, the Health Belief Model was adapted from the
behavioral
science theories to assist in the examination of health problems
and
related behaviors [18,19]. The Health Belief Model, is described
by the
explanation and prediction of a patient’s health-related behavior
is
guided by five conditions: (1) perceived vulnerability or

susceptibility
to the health problem, (2) perceived seriousness of the health
condition, (3) perceived barriers to the health behavior, (4) cost
and
benefits related to the health issue and (5) cues to action
relative to
behavior change [19]. This model truly frames the concept of
home
health care. Here, in the patient’s own familiar setting, the
nurse is able
to observe the patient’s vulnerability, perceived severity and
barriers
of his or her condition. As home health care continues over
days,
weeks or months, the benefits and costs are continually
addressed as
the patient works toward his or her optimal level of wellness.
When
the point of discharge or independent self-care arrives, cues to
action
are set in place to assist the patient and caregiver(s) to be self-
reliant
in health care needs related to chronic disease management [2].
In addition to the health belief model, the sociological
perspective
of symbolic interactionism completes the world view of this
impact
of telehealth on chronic disease management. The nature of
symbolic
interactionism is based on three premises: (1) human beings act
toward objects based on the meanings that the objects have for
them
(2) the meaning of these objects arises from social interaction
and (3)
these meanings are interpreted through a process used by the

person
when dealing with the object he or she encounters [20]. The
symbol
of the interactive telehealth device is individualized by the
meaning
that each home health patient attaches to this tangible object.
For this
study the agencies used three different brands a telehealth
monitoring
device all providing the same patient information for those in
the
telehealth group. Vital information of the patients’ health status
such as blood pressure, heart rate, weight and pulse oximetry
were
transmitted to the home health agency through a land-line phone
line
on a daily basis. By using the a telehealth monitoring device to
assist
in self-care, a positive connotation toward the device may
enhance
cues to action toward managing chronic disease such as heart
failure.
Purpose of the Study
The specific purpose of this research is to examine the use of
telehealth in home health care as it relates to patient satisfaction
of
home health care for participants with heart failure. The
independent
variable of telehealth home health services (TELE) was
compared to
the control of Usual Home Health Service (UHH). The
dependent
variable was defined as patient satisfaction and covariates that
were

controlled for included: age, gender, prior home health services
and
living alone status.
The research question that was examined: What is the difference
in patient satisfaction for patients using either telehealth vs.
usual
home health services in patients diagnosed with heart failure
after
Page 3/6
removing the effect of age, gender, prior home health services
and
living alone status? It is further postulated by the researcher
that
patients with TELE services are as satisfied or more satisfied
with care
when compared to patients receiving UHH.
Methods
In this descriptive, quasi-experimental research design, the
population was patients with heart failure receiving home health
care. The sample was taken from patients of independent home
health

agencies in rural, northeastern central Pennsylvania. Subjects
were
included in the study if they met the following inclusion
criteria:
1. Adult client aged 18 or older with a confirmed diagnosis of
(congestive) heart failure as the primary, secondary or tertiary
diagnosis receiving home health care by a Medicare-certified
home health agency.
2. Home environment supportive of telehealth equipment, that
being electricity and operating telephone land line.
3. Cognitive ability of patient and/or primary caregiver to use
telehealth equipment in the home determined by comprehensive
registered nursing assessment on admission to home health
services.
4. Patients were included regardless of the type or category of
pay
source for the said home health care services.
Participants were entered in to the study when they were
discharged from home health services. The researcher made
available
to the agency, a supply of mailings for both the Usual Home
Health
Group (UHH) and the telehealth home health group (TELE),
labeled
accordingly on the outside and inside return envelopes as UHH
for usual home health and TELE for telehealth home health
care.
Participants were identified by the agency and were entered into
the
study only once. Therefore, the sample consisted of
unduplicated

patients. The data collection time frame was a total of four
months
when the targeted number for each group was achieved.
Institutional
Review Board approval was granted by all participating
agencies.
A participant gave consent to participate in the study by
receiving
a letter to participants. The definition of UHH was the provision
of traditional part-time, intermittent, skilled nursing care in the
residential setting measured by home health visits made by a
licensed
practical or registered nurse by a participating home health
agency.
Subsequently the definition of TELE was the use of a daily,
interactive
device for managing vital signs, weight, pulse oximetry,
pacemakers
and other signs and symptoms of chronic disease to enhance
patient
self-care management in addition to occasional home health
visits
by a licensed practical or registered nurse. The patient
information
gathered through the device was transmitted back to the agency
where it was assessed by a registered nurse. Telehealth care was
then
measured by care provided by a participating home health
agency as
defined specifically by the agency within the parameters of the
global
definition of telehealth [1,21]. If the participant had
experienced both
types of care during the home health admission, the participant
was

