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'Words Up' - Supporting practitioners to embed changes in their clinical practice with Florence

posted 12 Mar 2018, 04:31 by Hollie O'Connell   [ updated 20 Mar 2018, 08:38 by Hannah Mountford ]

Sharon Smith 
Speech and Language Therapist 

13 March 2018 

I’m a Speech and Language Therapist working in the Highlands in a Universal Role in Early Stage.  This means that I have a role focussing on developing a service supporting language and communication development for all children in the early years up to Primary One stage.  My role is Highland wide, across the Highland Council area.

We know that high quality adult-child interaction supports children’s development and in the Highlands we have an initiative called 'Words Up': this is a universal approach to support the adults around the child to focus on developing high quality adult-child interaction, in order to develop the children’s language and communication skills.  'Words Up' uses key messages to support the adults to focus on and make changes to their behaviour when interacting with the children.

We provide a training session to practitioners (Early Years Practitioners, Teachers and Pupil Support Assistants) on the key messages and ask them to choose one to focus on and try to embed change in their everyday practice.  We know from experience that embedding change following training is really challenging, so we are always looking for ways to support this.  We chose Flo as a tool to support practitioners to make and importantly, sustain changes to their practice.  The interactions with Flo support the information they have been given in their training around the key messages, and practitioners are asked to rate how easy or difficult they are finding it to make the change: this helps practitioners to reflect on their learning and get support from our service when needed.

We initially found it challenging to convince practitioners to give Flo a chance, as she was new to us, and them.  Now we have received some feedback, the numbers of practitioners wanting to join in with Flo have increased and it is now easy to encourage more people, as we know that the feedback we’ve received so far has been very positive.  Practitioners reported that it has helped them to remember what they were focussing on and why they are working on a particular behaviour change.  We know from research that behavioural change can take years to embed in some settings, so using Flo as a tool to help do this is really useful for us.

Getting started with Flo

posted 28 Feb 2018, 13:33 by Hollie O'Connell   [ updated 28 Mar 2018, 02:00 ]

Raigmore Hospital 
NHS Highland Health Board 

Christine Taylor 
Clinical Nurse Specialist, Chronic Pain Service 

01 March 2018 

When I began to work with NHS Highland’s Chronic Pain Team, there was an existing Pain Management Group which ran for 6 weeks at a time for 3 hours every Wednesday.  Flo was supporting patients after they had attended the sessions to consolidate the learning and motivate them to integrate the techniques into their self-care. 

Due to the rural geography across the Highlands, part of my new role was to lead a “Distance Pain Management Plan” using a workbook alongside telephone support to try and help my patients implement some of the self-care strategies that we talk about, with the aim of patients improving their quality of living with chronic pain.

Where the idea started 
I had one patient who had been on the Distance Pain Management Plan for a year when I met him, on average this is twice as long as most patients.  The patient was very socially unsupported and became dependent on my calls, often waiting for them each month as a crutch for a chat.  This patient stood out to me as someone who would really benefit from increased support in between my monthly calls with him.  This would provide him with extra guidance and motivation to put in place some of the strategies that we discuss.  The frequent interactions with Flo around his pain management would be perfect; perhaps the patient would no longer be able to say, "I forgot to set a goal or listen to my relaxation CD" and I could really start to help him get on track with Flo’s help.  I spoke to my colleagues from the weekly groups who helped to get me started.  I was really excited at this point as I started to see how Flo could really unfold and start to fill a gap. 

One of the known challenges with the Distance Pain Management Plan is the patient taking those initial steps to improving their self-care after we first met in week one.  At this point it’s really important for patients to start taking actions, such as setting their baseline targets and incorporating key strategies into their lifestyle.  However very often when I called back one month later less than 50% of patients had actually put these plans in place, and were unfortunately experiencing the same pain level.

My aim with Flo was to really maximise the first month’s engagement with the patient and therefore keep them to the 5-6 month plan target, rather than what for many was becoming 7-8 months (or longer).  The Distance Pain Management Plan is more likely to be effective if patients put it into practice with support, so Flo seemed ideal for this.  The plan also gave me the opportunity to help more people as patients were achieving their pain goals quicker.
How did I get started?I contacted Joanna Gilliatt from our local TEC Team who was fabulous, and helped to agree the protocol most suitable for my cohort of patients.  Having never done anything like this before I was pleasantly surprised as to how easy it was.  Joanna kept me right with creating the content including how and why Flo would interact and also helped with any questions I had.  Joanna and I had 3 meetings and we were able to progress everything else via e-mail so it fitted into my part-time work and was very flexible to put together.

We found poor phone signal in some areas a little challenging along with some patients who were already on the plan being a little resistant, they could no longer say "I forgot" and had become used to my phone contact.  However with reassurance that Flo was there to support them in between they soon came on board.  New patients however were very accepting of the idea.

“My Friend” Flo
The one thing some patients comment at the start of using Flo is "will it feel cold and mechanical", but often after a month or two they feel that Flo has become a "friend" and tell me they actually look forward to her prompts.

Most importantly for me and my patients is the ease of use and the difference that Flo is making to keep patients on track.  Flo has also helped highlight which patients feel the plan is not for them earlier; when faced with Flo’s prompts they have a choice to make about taking part or not which was something that had not occurred to me.

I decided to use Flo to find out how patients felt about her; if prompts were too often, too few or just right.  So far all responses have been positive including comments of "doing things so as not to let Flo down" and "as memory and concentration poor a great help".  The Distance Pain Management Plans last for 6 months on average so I have only had feedback from 5 patients so far, but as of yet I have had no negative reviews.  My original patient who was the source of thought for starting with Flo would not take part, but I feel over the next year I will see benefits for me and my patients and hope that it becomes routine for all patients to start Flo automatically at the start of their plan.

To anyone thinking that Flo could benefit their work - try her out!  The TEC team were a fabulous help and resource. I had minimal computer experience and have never done anything like this before but got it off the ground easily.

