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Getting started with Flo - Our first 18 months in Powys

posted 5 Jul 2018, 02:12 by Hollie O'Connell




Victoria Deakins 
Professional Head of Occupational Therapy 

Kathryn Lloyd 
Service Development manager for Therapies and HS 


05 July 2018 


"
Our journey with Flo started just over 18 months ago.  We heard about Flo from our Director of Primary and Community Care and Professional Head of Occupational Therapist who described how Flo was supporting patients in other areas, from this we felt that she would be beneficial to the people of Powys.  The Director of Primary and Community Care then discussed Flo with his executive colleagues, and it was agreed that we should take Flo forward with our patients in Powys.

We initially held a workshop in Newtown with the Diabetes multidisciplinary team to introduce Flo and develop ideas for how she could be integrated into current practice, to improve patient engagement and adherence to shared management.  The teams demonstrated lots of enthusiasm and commitment and were able to develop three protocols on the day to support our local pathways:
  • Diabetes Type 2 Education
  • Newly Diagnosed Diabetes Type 2 for patients already prescribed Metformin
  • Newly Diagnosed Type 2 Diabetic patients who were not yet prescribed Metformin, with the aim of motivating patients to make the necessary lifestyle changes to avoid or delay the need for metformin to be prescribed.

Our first patient opted in to Flo on 31st October 2016, and we have now had 128 patients sign up to use Flo.  As introducing Flo is an add on to our current roles, there have been some time challenges, despite this, we have already developed a handful of new pathways, and we have seen some very promising results.  From our conversations with other teams there is significant interest in taking Flo forward and we are hoping to create extra capacity to support them.


Diabetes and Flo in Powys: Type 2 Education

Diabetes education is an essential part of good blood sugar control and avoiding long-term healthcare complications.   For each individual, there is a vast amount of condition-specific information they need to understand for successful diabetes management.   In Powys, patients with type 2 diabetes are invited to education sessions targeted at supporting them to understand their diabetes better, and to become confident in their self-management.

We have developed Type 2 Education pathways to support our patients identified as having sub-optimal control (HbA1c of 70 or over) of their type 2 diabetes.  The team felt that Flo was perfectly placed to maintain engagement after the session and to provide consistent reinforcement and motivation, helping patients to implement the strategies they had learned.  The team also hoped that Flo’s regular interactions would encourage patients to attend the scheduled follow up session that had previously been poorly attended.

The first 34 patients attended their educational session which aimed at helping them to learn more about their condition.  A second session took place 12 weeks later, which 21 patients returned to.  We also took the patients’ BP, weight and HbA1c at each session. In the intervening weeks, patients received motivational and supportive messages from Flo to reinforce their learning. For example:
  • “It takes roughly 66 days for any new behaviour to become a habit so keep going with your changes. Check out www.diabetes.org.uk for some useful tips. Flo”
  • “Monitoring your portion sizes can make all the difference to your blood glucose levels. Take a look at www.carbsandcals.com or your diary as a reminder. Flo.”
  • “Well done, you are nearly there now. Check out your workbook to see just how far you have come and to review your goals. Take care, Flo. “



After our programme became integrated with Flo, we saw some very promising clinical outcomes:
  • 90% of patients lost weight.
  • 57% of patients demonstrated a reduction in diastolic blood pressure.
  • 76% of patients demonstrated a reduction in their HbA1c.

In parallel, we also discovered that patients found the experience of using Flo to be positive:
  • 88% of patients reported that Flo was easy to use.
  • 67% of patients felt that Flo was convenient.
  • 64% of patients thought that Flo had helped them to manage their own health better.
  • 87% reported that they would recommend Flo to a friend or family member.

Pulmonary Rehab Programme – Increasing Motivation at Home

Across our pulmonary rehabilitation programmes, we sometimes find that our patients can struggle to complete their exercise plan between our face to face sessions.  Given that pulmonary rehab outcomes significantly improve when patients adhere to their exercise programme at home, we saw this as an ideal opportunity to introduce Flo.

The pulmonary rehab team wanted to maintain contact with their patients at home so they designed a protocol to maximise the impact of how Flo’s personna motivates patients.  Flo interacts with patients according to their exercise plan to gently motivate them to complete their daily exercises.

We also felt that it was important to include reviews with our patients at 3 and 6 months to gain an understanding of any pulmonary improvements demonstrated.  The 3 month review focused on any overall improvement in the patient’s adherence to their exercise programme, whilst the 6 month review targeted whether or not the patient had had any hospital admissions, if the patient had visited their GP and if so how many times.   It was great to hear positive feedback from our patients, and that the extra support they received from Flo made a difference to them.  As a result, we have since started to roll out the pulmonary rehab support protocol more widely across Powys.