included in the group for which he or she received the majority
of the
care as determined by the home health agency.
A questionnaire was used to determine the difference in patient
satisfaction scores between patients using usual home health
care or
telehealth home health care. There were two questionnaire
instruments
for this study including the first instrument of four self-report,
demographic questions of: age, gender, prior home health
services
and living alone. As these were just four demographic
questions, there
was no established psychometrics for these questions. The
second
instrument consisted of the questionnaire known and
documented
as the Home Care Client Satisfaction Survey (HCSSI-R)
developed
specifically for home health care [22]. This tool is a
measurement
of client satisfaction with home health services through a five
point
Likert scale for questions 1-12. The answers include the
following
choices: Very satisfied, satisfied, uncertain, dissatisfied and
very
dissatisfied [22-24]. Questions 13-15 are answered on a scale of
1-10
reflecting the patient’s perception of being very satisfied (1) or
very
dissatisfied (10). For the purposes of this research, only the
first 12
questions were used with permission by the author of the

instrument.
Reliability and validity has been shown for this tool as a
reliability of
0.59 and a validity of 0.37 [24]. Although, the validity of the
HCSSI-R
is not strongly represented, it is the only tool that has been used
and/or tested specifically in the home health discipline.
Therefore,
additional content validity was established through a review of
the
instrument by two professional home health care consultants.
By
using the two tools as described above, patient satisfaction with
home health services and demographics were collected.
Analysis was
completed using the computer analysis data program of SPSS
19.0.
At the time of the patient’s discharge from home health
services,
the agency addressed the envelopes and completed the mailing
of the letter to the participants and questionnaire to the
potential
participant. This was completed within one week from the time
of
discharge. A follow-up phone call was completed by the agency
to the
potential participant within to the patient 7-10 days after
discharge as
a reminder to complete the survey. When the researcher
received the
questionnaires, they were labeled on the return envelope as
UHH for
usual home health and TELE for telehealth home health and
sorted
accordingly for data entry and analysis, thus questionnaire were

anonymous to the researcher.
Results
Results were examined using the Analysis of Covariance
(ANCOVA). Further analysis of frequencies and description was
used to analyze the demographic data.
A total of 176 surveys were sent and a total of 86 returned for
a total response rate of 48.8% as shown in table one. Within the
Usual Home Health (UHH) group there were 110 surveys sent
and
53 returned for a response rate of 48.2% and the Telehealth
(TELE)
group demonstrated a response rate of 50% with 66 surveys
being
sent and 33 surveys returned. Overall, the response rate was
favorable
and consistent in both groups and overall total response as
shown
in table 1. The total response rate per agency ranged from
41.6% to
57.5%.
All research participants were recently discharged home health
clients that had received home health care either by UHH or
TELE
care. All participants were identified to have heart failure as a
primary,
secondary or tertiary diagnosis for home health care. The total
mean
age was 80.7 (sd = 8.9), while the median was 82 with an age
range of
59-99 years. For the respective groups of UHH (n = 53) and
TELE (n
= 33), the mean age was 80 (sd = 5.3), while the median was 82

with
an age range of 61-99 in the UHH group. In the TELE group,
the
mean age was 79.3 (sd = 4.2) with a median of 81 and an age
range of
Page 4/6
59-94. The majority of all participants were female 59.3% (n=
51) and
males represented 37.2% (n = 32). The majority of total
participants
had received prior home health services (68.6%, n = 59) but did
not
live alone (52.3%, n = 45) as demonstrated in table 2.
In the UHH and TELE groups, the percentage of respondents
were
consistent, having more female respondents than male
respondents.
Additionally, for those having prior home health experience the
response was yes for both the UHH and TELE groups making
this
consistent with the overall responses. Living alone status was
more
equally balanced throughout the UHH and TELE groups.

Therefore,
the overall profile of the majority of respondents was a female
who
had had a prior home health experience who may or may not
have
lived alone. This profile was represented equally for the UHH
and
TELE groups.
In order to determine statistical significance among the
demographic variables, a total of three chi-square tests were
conducted to examine the gender, prior home health experience
and
living alone status. No significant relationship was found for
gender
(x2(22) = 0.759, p>0.05); prior home health (x2(27) = 0.653, p>
0.05);
or living alone status (x2(21) = 0.949, p>0.05).
To answer the research question frequency distributions
were initially performed to clearly describe the data specific to
the
HCCSI questionnaire. The Analysis of Covariance (ANCOVA)
then examined the question of patient satisfaction. The
significance
level established to be p < (or equal to) 0.05. Participants were
overwhelmingly satisfied with services.
For all participants, the questions demonstrating the most
satisfaction were in the specific areas of: question four, respect
shown
by staff (q 4); question ten, staff’s response to concerns (q 10)
and
question twelve, having the same staff consistently (q 12). This
demonstrated a frequency of 78% (n = 67) respondents