Sustainable digital health, against the odds

posted 18 Feb 2018, 08:13 by Hollie O'Connell   [ updated 21 Feb 2018, 05:20 ]

for patients, not profit  

Phil O'Connell 
Creator of the NHS's Simple Telehealth  

20 February 2018 

We couldn't have wished for a better start to 2018.  In addition to the absolute privilege and joy of working with front-line clinicians and hearing first hand, how our work has helped to transform patients' lives, independent research projects by The Kings Fund and The Health Foundation have been published showcasing our work alongside the best of the best innovations in the NHS.  

Below I have set out a few insights into the attributes that make up Simple Telehealth and our sustainable methodology.

Unprecedented recognition

We were delighted in January to read that Simple Telehealth and Florence had received unprecedented recognition as an exemplar case study in two publications; The Kings Fund - "Adoption and spread of innovation in the NHS" and The Health Foundation - "AGAINST THE ODDS : Successfully scaling innovation in the NHS".  Using independent methodologies, both organisations researched innovations in the NHS to determine how and why some innovations had become successful, whilst others had not.   Out of the thousands of innovations in the NHS, The Kings Fund narrowed the field down to 8 and The Health Foundation narrowed their field to 10 exemplars, both of which included Simple Telehealth and Flo. This adds to the recognition received in the prior year in the Nuffield Trust publication "The digital patient: transforming primary care"? where Flo was  selected to feature in the top four! 
“Florence is a low-cost, low-risk innovation with a strong track record.”
The Kings Fund
“The benefits Florence can deliver are wide ranging”
The Health Foundation
"Flo has been formally evaluated, with positive results"
Nuffield Trust

This remarkable treble achievement is attributable to the fantastic work of members of the Simple Telehealth Community of Practice who ethically and genuinely focus on the interests of patients, which in turn ultimately benefits the whole Community. 

 Adding to the recognition, last year too saw Florence cited in NHS Scotland COPD best practice and NHS England Challenging Health Inequalities

The strangest secret

Our model is one of an enabler.  We don't "sell" solutions, rather we work with and help clinical teams to solve real world problems and share their learning freely amongst peers.  Our approach, developed with the help and patience of many enthusiastic clinicians is, like our name, "Simple".  

1)  Commissioners buy clinical services based on the assumption that an investment of A will yield outcomes of B for patient cohort of C.    2)  Commissioners accept the assumption that to achieve outcomes of B, clinicians will practice "best practice" care and patient cohort C will have a certain level of engagement and adherence, both with and to the care provided.    3)  The Simple approach, is to help patients improve their level of engagement and adherence to the best practice care already being provided.    4)  Consistent with literature, for cohort C the inevitable result of improved engagement and adherence with best clinical practice is better and faster clinical outcomes.

Attainment of better and/or faster outcomes than are achievable under normal care alone helps teams to solve real world problems, freeing up clinical time, reducing cost and reducing the risk of complications developing further down the line.  In regions where thinking goes beyond short term savings, such as Scotland, significant benefits can accrue, although some of the benefits are realised in other organisations, as the first academic study of Simple Telehealth showed;

Cottrell E, Chambers R, O’Connell P (2012) BMJ Open 2:e001391

Using simple telehealth in primary care to reduce blood pressure: a service evaluation. 

A number of GP practices undertook a service evaluation where Flo was used with hypertensive & chronic kidney disease patients to reduce poorly controlled blood pressure.   The direct results showed a faster and more significant drop in systolic blood pressure than in the controls, but for this CKD group, the literature predicted that the lowering  and better control of blood pressure would delay the need for dialysis as the disease progressed.   Given the average cost of dialysis of £30,000 per year,  a delay of just six months for only 2 out of 100 patients would save £30,000, which is significantly more than the cost of Flo.   Furthermore, for this group of patients, once the effect of Flo had been established, the clinical records showed that the limited use of Flo to augment normal care for a short period of time, had in fact had a lasting effect, way beyond the Flo intervention period.

It is the sum of the techniques and methods used to help patients to better adhere to, and engage with shared care plans and clinicians that enables such results.  The underlying technology plays it's part, but it is just one aspect in a unique combination.

Community of Practice

"Florence’s central team invest in organisations for the long term"
The Health Foundation

The Simple Telehealth Community of Practice led by Lisa Taylor, is without doubt the heart of our model, bringing members together to share knowhow, stories and material and to help each other to achieve successful outcomes.  Lisa's team's primary objective is to invest in organisations for the long term to continually increase their capabilities to ensure patients and the organisation benefit from evidence based implementations for the lowest possible cost.  Our commitment to do the right thing for the right reasons for the benefit of patients, appeared somewhat counter intuitive, as we would be investing in organisations to be able to do things themselves that a protectionist industry would normally charge for.

However this very approach gives organisations the tools, skills and knowhow to adopt, adapt and to innovate, leading to a diverse array of uses in clinical areas and with patient cohorts we would never have been able to envisage.  

"The flexibility of the platform and capability support model enables adoption in a wide variety of contexts, as well as co-production of the way in which Florence is adopted in each site with clinicians and patients."
The Health Foundation

Of particular importance are the regional and national learning and network events inspired by Lisa.  At these events clinicians gather with their peers and showcase case studies and published literature on their local adaptions and uses.  With the methodology being condition independent, these events attract clinicians with diverse clinical interest but uses and techniques presented are totally transferrable.  A huge amount of energy is generated by these events and some of the patient stories evoke an emotional response leaving not one dry eye in the house.  In short these events are inspirational and a joy to attend.

The Simple Telehealth methodology goes way beyond the system itself.  One aspect covers the development and adoption of best practice shared clinical management plans, which sounds obvious doesn't it?  What we find, however is that not all clinical teams have a systematic way of implementing best practice across the team and there can be variations of "best practice" in use.  Simple Telehealth is a catalyst, it provides a framework for adoption of a common understanding of best practice and with a wealth of materials already shared in the Community of Practice there may already be something to draw on.  These materials are not specifically for use with the system, the objective of the development of the materials is that they are simply the embodiment of best practice and can be used stand alone in normal practice.   Members report that this alone delivers positive results for the team, but considerably more significant improvements are made when Florence is used to augment them.