Patients enrolled on both the Pulmonary Rehab Programme and Type 2 Education pathway were captured in the video “Florence and the [Telehealth] Machine - Using Everyday Technology to Support Patients” which was showcased at our AGM to promote the work we have been doing with Flo.   


Flo and our Falls Programme

We also decided to create a protocol to understand how Flo could provide additional support to our patients who were enrolled with our falls prevention programme “Confident Strides”.  Flo’s protocol complimented the existing 6 week falls prevention programme, and continued for a further 4 weeks once the programme had ended to consolidate and reinforce learning.   Throughout the programme, Flo motivated patients to complete their exercises and asked them to reflect each week on how many times they had done this successfully.  The aim was to motivate patients to engage better with the programme, and reduce their risk of falls.

Similar to the pulmonary rehab pathway, Flo asked patients review questions at 3 and 6 months to provide clinicians with the opportunity to evaluate both the patient’s progress and the effectiveness of Flo.  Questions at 3 months centered around if the patient had experienced any further falls, and if so how many.  Questions at 6 months then asked patients if they were still exercising, whether they were maintaining their goals, and whether they felt that Flo had helped them.  Once again, we received some great feedback, with patients telling us that Flo was useful to them, and that she helped to remind them to do their exercises.  This demonstrated to us how Flo could be a useful tool for improving patient’s compliance, motivation and engagement with their own health.  We did find that some patients had trouble responding to Flo at times, but we used this as a learning opportunity moving forwards, and now aim to provide patients with a prompt sheet to help them with their replies.

Epilepsy: Flo’s simplicity improves medication compliance

posted 12 Jun 2018, 01:48 by Hollie O'Connell


The Shrewsbury and Telford Hospital  
NHS Trust 
Conor Smyth
Specialist Epilepsy Nurse 


15 June 2018 



Conor Smyth is a Specialist Epilepsy Nurse at The Shrewsbury and Telford Hospital, he works within the neurology team to provide care, advice and support to his patients with epilepsy.  Conor has recruited Flo to help his patients for a number of years now, and he recently took some time to share his experiences of using Flo.



"
Getting Started

My journey with Flo started around 5 years ago when I met with Lisa and we discussed how Flo could help patients in my cohort to develop better medication habits, and reduce the likelihood of the avoidable side effects on non-adherence to their regime.  I introduced Flo to prompt patients at agreed times to take their medication, and the use has been sustained across the cohort.  I haven’t used Flo’s other features yet, e.g. recording number of seizures, as I like the simplicity and impact of the reminder messages.  I think that it’s the simplicity that has appealed to a lot of my patients as well, as when I discussed Flo helping them to remember to take their medication they seemed quite keen to take it up.

Currently I have a caseload of around 35 patients; most are under 30 years old, including a significant proportion of teenage patients. It can be difficult at any age to get into a routine of taking medication, and sometimes more challenging in the teenage age group.  We do see the effect of challenges around medication compliance, especially amongst the younger patients.   For some, there are additional cognitive issues that can be associated with their epilepsy, so ensuring that they take their medication as prescribed can be tricky.

What we did before Flo

Before using Flo, we would talk patients through practical ways to remind themselves to take their medication in clinic, for example using dosset boxes that would clearly show whether they’d taken their medication or not.   Another common tip would be to suggest that they put their medication in places that are part of their daily routine, for example by the kettle so it’s there in the morning when they make their first cup of tea.  We do find that a lot of people have family members around to remind them, so a lot of the time they were having to do the prompting; this can put pressure and strain on family members or any other carers the patient may have. 

How do we use Flo and how does Flo help patients?


Now Flo helps my patients to take their medication on time; the frequency of Flo’s prompts varies dependent on the patient’s dosage, but it’s normally twice a day.  What I’ve seen is that Flo can really help to promote more independence and better self-management.  This then helps to take some of the responsibility away from family members or carers.  We find this is particularly helpful for our teenage patients. 

Parents usually take on the responsibility of reminding them to take their medication, and then often worry that they’ve created a dependence as they won’t be there to prompt them in a few years when they go to university or move out.  Knowing that Flo is there to help provides consistency and takes the onus off parents, and reassures them that it’s a way going forward for their children to become more independent and still manage their epilepsy.



When I introduce patients to Flo, I make sure to explain everything as clearly as I can; I try to make sure the patients understand that Flo isn’t a real person, she’s a computer system that will send them text messages, like a helpful friend.  We do sometimes have patients who aren’t keen because they feel like “Big Brother is watching them”, but the majority say “Yeah I’ll give it a go!”.  I don’t have many patients that drop or opt out, so obviously they don’t mind using Flo and think that she’s a good idea.