answering very
satisfied or satisfied for total participants. In the area of
dissatisfied or
very dissatisfied, there were only two responses (n = 2)
representing
2% of the participants. The areas were: question 11, scheduling
care
at times you wanted (q 11) and question 12, having the same
people
consistently (q 12). This is shown in Appendix A.
The most satisfied responses for the UHH group were in the
areas
of: question four, respect shown by staff (q 4); question five,
staff’s
knowledge of the patient’s health problems (q 5) and question
ten,
staff’s response to patients’ concerns (q 10). There was a
consistent
number of participants in the UHH group that answered very
satisfied or satisfied to all questions representing 80% (n = 69)
of the
respondents. In the area of dissatisfied or very dissatisfied,
there were
only two responses (n = 2) as indicated above in the total
responses.
It is noted that both of the above responses for dissatisfaction
came
from the UHH group. However, it is also noted that in the
category
of uncertainty for the UHH group, 15 of the total 17 responses
came
from the UHH participants, making the UHH group the least
satisfied
overall as shown in Appendix B.

In the TELE group, the most satisfied responses were in the
areas of: question 4, respect shown by staff (q 4); question
three,
dependability of staff (q 3) and question 12, having the same
people consistently (q 12). There were 94% (n = 31) of
participants
in the TELE that indicated being very satisfied or sati sfied in
these
respective areas. In the areas of uncertainty, the TELE group
had only
2 responses for a total of 6% (n = 2) in this category. There
were no
responses in the areas of dissatisfied or very dissatisfied for the
TELE
group. Overall, it is clear to see as shown in Appendix C, the
areas
of importance for patients in home health care as respect shown
my
staff and staff’s response to concerns especially in the UHH
group.
There were no responses in the category of very dissatisfied
among
the participants.
The dependent variable, total patient satisfaction score, was
calculated using reverse scoring for all satisfaction questions,
such
that the higher the number, the greater the satisfaction and a
lower
number indicated dissatisfaction. The mean, total patient
satisfaction
score (n = 86) on the HCCSI –R questionnaire was 55.72 (sd =
4.8),
with a median of 58 and a range of 40-60. For each of the two
groups,
UHH and TELE, the patient satisfaction score was determined

also.
For the UHH group (n = 53), the mean satisfaction score was
54.96
(sd = 5.2) and the median was 57 with a range of 40-60. For the
TELE
group (n = 33), the mean satisfaction score was 56. 94 (sd =
3.8), with
a median of 58 and a range of 47-60. The Z scores for total
patient
satisfaction demonstrated that all scores were within three
standard
deviations for the UHH
(-2.83/+.95) and TELE (-2.55/+.78) groups respectively, giving
further support to the normality of the dependent variable,
patient
satisfaction.
The main effect of patient satisfaction was significant (F (1.69)
= 4.257, p < 0.05), with TELE having a significantly higher
patient
satisfaction score. Co-variates, age (F (1.69) = .372, p > 0.05),
gender
(F (1.69) = 3.578, p > 0.05), prior home health experience (F
(1.69)
= 1.195, p > 0.05) and living alone status (F (1.69) = 2.526, p >
0.05),
were not significant related to patient satisfaction. The effect
size was
0.058 indicating a moderate effect size.
Table 1: Response Rate of All Questionnaires.
Usual Home Health (UHH)
Telehealth

(TELE)
Total
Surveys Sent 110 66 176
Surveys Returned 53 33 86
Response Rate 48.2% 50% 48.8%
Table 2: Demographic Information of Respondents.
UHH TELE Total
n (%) n (%) n (%)
Gender
Male 19 -37.30% 13 -40.60% 32 -38.50%
Female 32 -62.70% 19 -59.40% 51 -61.50%
Total 51 32 83 -100%
Prior Home Health
Experience
Yes 37 -75.50% 22 -71% 59 -73.80%
No 12 -24.50% 9 -29% 21 -26.20%
Total 49 31 80 -100%
Living Alone Status
Yes 24 -46.10% 15 -46.80% 39 -46.40%
No 28 -53.80% 17 -53.10% 45 -53.60%

Total 52 32 84 -100%
Page 5/6
Since the analysis of covariance produced non-significant
results relative to the covariates, an independent samples t-test
was
completed to examine patient satisfaction based on the groups
(UHH
and TELE). An independent t-test comparing the mean patient
satisfaction scores of the UHH and TELE groups found a
significant
difference between the two groups (t (81.469) = -1.991, p <
0.05). The
mean of the UHH group was significantly lower (m = 54.96, sd
= 5.2)
than the mean of the TELE group (m = 56.94, sd = 3.8).
Reliability was
conducted for the HCSSI using Chronbach’s alpha
demonstrating the
reliability coefficient as 0.94.
Supplemental analysis was conducted on gender relative to
the dependent variable, patient satisfaction. It was noted that
the