"The Florence team highlight the importance of gathering evidence on how Florence is used in a particular context, or with a focus on a particular cohort and their clinical outcomes."
The Health Foundation

Critically, being part of the Community of Practice means uses need to be evidence based so the design of uses, evidence and sharing studies and evaluation is key to the whole community.   It is as important to share what doesn't work as what does work and how that has been achieved. 

Whats not worked

The UK landscape has changed considerably since I designed Simple Telehealth and Florence.   Many suppliers of "Telehealth" or should I now say "digital" systems have come and gone, some of which had good technology platforms too.   Reputable names like O2, Bosch and Philips have withdrawn from the difficult 'market' and other capital backed companies are struggling, recording eye watering losses year on year.  Set against this, a number of smaller companies are thriving and these tend to be those who are ethical and patient, not profit focussed.

We've observed that the usual methods to market, promote and implement haven't worked and whilst in common practice amongst tech companies even today, hyperbole will have a negative effect.  Early in our journey, Dr Ruth Chambers OBE kindly took the time ( and a lot of patience)  to educate me in the culture, desires and drivers of the clinical world, and it is this on which our methodology is based, and we've built on this ever since.    

The 'push' culture of the NHS seems not to work for us and whilst even centrally funding organisations to buy into this or that can provide a temporary 'fix', it's not sustainable as the real test comes when central funding is withdrawn.  This can also be true of regional support models.   This can look like a lower cost option on the accountants spreadsheet but a regional team can be distanced from the many real problems and opportunities on the clinical front line and so the very opportunities are lost that would enable the realisation of the desired benefits, no one wins and it is the very opposite of what is needed for successful innovation.  We have to 'trust' clinicians to do what is best for their patients and give them the tools to innovate.

"The business model is explicitly not-for-profit, and has a strong narrative that focuses on a desire to satisfy the goals that clinicians are passionate about: better patient outcomes and effective use of NHS resources."
The Health Foundation

Clinician innovators

The Simple Telehealth methodology (incl Florence) is designed to fit with clinical practice and offers clinicians the tools to easily augment best practice care.  It is condition independent and once familiar with the framework, clinicians are able to adapt it to new cohorts or even individual patients.   From a base of  COPD and mental health in 2010, the 2017 graph below shows how innovative clinicians have adopted and adapted it into their own diverse clinical areas of interest.

However there are exciting developments ahead where clinicians are using the framework to help new cohorts of patients, some of which are new to digital health interventions.  The graph below summarises some of the 'other' areas of interest in 2017.

“Its greatest strength is offering a simple, adaptable framework for clinicians to work more effectively with patients and for patients to take a greater role in managing their conditions, without the need for costly investments”
  The Kings Fund

Simple Telehealth; Next generation

We started with Florence in the UK, then worked with the VHA to bring Flo's cousin 'Annie' to life in the USA, and having almost run out of superlatives, we are extremely excited to be talking about the next generation of Flo's family, Nellie in Australia and Clara in the USA too!

This next-gen version of the persona based software uses clever technology allowing us to leverage learning from 8 years with Flo and Annie.  I'm delighted to say that Nellie successfully passed her field trials in Melbourne at the first attempt and has now graduated to use in clinical practice across a range of clinical applications.  

The team in Melbourne are firmly members of our Community of Practice and are already involved.  For a little insight, take a look at these two videos from the Nellie conference, filmed at the Royal Yacht Club, Melbourne in November 17.   

Dr Geoff Campbell - 'Nellie' in hypertension diagnoses

Dr Elizabeth Deveny - 'Nellie' in primary care

Nellie and Clara will continue evaluation in Australia and USA throughout 2018.   Some of Nellie's talents include workflow specific views, dynamic dashboards and patient records that update live as patients interact, simple to use sliders to adjust values, interactive graphs and charts, and access to local and community wide libraries to browse and share clinical protocols and resources.

One of the key considerations in the design of Nellie is it structure, which is tightly designed around the needs and capability of clinical teams and the Community of Practice.  The Flexibility of Florence is one of it's strengths and it's structure encourages innovation within organisations but there are still constraints around the ability of individual teams to be able to innovate and share their work.  The flexibility designed into Florence was considered a departure from industry norms at the time, but I'm pleased to say that Nellie goes further, allowing clinical teams to innovate in an exciting and "radically different way".  We can only wait and see where innovative clinicians take us with Nellie!

Modelling Language

With the growth of the Community of Practice over three continents and three platforms, to help members more easily share ideas and protocols we've created the Simple Protocol Modelling Language which uses a schematic approach to design and visually communicate the structure, make-up and content of Simple Telehealth protocols.

Florence data integration

Not cited in this years recognition, but worth a mention is data.  For some time members have been able to integrate their Florence data with third party clinical and analytical systems.  The process is usually automated via an API, however we've found that the real world is somewhat removed from the hype around data integration.  Pushing data like blood pressure readings into clinical systems can not only be costly but also result in in-appropriate data in a clinical system, thereby increasing legal risk for clinicians.

Indeed, hyperbole encouraged by tech companies around 'interoperability' has been called out as a "red herring" at a recent digital health European Knowledge Transfer Group meeting at the House of Lords on digital health.

In contrast, in a focussed Scottish programme for example, readings are extracted and processed analytically outside of Florence before being summarised and sent back to the clinical team or primary care practice on an exception or acceptable and appropriate routine basis for review by the patients clinician.   The value added benefits of this method reduce inappropriate clinical work and allow routine reviews to be done via the telephone, rather than needing a face to face appointment.  A key differentiator here is that the service is independently evaluated and is welcomed and needed by front line clinicians.