significance level for this covariate was 0.57, the closest of all
covariates
to a significant level. A t-test showed that by Levene’s test for
equality,
that equal variances could be assumed and the significance was
0.131,
demonstrating that gender (n = 51) with a mean satisfaction
score of
56.31 (sd = 4.48) was not significant in relation to patient
satisfaction.
Since three different agencies were utilized in the study and
contributed to the participants or sample, a chi-square test of
independence was used to examine a possible relationship of
three
agencies to the groups (UHH and TELE). A significant
interaction
was found (x2(2) = 0.000, p < 0.05) in that Agency 2 had a
higher
percentage of satisfied participants in the TELE group compared
to
the other two agencies (Agency 1 and 3). Upon further analysis,
using
the results of the ANCOVA, no co-variate was statistically
significant
as was expected, due to no significance found in the chi-square
test of
independence results reported in the demographic section.
However,
the results of the above chi-square test of independence related
to the
relationship of agencies to the groups (UHH and TELE)
prompted a
last ANCOVA with the groups of UHH and TELE as a fixed
factor
utilizing the agency as a co-variate and the total satisfaction

score as
the dependent variable. This revealed that the main effect for
agency
was not significant (F (1.83) = 0.536).
Study limitations that were identified in this research were the
descriptive, quasi-experimental design with convenience
sampling
inhibiting the ability to generalize the findings to a larger
population.
This design did not support a cause and effect relationshi p for
the
findings.
Conclusion
As one of the largest generations, the baby boom generation,
entered the Medicare eligible age group in 2011. These persons
with
chronic disease will consume more and more of the total health
care
dollars spent in the United States [5,9,15]. In addition to taxing
the
health care system, there is shortage of nurses in supply to meet
this
demand. Implementation of telehealth devices is not reimbursed
and
therefore the cost of using this technology for the benefit of
patient
care must be absorbed solely by the agency [21]. The benefit of
telehealth is practically recognized by agencies and
administrators
of home health care but the value must be proven to health
insurers
in order to use this technology to its greatest benefit in
managing

chronic disease for an aging population.
The specific diagnosis of heart failure was chosen for this study
due to the high rate of re-hospitalization and thus the high cost
of
care associated to this disease. It has been well documented that
the
high prevalence rate of heart failure combined with high cost
care
and poor self- management create a challenging issue especially
in
persons living in the community [1,17,25]. By applying
evidence-
based knowledge to home health care delivery, the use of
telehealth
in home care demonstrates the patient’s comfort level with
using an
electronic device when the nurse cannot be there.
In the examination of patient satisfaction, one is able to gain
insight toward patients’ perception of a telemonitoring device to
symbolic interactionism and theorize that telehealth care is not
a
barrier to a patient’s comfort level with home care services.
This goes
beyond the traditional methodology of basic patient education
and
uses the object of telemonitoring as an external influence to
promote
positive health behaviors toward the management of heart
failure.
Within the philosophy of working smarter and not harder or
doing
more with less, this appears to be a valuable pursuit.

Although patient satisfaction is a common variable in health
care,
it has not been researched in relation to comparing these two
types
of health care delivery in the area of home health. The
comparison
of cost-effectiveness and clinical outcomes has been minimally
researched by comparing usual home health and telehealth care,
but
patient satisfaction has not been included as a variable.
Therefore, this
study aimed to explore patient satisfaction in this unique
population.
It was hypothesized that patients receiving telehealth care
would be
as satisfied or more satisfied with their home health care.
Although
the sample was small, there was a statistically significant
difference in
patient satisfaction when comparing telehealth to usual home
health
care supporting the hypothesis.
This research focused on a basic premise of a unique
application of
technology to an age-old practice of the visiting nurse. The
finding of
a significant difference in patient satisfaction in telehealth
compared
to usual home health care is another important piece of the
puzzle in
caring for individuals with chronic disease. In an aging
population
and a broken health care system, the practical cost of investing
in newer technologies in relation to the benefit of the efficiency
of

using a telehealth system appears an obvious solution. By
allowing
a home health nurse to effectively manage potentially more
patients
with improved patient satisfaction the home health industry
moves
forward in the battle of doing more with less. This investigation
of
patient satisfaction reinforces the importance of taking action in
the
home health industry to use telehealth as a reimbursable service
and
case management tool.
Acknowledgement
The researcher wishes to thank the home health agencies who
participated in this study. There was no grant funding for this
research.
References
1. Dansky KH, Vasey J, Bowles K. Impact of telehealth on
clinical outcomes in
patients with heart failure. Clin Nurs Res. 2008; 17: 182-199.
2. Hoban M, Fedor M, Reeder S, Chernick M. The effect of
telemonitoring at
home on quality of life and self-care behaviors of patients with
heart failure.
Home Healthcare Nurse. 2013; 31: 368-377.
3. Radhakrishnan K, Bowles K, Hanlon A, Topaz M, Chittams J.
A retrospective
study on patient characteristics and telehealth alerts indicative
of key medical

events for heart failure patients at a home health agency.
Telemed J E
Health. 2013; 19: 664-670.
4. Centers for Disease Control. Census and Statistics. 2014.
https://www.ncbi.nlm.nih.gov/pubmed/18617707
https://www.cdc.gov/datastatistics/index.html
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5. Meyer M, Kobb R, Ryan P. Virtually healthy: Chronic
disease management in
the home. Dis Manag. 2002; 5: 87-93.
6. Shea S, Weinstock RS, Teresi JA, Palmas W, Starren J,
Cimino JJ, et al. A
randomized trial comparing telemedicine case management with
usual care

in older, ethnically diverse, medically underserved patients with
diabetes
mellitus. J Am Med Inform Assoc. 2006; 13: 40-51.
7. Centers for Disease Control. The state of aging and health in
America. 2013.
8. Institute of Medicine (US) Committee on the Future Health
Care Workforce
for Older Americans. Retooling for an Aging America: Building
the Health
Care Workforce.
9. Meyer M, Ryan R, Kobb R, Roswell RH. Using home
telehealth to manage
chronic disease. Federal Practitioner. 2003; 20: 24-41.
10. Centers for Medicare and Medicaid Services. Home Health
Care
Expenditures. 2014.
11. DelliFraine J, Dansky KH. Home-based telehealth: A review
and meta-
analysis. J Telemed Telecare. 2008; 14: 62-66.
12. Clarke M, Shah A, Sharma U. Systematic review of studies
on telemonitoring
of patients with congestive heart failure: A meta-analysis. J
Telemed
Telecare. 2011; 17: 7-14.
13. Dang S, Dimmick S, Kelkar G. Evaluating the evidence base
for the use of
home telehealth remote monitoring in elderly with heart failure.
Telemed J E
Health. 2009; 15: 783-796.

14. Chen H, Kalish M, Pagan J. Telehealth and hospitalizations
for medicare
home healthcare patients. Am J Manag Care. 2011; 17: 224-230.
15. Ofman JJ, Badamgarav E, Henning JM, Knight K, Gano AD
Jr, Levan RK,
et.al. Does disease management improve clinical and economic
outcomes
in patients with chronic diseases? A systematic review. Am J
Med. 2004;
117: 182-192.
16. Whitten P, Love B. Patient and provider satisfaction with
the use of
telemedicine: Overview and rationale for cautious enthusiasm. J
Postgrad
Med. 2005; 19: 294-300.
17. Quinn C. Low-technology heart failure care in home health.
Home Healthc
Nurse. 2006; 24: 533-540.
18. Campbell C. Health education behavior models and theories.
A review of
literature part1 Health Curriculum Research. Retrieved April.
2001; 14: 2012.
19. Rosenstock IM. Historical origins of the health belief
model. Health Educ
Monogr. 1974; 2: 328-335.
20. Blumer H. Symbolic Interactionism: Perspective and
Method. Berkeley:
University of California Press. 1969.

21. Dombi WA. Avalere health study conclusively proves home
care is cost
effective, saves billions for Medicare yearly, and effectively
limits re-
hospitalization. Caring. 2009; 28: 22-23.
22. Reeder PJ, Chen Sp. A client satisfaction survey in home
health care. J Nurs
Qual Assur. 1990; 5: 16-24.
23. Laferriere R. Client satisfaction with home health care
nursing. J Community
Health Nurs. 1993; 10: 67-76
24. Westra BL, Cullen L, Brody D, Jump P, Geanon L, Milad E.
Development of
the home care client satisfaction instrument. Public Health
Nurs. 1995; 12:
393-399.
25. Ross JS, Chen J, Lin Z, Bueno H, Curtis JP, Keenan PS, et
al. Recent
National trends in readmission rates after heart failure
hospitalization. Circ
Heart Fail. 2010; 3: 97-103.
http://online.liebertpub.com/doi/abs/10.1089/109350702320229
186
http://online.liebertpub.com/doi/abs/10.1089/109350702320229
186
https://www.cdc.gov/aging/pdf/state-aging-health-in-america-
2013.pdf

http://journals.sagepub.com/doi/abs/10.1177/1090198174002004
03
http://journals.sagepub.com/doi/abs/10.1177/1090198174002004
03
https://books.google.co.in/books?id=HVuognZFofoC&printsec=
frontcover&dq=Symbolic+Interactionism:+Perspective+and+Me
thod+1969&hl=en&sa=X&ved=0ahUKEwi07Kj67ZzXAhXELo8
KHbnHBVoQ6AEIJTAA#v=onepage&q=Symbolic
Interactionism%3A Perspective and Method 19
https://books.google.co.in/books?id=HVuognZFofoC&printsec=
frontcover&dq=Symbolic+Interactionism:+Perspective+and+Me
thod+1969&hl=en&sa=X&ved=0ahUKEwi07Kj67ZzXAhXELo8
KHbnHBVoQ6AEIJTAA#v=onepage&q=Symbolic
Interactionism%3A Perspective and Method 19