House of Lords Symposium - East London Foundation Trust share their outcomes via the European Knowledge Tree group (EKTG)

posted 1 Feb 2018, 02:52 by Hollie O'Connell

East London 
Foundation Trust 

07 February 2018 

Raguraman Padmanabhan, Telehealth Service Lead within East London Foundation Trust, supported by Simple Shared Healthcare, were invited to showcase their innovative redesign to support patients in East London to become more connected with their healthcare and improve their capability to self manage via Flo at the “Developing Digital Transformation of Health and Care Symposium” led by the European Knowledge Tree Group for eHealth (EKTG) at the House of Lords Symposium on 22nd November 2017.

The invitation to showcase the opportunities delivered with Flo in East London to such members as Lord Willis, House of Lords Member, Norman Lamb MP (Chairman of the Commons Science and Technology Committee) was a proud moment for both East London Foundation Trust and Simple Shared Healthcare.  The session ignited an engaged discussion around further possibilities and the wider context of eHealth implementation across the UK.

East London Foundation Trust’s Contribution
East London Foundation Trust have an ongoing relationship with the EKTG with a particular interest in the EKTG’s role in educating and upskilling medical and nursing students around the role of technology in modern healthcare systems.  This created an opportunity for Ram to share how East London Foundation Trust emerged as the first UK organisation to achieve the benchmark of the European Code of Practice for Telehealth services in 2014 and how they have employed television, SMS and telephone technologies to deliver safe and effective healthcare.  Ram shared East London’s commitment to technology's role on constant innovation, sustained behaviour change and self management and the following outcomes from their application of Flo:
  • 50% reduction in grade 2 pressure ulcers for patients supported via Flo
  • 250 potential district nurse visits/calls saved for patients supported via Flo
East London Foundation Trust also have a randomised control trial underway evaluating the effectiveness of a mobile technology (Flo) intervention in comparison with routine care for patients with severe mental illness, aiming to foster self-management and timely communication between patients and clinicians, hereby impacting upon treatment adherence and relapse rates.

What is the European Knowledge Tree Group (EKTG) for eHealth?
The increase in available health information plus the evolution of our patients from passive receptors of medical treatment to an active, well-informed and responsible participants forces us to find new solutions to provide assistance and ensure a good quality of life for patients and senior citizens. 

Chaired by Peter Saraga, the EKTG was founded in 2010 with the aim of pushing for more research in these areas and promoting better practical implementation of such solutions in Europe.  The EKTG for eHealth brings together the knowledge and experience of some of the most active users and patients, technologists, academics, service providers from health and care, local and central government officials, and entrepreneurs, from Europe and around the world, to promote excellence and to enhance and support research, policy formation, education and entrepreneurship and other activities that advance and enrich eHealth in all its forms.  Under the backdrop of the Tallinn Declaration which promises a digital future for Europeans senior representatives join together to showcase best practice examples of eHealth delivered at scale from the UK and across Europe, and help the EKTG lead the way https://www.ektg4ehealth.org/

What’s Next?
Following on from the discussion Karen and Lisa were invited to share further learning from the Simple Telehealth Community at the next eHealth Symposium “Building the European Digital Health Environment – Turning Best Practice into Mainstreamed Implementation!” in January 2018 to discuss specifically “Making eHealth a Reality - Learning from Simple Telehealth’s Community of Practice”.  The approved abstract is available to download below.

How can I contribute or find out more?  If you would like to learn more or get involved with the EKTG as a supporter or contributor please contact Maggie Ellis, Lead Academic and Co-ordinator EKTG, London School of Economics m.ellis1@lse.ac.uk

RCNi Primary Health Care; Being tech savvy-enhances the care you give

posted 15 Nov 2017, 02:05 by Hollie O'Connell

15 November 2017 

“ Technology works as a link, providing extra support and building confidence. ”  
Ann Hughes 

As a practice nurse herself, Ann understands the questions that those new to using technology may have which is something she addresses in her article.

Ann Hughes, a Practice Nurse with North Staffordshire CCG’s has recently been published in the RCNi’s Primary Health Care Journal (October 2017).  Ann tackles how embracing technology – including Flo – can enhance the care you are able to give to your patients.

“I don’t like change”
For many clinicians, change can be unsettling, especially given the rate of rapid transformation that the NHS is experiencing.  Ann asks readers to consider how they can continue to give the best level of care to their patients, many of whom are living longer with combinations of long term conditions (LTCs).  Her answer to the issue of dealing with change is simple; introduce things slowly so that confidence can be built up gradually.  Eventually, using new technology becomes simple and second nature!

“My patients won’t be able to do it”
It is often assumed that older patients won’t have the knowledge required to use technology to help them self-manage their health.  However, as Ann points out, using technology is the norm, and many older patients use a mobile phone or tablet, and we shouldn’t underestimate our older population.  Ann also adds that for those not using technology, introducing it can be a great boost, as secondary benefits such as now being able to contact friends and family, becoming less isolated in the process.

“How can technology provide a better service than I can personally?”
Clinicians are, of course best placed to provide care to their patients, so for some there may be the concern that health technology will reduce the quality of care patients receive.  However, as Ann suggests, it is important to see technology as an addition to the care that clinicians provide, rather than a substitute for it.  As Ann puts it, technology relies on a clinician’s professional knowledge first and foremost.

“What benefits does it have for the patient?”
Ann reminds us that for many patients, it can be diffi
cult to retain all of the information they are given during a face to face consultation, especially if their condition is new to them and they are feeling overwhelmed.  This is where Flo can help.  Technologies used in healthcare ensure that the real time guidance received by patients is current and correct, resulting in patients with increased confidence and capability to self-manage; and the motivation to do so.
“What proof do we have that this works for our patients?”
It is one thing to be told that technology is helping to improve patient’s lives, but another to see real life examples of this.  Ann provides us with two of her own first hand experiences, both of which showcase how Flo is helping patients.

Firstly, Ann talks about a patient who used Flo to help monitor their pre-op blood pressure.  The patient’s initial cataract surgery could not proceed due to elevated blood pressure, but, with Flo’s support, within three days the patient demonstrated enough stable readings sent via Flo from home for this to go ahead.  The patient’s quality of live has improved greatly since her surgery, demonstrating how technology such as Flo really can improve patient’s lives.