http://journals.lww.com/jncqjournal/citation/1990/11000/a_clien
t_satisfaction_survey_in_home_health_care.4.aspx
http://journals.lww.com/jncqjournal/citation/1990/11000/a_clien
t_satisfaction_survey_in_home_health_care.4.aspx
https://www.ncbi.nlm.nih.gov/pubmed/19903931TitleIntroducti
onTheoretical and Conceptual FrameworkPurpose of the
StudyMethodsResultsConclusionAcknowledgementReferencesT
able 1Table 2
Page 1 of 7
Submit by the due date and time listed in your syllabus.
Overview
This assignment will allow you to create an evidence-based
practice project that includes the
development of a PICO question and follows the initial steps of
the Iowa Model. You will share
your findings using an APA formatted paper.
Submitting your assignment
• Save this document to your desktop as a Word document.

Grading Rubric
Use this rubric to guide your work the assignment. Points are
awarded for each section based
on content and clarity of expression.
Paragraph
Accomplished
(Maximum points
awarded)
Proficient
(Points awarded based on
content)
Needs Improvement
(Minimum points
awarded)
Initial PICO
question
completed /
nursing research
article selected.
Research article is a
quantitative article, nursing

focused, and is 5 years or
less from current
publication date.
Article must be uploaded
in pdf format
Please note: if you forget
to upload your nursing
quantitative research
article, a 5 point penalty
will be applied to your
paper
5 to > 3 points
Research article is a quanti-
tative article that is nursing
focused but is greater than
5 years old.
3 - >2 points
Research article is not
nursing focused or is a
qualitative article, sys-
tematic review, meta-
synthesis, meta-analysis,
meta-summary, integra-
tive review, clinical infor-
mation article or “how-to”
article.

No article uploaded.
2 to >0 points
Opening
Paragraph
(Paragraph #1)
Introduction statement(s)
present.
PICO question with all el-
ements present.
Statement of importance
with two facts such as
costs, morbidity, mortality,
safety. Include related
statistics with citation and
is 5 years or less from
current publication date.
Facts must be from a
source besides the primary
No introduction
statement(s).
PICO statement is
incomplete.

incomplete or missing.
Citation is incomplete or
missing.
Facts are from the primary
article, the guideline, or the
fourth resource.
No introduction
statement(s).
PICO statement grossly
incomplete or missing.
missing.
No citation
Page 2 of 7
Paragraph
Accomplished

(Maximum points
awarded)
Proficient
content)
Needs Improvement
(Minimum points
awarded)
research article, the
guideline, or the fourth
resource
10 – >8 points
9 – >3 points
3 - >0 points
General format.
Paper is five to seven
double spaced pages (not
including cover page or
references). Paper
includes the following
headings: Summary of
Research Article, Major

Variables, Strengths and
Weaknesses, Practice
Guideline, Fourth
Resource, Conclusion
5 points
Paper more than six pages,
headings missing, or incor-
rect headings.
4 – 1 points
Paper greater than six
pages and headings miss-
ing or incorrect.
0 points
Summary
paragraph for
your nursing
quantitative

research article.
(Paragraph #2)
Correctly identified design,
sampling method, and
setting of study.
Identified major findings of
study.
Major findings include
information from the
Results and / or
Discussion sections.
Major findings clearly tied
to PICO question.
Facts connected to your
nursing practice.
15 points
Design, sampling method,
or setting incorrect.
Identified findings are not
the most important findings.

Only one finding includes
results or discussion sec-
tions.
Major findings not clearly
tied to PICO question.
Facts not clearly connected
to your nursing practice.
14 - >3 points
Design, sampling method,
and setting not identified.
No major findings clearly
identified from the article.
No findings from the
results or discussion
sections
No attempt to connect the
major findings from the
article back to the PICO
question.

No attempt to connect the
major findings from the
article back to your
nursing practice.
3 - >0 points
Major research
variables.
(Paragraph #3)
All major research
variables included.
Conceptual definition for
each variable mentioned
or its absence noted.
Operational definition for
each variable mentioned.
Correct level of
measurement given for
Some major variables
missing or variables
included that are not
actually major research
variables.

Incorrect or missing
conceptual or operational
definitions.
Incorrect or missing levels
of measurement.
Paragraph missing.
Page 3 of 7
Paragraph
Accomplished
(Maximum points
awarded)
Proficient
content)

Needs Improvement
(Minimum points
awarded)
each variable.
10 points
9 - >1 points
0 points
Two additional
strengths or
weaknesses from
your nursing
quantitative
research article.
(Paragraph #4)
Two strengths or two
weaknesses or one
strength and one
weakness are specifically
identified from your
nursing quantitative
research article.