The second patient that Ann discussed was struggling to cope with managing her COPD, resulting in numerous calls to paramedics, A&E admission and two inpatient stays within only 2 months.  The patient was introduced to Flo and replied when prompted with her oxygen saturation levels and sputum colour readings daily.  Depending on the patient’s condition that day, they would receive advice from Flo according to the shared management plan they agreed with their clinician.  Over the first 12 months using Flo, the patient only attended her GP surgery once!  The patient is now living a more active life, and her condition is far more controlled.

Ann believes that technologies, such as Flo, can benefit both patients and healthcare teams:
  • Improve patient confidence. 
  • Improve quality of care. 
  • Help to avoid unnecessary surgery attendances. 
As you can see, having first-hand experience Ann really does believe in using technology such as Flo to improve the quality of care that can be given to patients.  Ann has previously described herself as a “technophobe”, so to see her embracing and recommending technology in healthcare is inspiring!

Flo joins the 'Free Condoms No Fuss' C Card Scheme

posted 11 Oct 2017, 03:41 by Hollie O'Connell   [ updated 23 Nov 2017, 04:55 by Hannah Mountford ]

Janet Robison
Project Co-ordinator for C-Card Schemes
NHS Lanarkshire

11 October 2017

The Blood Borne Virus and Sexual Health Promotion Team operate the Condom Distribution Schemes (CDS) within Lanarkshire and are hosted within the Health Improvement Department.  Improving the visibility of sexual health, especially amongst younger populations is a key concern; in 2015 68% of all diagnoses for chlamydia were amongst individuals under the age of 25.  Young people under 25, especially females, define the cohort most at risk of being diagnosed with an STI (FPA, November 2016).  In addition to contracting an STI from unprotected sex, the risk of pregnancy also increases.  ISD Scotland July 2017 data tells us that women under 20 living in the most deprived areas have up to five times higher pregnancy rates than those living in the least deprived areas compounding the importance of ensuring that contraception is easily accessible to the younger population.

The team conducted a pilot “Condoms by Post” project whereby service users could receive a packet of condoms via the post by completing a request form online.  The purpose of the pilot was to highlight Lanarkshire’s C Card Centres where members of the public can visit to obtain supplies of free condoms, and encourage service users to access these areas.  The next stage of the pilot project was to evaluate and understand the experiences of our service users.   

How did you meet Flo?
Working within Health Improvement Department you hear about a number of new programmes or processes that are becoming available for staff to utilise.  A member of the BBV and Sexual Health Promotion Team had reported that there was a tool named Florence (or Flo) being used across Lanarkshire to support patients with aspects of their health using their own mobile phones to engage via text messaging.  These service users reply to Flo with, for example, their blood pressure readings to improve their confidence and ability to self-manage and be remotely monitored by clinicians.  The CDS initially made contact with our local Telehealth Programme Manager to discuss the best way to drive this opportunity forward.

What did you want to achieve?
Initially, our main aim for Flo was to make sure that we received enough data to evaluate the “Condoms by Post” project.  We hoped to maximise the likelihood of receiving feedback by harnessing Flo’s ability to engage with patients offering us an ideal opportunity to harness a proven tool to engage patients and service users which seemed perfect for our cohort who did not like to communicate in person, particularly in relation to a sensitive subject.

Previous feedback suggested that people feel embarrassed talking about any areas of sexual health, which also includes condoms.  Introducing Flo seemed like an ideal opportunity to break down this barrier.  We realised that Flo could be used to remind our service users about the help that was available to them.  We therefore developed a secondary aim, which was to provide extra support and information to our service users in a convenient and discrete manner.

How was Flo introduced to service users and the team? 
It was important early on to ensure that we had consent from our service users to join in with Flo, so during the planning stage before the development of the protocol, the following information was added to the online form to maximise the responses from service users.  This ensured that the team had the appropriate permissions to contact service users:

The CDS team members received a training session from our local Telehealth Programme Manager to understand how to add service users to Flo and assign the agreed protocols, allowing Flo to interact and understand how service users felt about the service. 

To ensure the CDS team received the meaningful feedback to support project evaluation, the CDS team and Telehealth Programme Manager developed a protocol with a small number of questions for Flo to ask service users within an 8 week timescale.

We agreed the timescale to ensure that Flo kept the service users attention avoiding lengthy questions, and also to ensure enough time was given for the service users to use the service by visiting a C Card centre and obtaining additional supplies of condoms.

What happened next?
The CDS team made good use of the protocol to benefit the service.  At the 4 week period a message was sent from Flo to service users reminding them that free condoms are available from C Card centres, and also motivating service users to use the BBV and Sexual Health Promotion Team’s existing website to gain additional knowledge and resources.

In the end, Flo not only helped us to evaluate the project, but we also recruited her as a useful and discreet reminder to service users of additional services available to them.

The Telehealth Programme Team was a tremendous support to the CDS team when creating and implementing this work.  The guidance the team offered was invaluable, alongside the support and advice they provided whenever required, this made a huge difference to implementation.

I would absolutely recommend using Flo to other colleagues who are considering integrating her within the workplace.  Through consultation with users in relation to the work within the BBV and Sexual Health Promotion Team, the feedback being received is that people are in fact communicating more online due to its convenience and accessibility.  To support this, there is now published literature available demonstrating that a high number of people access their information online and also on the go via their mobile phones.

Using Flo is a method of communicating in a way that backs up this evidence and research.

Integrating Flo meant that the CDS team efficiently received the information we needed to evaluate the “condoms by post” pilot helping us to deliver the best service possible to our service users.  85% of our service users also responded that they found Flo easy to use.

For more information please contact janet.robison@lanarkshire.scot.nhs.uk

Five steps to Florence

posted 7 Sep 2017, 01:41 by Hollie O'Connell   [ updated 16 Oct 2017, 05:12 ]

Shona Burge 
Home Mobile Health Monitoring Development Manager 

12 September 2017 

What a service team’s journey with Flo looks like in Tayside “We are one big team” 

" Thanks to funding from the Scottish Government Technology Enabled Care Fund, Angus, Dundee and Perth and Kinross Health and Social Care Partnerships (HSCP) together with NHS Tayside began their journey with Florence or ‘Flo’ in September 2016.  As the newly appointed Health and Mobile Health Monitoring Development Manager for the hosting organisation Angus HSCP, I began one of the steepest learning curves I’ve faced.  This has also turned out to be one of the most satisfying and enjoyable.  Aside from the unfaltering support of my manager Sally Wilson, one of the main reasons for this is the enthusiasm and commitment of the first wave of teams to trial Flo across Tayside.  Being new to Flo we decided to engage as many services as were interested in trying out this innovative way of working.   We loved the idea of using everyone’s best friend, the mobile phone to welcome Flo – ‘The clinician in your pocket’.  Sally had already been speaking about Flo and extolling her virtues to others before I came onboard so we had a group of interested parties ready and waiting for me to hit the ground!  Thankfully Sally had me on a kind of umbilical bungee cord and was always on hand to pull me in for that steadfast support and encouragement. 

We have started with five services those being: Weight Management, Smoke Free Pregnancy Services, Oral Nutritional Support, Heart Failure and Edzell Health Centre who wanted to use Flo to monitor hypertension.  We have a bit of a process we follow with services, some steps need more input from us, others require the teams to free up a bit of capacity to get ‘Flo ready’.  The process as always has evolved as we have moved through it.

Step 1: Clinical Engagement 
The role of promoting Flo has been undertaken by both Sally and myself.  Sally sends out the message to senior colleagues and I follow up with the practical stuff.  So either we send relevant case studies and/or links to www.simple.uk.net or we gave short informal or more formal, invited presentations to services that have heard about Flo and were interested to hear more about how Flo works, what Flo can do and how Flo can help people self–manage their condition.  Basically we talk about Flo most of the time. 

Step 2: Planning 
If a service team is interested and thinks they would like to try Flo we arrange a visit.  In preparation for this the team is provided with relevant, example protocols where possible or protocols that could help thinking – i.e. hypertension protocols to demonstrate how readings can be taken by patients at home and fed-back to clinicians for decision-making. 

We found health behaviour change protocols, around weight management for example useful for other topics as well as the essence of the messages remain the same, only the topic changes.  The team also receives the ‘Scoping Document’ and are asked at this stage to just have a think about how Flo could integrate with their existing pathways; what their intended targets and cohorts would be; how Flo would assist self-management and patient support while freeing up clinician and patient time rather than building in extra work. 

At the visit we go over the scoping document as a tool to discuss ideas in more detail, what their specific protocol might look like and importantly discuss whether there is capacity and confidence in technology for the team to designate a member to become a System Administrator and be able to add protocols to Flo or if indeed this is required by me. 

In cases where the protocol is fairly simple I would have capacity to build it, however if the protocol is likely to be more complex, or specialised and have many iterations I do request a team member dedicates time to this as it generally needs specialist experience to complete this.  Team administrators who have a good understanding of the service and close contact with clinicians tend to be the key personnel here and this is something that can be identified fairly quickly in negotiations. 

Sometimes there is no administration support available; however there is usually a key member of the team that identifies themselves as suitable for the System Administrator role.  At this stage we also consider evaluation and agree timetables for implementation.  I explain what information we can gather from Flo and what we will need from the services.   By this stage the team knows what will be required in terms of input upfront and this is usually balanced out by the team understanding the long-term advantages that Flo can bring.

Step 3: Developing Protocols 
The team will then identify which members will require training to use Flo; this is either provided on-line from the team at Simple Shared Healthcare or delivered locally with live support from them.  Some time is then required to develop protocols – this interim ‘work period’ is very important and can require careful monitoring so that Flo doesn’t fall off the radar due to other work pressures, but so far we have found teams are generally keen on making Flo work and excited to put her into practise so keep apace with agreed schedules. 

At this stage I will act as ‘super user’, set up the ‘TEST’ groups for teams and provide access for System Administrators to access protocols to work on if appropriate.  During this stage I work closely with team System Administrators to get test protocols ready for testing with staff members. 

Steps 4 & 5: Going Live and Evaluation 
Once the team is happy with their protocols and have tested on colleagues we ‘go live’ in accordance with the integration to pathways agreed at Step 2.  Monitoring and data collection takes place on a monthly basis according to the reporting periods of the National Technology Enabled Care Team in Scotland and to meet any service requirements. 

During our journey I cannot stress how invaluable the support from the National Action Group and from Simple Shared Healthcare themselves has been, and continues.  Resources are shared; happily and easily, there are many questions - but none are ever ‘daft’; sometimes we excel ourselves and come up with a new question – but someone always finds the answer.  The sharing and learning is real and crucial on a practical level.  We are one big team.  "

NHS Scotland Event - Working Differently Across Boundaries: Transforming Health and Social Care

posted 12 Jul 2017, 09:40 by Hollie O'Connell   [ updated 16 Oct 2017, 05:12 ]

Lisa Taylor 
Hannah Mountford 

14 July 2017 

The national NHS Scotland Event took place on the 20th-21st June in Glasgow.  This is the foremost healthcare event in Scotland is now in its twelfth year, and continues to aim to promote best practice and innovation

The theme for this year’s event was “Working Differently Across Boundaries: Transforming Health and Social Care” focussing on the development of services to meet the increasing demands of an aging population whilst improving patient experiences and satisfaction. 

Innovation is key, and NHS Scotland’s continuing implementation of its TEC strategy is highly important to this.  Flo continues to be a sustainable innovation now adopted by two thirds of Scottish Health Boards, evident by the number of our Simple Telehealth Community Members selected to showcase their outcomes delivered via a combination of existing adoption of evidence based practice and new innovative approaches.