The student choices for
strengths / weaknesses
must focus on the methods
used by the authors for
sampling, measurement
methods used (ex. a
questionnaire), or how the
data was collected (data
collection) with examples
from the student’s
research article.
10 - >8 points
Only one strength / or
weakness explained well
with second strength /
weakness only identified.
Strengths / weaknesses not
based on sample,
measurement methods, or
data collection.

8 - >3 points
Strength / weaknesses
identified are not based
on these three critique
skills.
No strengths /
weaknesses identified.
3 - >0 points
Clinical practice
guideline
summary.
(Paragraph #5)
Name of the clinical prac-
tice guideline and specific
website identified.

Guideline is the most re-
cent version or published
within the past five years.
Three facts clearly identi-
fied that were found within
the guideline and relate to
the practice of a BSN.
Facts clearly tied to PICO
question.
nursing practice.
10 - >8 points
Name of the clinical
practice guideline or
website not clearly
identified.
Fewer than three facts
clearly identified that were
found within the guideline or
facts not specifically related
to the practice of the nurse.
Facts vaguely tied to PICO
question. Facts vaguely
connected to your nursing
practice.

8 - >3 points
Name of the clinical
practice guideline and
website not stated.
What is given is not a
clinical practice guideline.
No clearly identified facts
from the guideline.
Facts not tied to PICO
question or nursing
practice.
3 - >0 points
“Fourth
resource”
summary.
(Paragraph #6)
Three facts clearly
identified from the fourth
resource which is 5 years
or less from current
publication date.

Facts clearly tied to PICO
Less than three facts clearly
identified from the fourth
resource.
Facts not clearly tied to PI-
No facts clearly identified
from the fourth resource.
Fourth resource is not an
academic source.
No attempt to connect
facts from the fourth
Page 4 of 7
Paragraph
Accomplished
(Maximum points
awarded)
Proficient

content)
Needs Improvement
(Minimum points
awarded)
question.
nursing practice.
10 - >8 points
CO question.
Facts not clearly connected
your nursing practice.
8 - >3 points
resource back to the
PICO question.
No attempt to connect
facts from the fourth
resource back to your

nursing practice.
3 - >0 points
Closing
Paragraph(s)
(Paragraph #7
and #8, if
needed)
PICO question is restated.
A summary of what was
learned (from all sources)
is present.
Recommendations for
practice are offered.
10 - >8 points
Missing one or more of the
following elements:
PICO question.
A summary of what was
learned.
Recommendations for prac-

tice.
8 - >3 points
No PICO question.
Poor or no attempt to
summarize information
from the resources.
No / vague
recommendations for
practice are offered.
3 - >0 points
APA Style and
Formatting
APA formatting for this paper will follow the guidelines for
general formatting, in text-
citations, margins, headings (if desired) alignment and line
spacing, font type and size,
paragraph indentation, page headers, and the reference page as
explained in the 7h
edition of the APA Manual.
Helpful Hints:
• Do not use 1st person in a formal paper.
• Do not use direct quotes, instead summarize and paraphrase
what you
are reading. Direct quotes will receive multiple point

deductions. These
deductions are separate from the 15 points for APA.
• Please do not forget to use the approved CONHI cover page.
• Check your references format before submitting your paper. A
ten-point
deduction will be applied to your paper if the References page
is
omitted.
The first time an APA error is discovered, it will be pointed out
to you and a point will
be deducted from your paper. Maximum number of points
deducted for APA errors:
15 points
Excessive Direct
Quotes
Note! Five points will be deducted for each direct quote in the
paper. If
the quotes exceed 10, then fifty points will be deducted.
Page 5 of 7
Instructions for Completing Your Assignment
o Step one: Using the topic you chose, identify a nursing
clinical practice question that you would

like to explore.
o Step two: Use the PICO(T) question in the final form
approved by your instructor or coach.
o Step three: Search for a nursing quantitative research article
(or two) that relates to your PICO
question using Academic Search Complete, CINHAL, Pubmed,
Google Scholar, or any other data-
base that contains nursing research articles. Please note: you
can use the article that you sub-
mitted in Module Two to meet this requirement so long as it was
approved.
o The article you will find must meet the following mandatory
requirements:
▪ It must be based on the approved topic list unless other
arrangements were
made with your instructor or coach.
▪ It must be from a nursing research journal or have a nurse as
an author.
▪ It must be no more than 5 years old from the current
publication year.
▪ It must include implications and / or interventions that are
applicable to nursing