NHS Tayside
Sally Wilson, (Locality Integration Improvement Manager) and Shona Burge, (Home Mobile Health Monitoring Development Manager) described how they have led the way bringing Flo to NHS Tayside supporting people with long term conditions to better self-manage their health.  Although it’s early days in terms of the implementation of Flo, feedback from patients so far has been promising: 

The service has altered my life, I feel supported… it’s great ” 

I now feel that I am not on my own ” 

I was astonished at how ‘Flo’ Changed my medication habits  

Jacqueline Walker, Nutrition Managed Clinical Network Manager and her colleagues, described the development of NHS Lothian’s new Oral Nutritional Support Pathway (ONS) supported by Flo for personal health support and home monitoring.  Flo’s integration is brand new to the pathway however, the team has a long term view with expected outcomes by 2020 that will focus on creating co-produced pathways to improve diagnosis, treatment and review of ONS.

NHS Lothian
Meanwhile, Mary Paterson, (e-Health Research Group, Centre for Population Health Sciences) Brian McKinstry, (e-Health Research Group, Centre for Population Health Sciences) Grahame Cumming (Innovation Lead) and Elizabeth Payne (Telehealth Lead -Home Monitoring) from NHS Lothian presented on how they have been using Flo to help patients to self-manage their blood pressure at home.  The poster describes positive results, receiving great feedback from patients and healthcare professionals alike.  Patients feel that using Flo is convenient, while staff appreciate having access to reliable home readings to inform treatment decisions earlier A significant reduction in the number of appointments has been demonstrated, creating capacity in primary care.

Parallel Session: Delivering Care in the Digital Age – Embracing Technology and Data Intelligence to Transform Health and Social Care
In addition to those who shared their posters, two further members of the Simple Telehealth Community took part in a parallel session held on both days of the event.  Michelle Brogan (Service Development Manager)  described the impact demonstrated by Home and Mobile Health Monitoring (HMHM) and the potential benefits.

NHS Lanarkshire’s Morag Hearty (TEC Programme Manager)  shared her experience of implementing TEC solutions, namely Flo, at a local level.  Morag discussed both the enablers and challenges that had arisen during implementation, as well as an overview of the outcomes from NHS Lanarkshire’s BP Monitoring Early Rapid Improvement Study, in summary:
  • NHS Lanarkshire now have over 40% of their practices active 
  • 3,868 clinical contacts have been avoided 
  • Average cost per patient of £6.72  
  • 100% of GPs asked (n=104) agreed that their patient being supported via Flo to manage their blood pressure at home helped their clinical decision-making 
  • 99% of patients found Flo easy to use 

Morag also shared some of her top implementation tips with the audience, including:
  • Listening to the staff and patients alike, taking their views in to account 
  • Keep it simple to start with – look for a quick win to help convince people that what you want to implement really does work 
  • Be creative and communicative 

Morag also used this opportunity to promote Fraser – a figure who is well known to the Simple Community!  Have you #FoundFraser yet?  Visit the website here.

Caring for Carers

posted 6 Jul 2017, 08:55 by Hollie O'Connell   [ updated 16 Oct 2017, 05:13 ]

NHS Sunderland 
Clinical Commissioning Group 

Rachael Forbister 
TECS Programme Manager 

11 July 2017 

Sunderland Carers Connect Service 

For those who don't know me, my name is Rachael Forbister, and I’m based at Sunderland CCG.  My role involves developing and leading on a number of TECS projects across the city, including Flo.  I've been very privileged to be involved in this work for over 5 years; every day I'm grateful, and every day I learn something new.  It certainly gets me out of bed on a morning!  Believe me, it's not a perfect world, and I've made plenty of mistakes along the way but that's how we learn and grow.

Over the past 18 months we have had the opportunity to develop a fantastic Carers pathway which incorporates Flo.   The idea came from some of our nursing team who contribute to a palliative care group.  They often found that the carers struggled with their caring role, and felt it would be great to do something for them.  With a readymade network in Sunderland and our local commissioned service, Sunderland Carers' Centre, we were able to set up a group of carers who shared their stories, and then used those stories in to design a service that would help them to look after their own health whilst being a carer.

It took a few sessions, with a few hiccups in the middle, to help develop the concept.  The group was made up of 8 carers, most of whom looked after their elderly relatives, although we did have a mental health and learning disability focus as well.   Pulling together their ideas, the working group was able to map out a pathway which could be used to build a protocol using Flo that matched their requirements.  The protocol was made up of education and motivational messages, sign posting for additional services, as well as questions to monitor the mood of carers.
The second key element was the engagement with the local authority as a key stakeholder.  The main concept of the system was that anyone who reported a low mood score would want a phone call back for additional support.   The local authority was able to provide this service through their telecare team on a 24 hour response.  Using the local authority’s call alarm system, Jontek, we were able to get Jontek and Flo to talk to each other.  Although it may be a buzz word, “interoperability” was vital in allowing us to achieve our goal.

Once the protocol was built one of the carers fully tested it to make sure it worked in the way we wanted it to.  This included generating alerts, and then subsequently checking on how the staff responded to these.  The user testing then allowed us to further improve the protocol and make some essential tweaks.

We went live with the service on National Carers Day in November.  A celebration event with tea and cakes was held for all of those involved with the development of the protocol in Flo.  We were also shortlisted for an award at Sunderland City Council Star Awards.

The service has since been reviewed; we have improved the evaluation element of it and created triggered questions to make it easier for carers using it.

It’s now part of the Carers' Centre service offering, and offering it to carers is handled as “business as usual”.  I’m immensely proud of the work everyone has put in to making this happen, especially our carers.

East London patient's receiving "seamless service" to support self management with Flo

posted 28 Jun 2017, 01:13 by Hollie O'Connell   [ updated 16 Oct 2017, 05:13 ]

East London 
NHS Foundation Trust 

Raguraman Padmanabhan 
PGDip (Lond), BPT (Ind), MCSP, MAACP - Clinical and Operational Lead 

29 June 2017 

As the Clinical and Operational Lead for Telehealth at East London NHS Foundation Trust (ELFT), I have been leading on the partnership between ELFT and Florence since 2013 to support people with chronic physical illness, improving their treatment adherence, engagement and self-management.  The number of pathways, innovation ELFT are developing is expanding, an increase in positive outcomes is being delivered and there is growing recognition for the teams involved.

ELFT is committed to facilitating integrated care and accessing best practice technology to support patients being managed in the community.  Examples of current pathways where Florence is supporting patients to self manage their condition include diabetes, chronic obstructive pulmonary disease and hypertension, to name a few.   From local evaluation of outcomes, Flo has proven to have a significant and positive effect on patients as they are provided the opportunity to experience the benefits of supported self-management and receive a seamless service.  Patients report back that they “ love Flo .

Overall Flo has also been used successfully in ELFT to monitor patients with long-term conditions and in mental health settings and plays an important role in facilitating and integrating care in the wider community.

HRH The Prince of Wales Award for Integrated Approaches to Care Award

At the end of 2016, we were honoured to be shortlisted for the HRH The Prince of Wales Award for Integrated Approaches to Care as part of the Nursing Times Awards.

The teams’ nomination was in recognition of ELFT’s innovative Telehealth Service including Flo helping patients manage their diabetes and other long term conditions better, maintain their health and live independently at home.

This prestigious award sought to reward nurses whose work is reducing the burden on the health service by preventing ill health and/or offering truly holistic care to patients who have long-term conditions or complex needs.

Created specifically to reflect HRH The Prince of Wales’s long commitment to holistic healthcare, the award identified those nurses from the community or hospital sector who have joined forces with other organisations, such as those from the voluntary and/or third sector, to help promote public health and prevent disease and/or manage long-term conditions in a holistic and integrated way that improves patients’ quality of life and independence.

From almost 200 applicants the team were shortlisted to only 8 and following an interview process were invited to Clarence House where HRH Prince Charles was keen to find out more around how digital empowerment via Flo worked in an integrated model.

What our patients are telling us - Diabetes Pathway

The Diabetic Specialist Nurse Team in East London have recruited Flo as part of their team for some time now to motivate their patients to better engage with their diabetes in between scheduled contacts.

Patients benefit from a daily message from Flo as a reminder to take their blood glucose measurement, with Flo sending advice back depending on the patient’s reading.  The team now has access to their patient’s daily readings which they would not have had otherwise offering not only the opportunity for earlier intervention should the patient’s diabetes exacerbate, but the additional patient reported measurements have proved to enable a more effective consultation either face to face or via Skype.

Evaluation with patients demonstrated that the appointment felt more focussed, took less time and the patient felt that they received more attention and had an increased feeling of control over their diabetes.

A short video of the team’s approach is available here and you can hear patient, Yvonne explain the difference that Flo has made to her 

I used to forget to take my blood glucose in the morning, now I have a reminder as soon as I get up and I can keep an eye and regulate what I’m doing.  Flo is definitely part of our family now

As an example, another one of our diabetes patients who has been using Flo for a while commented that he "prefers sending in the blood glucose readings via Flo".  The patient mentioned that it "gives him the confidence" knowing that someone is able to keep an eye on things.  The patient reported that he ‘loved’ the option of having a print out of readings from his Diabetic Specialist Nurse, if needed.

The patient also finds it reassuring to get a call from his Diabetic Specialist Team if they have identified up anything that requires early intervention from the readings that he has been reporting from home to Flo.  The patient also enjoys being able to speak to someone right away if Flo has advised him to contact the team due to his diabetes needing further review.

The patient’s GP is also happy that the team is provided with access to the patient’s readings in Flo as and when needed for review and initiation of further management.

The patient fed back that he would recommend this service to friends and family and is happy to be part of this service for the foreseeable future.

Another patient had a technical issue with one of the network providers and since it could not be solved despite several attempts, changed his phone so that his Flo connectivity remained intact.  The patient reported it was "the best thing ever for him to be in touch via Flo to self-manage his diabetes" and that didn’t want to lose Flo.

The service users also pointed out that Flo is well placed within a preventative and public health arena and is also accessible to patients.

Pressure ulcer prevention and management 

Another area that Florence is used to help support patients at ELFT is those patients are at risk of developing pressure sores or those who have a recently healed pressure area.   Patients identified by their District Nurse, Allied Health Professional or Tissue Viability Team; due to the volume of referrals the patent is referred to the Telehealth Team as a single point of access.  The Telehealth Team are co-located with the District Nurse Teams and will fast track a visit to address issues coming via Flo from the patient, providing a safe and coordinated pathway onwards.

Using a combination of targeted prompts, condition education and motivation; Flo interacts with patients around key areas such as positioning, equipment, nutrition, eating/drinking and the health of the patient’s skin and pressure area.  If a need is indicated, Flo will prompt the patient to make contact with the team as further intervention is required.

What has been the Impact?

The use of Flo to support patients in this cohort has proven to reduce the pressure on our community services with time being released to focus on patients with more acute and complex needs.

The teams have noticed how patients and carers have embraced this simple technology in shaping their care and also how Flo has improved compliance to agreed self-care arrangements.  In addition, with Flo providing remote support determined by their clinician, patients report feeling that they having access to a clinician when needed.  This gives patients the confidence to report to us any issues or concerns with their pressure area round the clock, knowing interactions with Flo will be reviewed and triaged accordingly, which also complements business continuity.

Supporting Service Users with Mental illness

The Mental Health team were selected by The Health Foundation to be part of its £1.5 million innovation programme, Innovating for Improvement supporting twenty health care projects in the UK with the aim of improving health care delivery and/or the way people manage their own health care by testing and developing innovative ideas and approaches and putting them into practice.

Flo is already used in Newham in supporting people with chronic physical illness to improve treatment adherence, patient engagement and self-management but this will be the first time it has been tested in a controlled trial for people with a severe mental health condition. 

Led by Professor Frank Röhricht ELFT’s REFRAME project is a feasibility randomised control trial using Flo to support service users with severe mental illness.  The research aims to understand if Flo’s interactive text messaging intervention can improve the care and self-management of patients with severe mental illness.  This is an ongoing project, we can’t say too much now, but watch this space!

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