practice.
▪ It may not be a qualitative article, systematic review, meta-
synthesis, meta-
analysis, meta-summary, integrative review or a retrospective /
quality im-
provement study. For more information on how to recognize
these types of ar-
ticle see Grove & Gray (2019) pp. 21-23.
▪ It may not be a clinical information article or “how -to” article.
o Step Four: Collecting More Evidence (Do the research)
▪ Find a credible scholarly or government resource published
within the past 5 years that
provides you with at least two facts (ex. costs, morbidity,
mortality, safety, or other re-
lated statistics) for why your clinical problem is important
(provide statistics). (The in-
ternet is a great place to get this information…just don’t forget
to cite this information
and add it to your reference page).
▪ Find a clinical practice guideline that relates to your question.
It must have information
that relates to the role of the nurse. Guideline is the most

recent version or published
within the past five years. (It is true that guidelines are not
always updated within 5
years so you will need to discuss this.) There are several
websites listed in your textbook
that can help with searching for guidelines. The UTA library
also has resources for clini-
cal practice guidelines.
▪ Find a clinical “how-to” article, a nursing professional
practice website, a systematic lit-
erature review, a meta-analysis, or some other credible
academic resource published
within the past 5 years that relates to your practice question.
▪ Hint: Did you notice that you will be finding a total of four
different sources of infor-
mation for your PICO question? To re-cap, these four sources
are:
• Statistics you are reporting in paragraph one.
• Nursing quantitative research article for paragraphs 2, 3, and 4
• Clinical Practice Guideline (paragraph 5)
• A source of your choosing (paragraph 6)

of 7
o Step Five: Write up your findings in APA format and submit
them to assignment portal by the
due date and time listed in your syllabus. Here’s how to write
up your findings:
▪ Start with a 7th edition APA cover page. An example is
provided by the instructor.
▪ Paragraph #1: This is your opening paragraph. Start with an
introduction statement.
What is your PICO question? Describe why was it important
(share the dollars, morbidity
/ mortality, statistics, safety stats you found with citation)?
▪ Paragraph #2: What did your nursing quantitative research
article add to your
knowledge on this topic? State the design (descriptive,
correlational, predictive correla-
tional, experimental, or quasi-experimental), sampling method,
and setting of the study
(this should only take one sentence: e.g. “Smith and Johnson
conducted a predictive
correlational study using a convenience sample from a
psychiatric outpatient clinic.”).

State the major findings of the study (maximum 3 findings). The
findings you share
should come from the results or discussion settings and should
be relevant to your PICO
question and your practice as a nurse.
▪ Paragraph #3. Mention the major research variables in your
article. Do not include de-
mographic variables unless they are important to the results of
the study. For each ma-
jor variable, give a conceptual and operational definition (if the
authors did not give a
conceptual definition you can say “not given”). Give the level
of measurement for each
variable (nominal, ordinal, interval, or ratio).
▪ Paragraph #4: Using the skills you have learned in your
critique of a research article, de-
scribe two strengths or two weaknesses (or one strength and one
weakness) that you
found as you read this article. Go back to what you learned in
your article critique about
sampling methods, measurement methods (ex. questionnaires),
and data collection (how

did they collect the data to make sure you are being thorough in
your assessment. Be
specific, so that your instructor, if reading the article, can find
them too. Do not re-state
the limitations provided by the authors of your study unless
they have to do with the
study’s sampling, measurement methods, or data collection. Do
not discuss the re-
search design or the descriptive or inferential statistics used by
the authors as a strength
or weakness of the study, as this is not related to with the
study’s sampling, measure-
ment methods, or data collection.
▪ Paragraph #5: What is the name and website of the clinical
practice guideline that you
found? Share at least three facts that you found within the
guideline that is relevant to
the PICO question and your practice as a BSN nurse and cite the
guideline appropriately.
▪ Paragraph #6: Identify the fourth resource you found (clinical
“how-to” article, a nursing
professional practice website, a systematic literature review, or
a meta-analysis) that re-
lates to your practice question. Share at least three facts that

you found within this
source that is relevant to the PICO question and your practice as
a nurse, and cite ap-
propriately.
▪ Paragraph #7 (and #8 if needed): re-state your PICO question
and briefly summarize
what you have learned through your search. What would you
recommend, if anything,
as a change in practice for nurses? Why? Remember, this is
your closing paragraph(s).
▪ Note to students about writing up your findings:
Page 7 of 7
o This is a formal APA paper. Look at the Rubric for more
APA information for this pa-
per.
o Your paper must be no more than seven pages (double
spaced), not including the
cover page and references. Use the following headings for
paragraphs 2 through 7:
Summary of Research Article, Major Variables, Strengths and
Weaknesses, Practice

Guideline, Fourth Resource, Conclusion
o Turn your paper (as a word document) and article (in pdf
format) that you used for
paragraphs 2, 3, and 4 in to the assignment submission link in
Module Four at the
due date and time listed in your syllabus.
o Possible points for this assignment: 100 points

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