We do get occasional feedback from patients; I ask them how they’re doing, and how they’re getting on.  Patients tell me their epilepsy is much improved, and that they found Flo useful; as far as I know, I’ve not heard any negative feedback from my patients who use Flo.   I think that it is convenient for patients, particularly teenagers, as they always have their phone with them, and Flo’s messages aren’t intrusive.


Using Flo as a clinician


As I started using Flo I found that it was plain sailing – it was simple and easy for me to get to grips with and use.  We do have some issues where patients come in and when I ask if they are still getting messages from Flo, and they say “Oh no I’ve changed my phone number”, but they haven’t told me.  I know that could be helped if there were some messages where Flo would ask them to reply, but I would prefer to keep things simple and light-touch for my patients.  I think that sometimes when you put too much demand on patients, they can withdraw from it to a certain extent.

In terms of me using Flo day to day with patients, I find Flo very useful and very accessible.  With the PC that I use in clinic, I can just open up Flo online and add protocols or patients with their phone number there and then. The ease of it is very, very good, and I would recommend Flo to other clinicians.

"

Patient Evaluation

Conor has also been developing some patient evaluation questions that Flo can send to his patients.
  • Does Flo help you to remember to take your medication as prescribed?
  • Has Flo helped you to self-manage your condition better?
  • Would you recommend Flo to your friends and family? 


"
Of the patients who responded, all told us that they found Flo helped them to remember to take their medication and that they would recommend Flo to friends and family, while all but 1 patient told us that they thought Flo had helped them to self-manage their epilepsy better.  This feedback is very promising, and demonstrates how Flo is helping patients to take care of their health and self-manage their care better.

"

Mental health - Innovating for improvement

posted 17 May 2018, 02:27 by Hollie O'Connell   [ updated 6 Aug 2018, 02:41 by Hannah Mountford ]



East London 
NHS Foundation Trust 

Raguraman Padmanabhan 
Telehealth/Care Navigators Clinical and Service Lead 



21 May 2018 




ELFT is committed to continuously driving forward the integration of care, and ensuring that our patients have access to best practice technology to support their management in the community.  As mentioned in my previous blog in June 2017, Flo has proven to have a significant and positive effect on patients by her providing the opportunity to experience the benefits of supported self-management and receive seamless care.

Flo has previously been used successfully at ELFT to monitor patients in mental health settings and plays an important role in facilitating and integrating care in the wider community, with the initial pilot study aiming to explore the feasibility and the potential clinical benefits of an enhanced community care intervention such as Florence (Flo).



East London NHS Foundation Trust (ELFT) Telehealth’s project REFRAME is led by Dr.Frank Rohricht, Mobile Technology Health Manager for Patients with Severe Mental Illness, as a feasibility Randomised Control Trial innovation project, vitally supported by the Health Foundation.

We at ELFT-REFRAME believe that the project will have significant effects both in terms of consecutive research projects, but also immediately within ELFT as an important contribution to our quality improvement (QI) work in the area of community recovery care.

Severe mental illness (SMI), in particular chronic psychosis (Schizophrenia, Schizoaffective Disorder, Bipolar Disorder), is associated with poor clinical and psychosocial outcomes.  Due to the complexity of the disorder, service users require multidisciplinary flexible care arrangements involving different providers, often resulting in poor treatment adherence and problems with therapeutic engagement as well as a lack of empowerment.

This pilot study was aiming to explore the feasibility and the potential clinical benefits of an enhanced community care intervention, that uses an interactive simple technology based (SMS text messaging) communication system.  The intervention is provided in the spirit of recovery oriented care and supports service users gaining more control over their problem monitoring, as well as the necessary appointment arrangements with health professionals.

Flo as an intervention provides a user friendly, easy to use and non-stigmatising add-on to the patient’s current care pathway at low cost, managed by service users free of charge on their own mobile phones.

The recovery care intervention provided via Flo has three components: medication and appointment reminders, daily individually defined wellbeing scores and optionally coded keyword requests for help across psychosocial and medical care needs.

The Feasibility Trial Method
We conducted a randomised controlled trial to test the feasibility and evaluate the effectiveness (six months after baseline) of the intervention in comparison with routine care (treatment as usual) for service users with severe mental illness (i.e. psychosis).


The Innovation – The Intervention
Flo was already being used by other clinical teams within ELFT (specifically by Community Health services in Newham) for long-term condition physical health care management in the community.

The intervention utilises the anticipated benefits of Flo for service user’s treatment adherence/therapeutic engagement. We created an innovative mental health care protocol that enables service users to develop and monitor their individually agreed own wellbeing scores in collaboration with the clinicians. Simple messaging language and keywords are utilised to foster service user-clinician communication outside routine appointments.

The intervention consists of three elements designed for the innovation project:

1. Flo interacts with service users via four SMS text messages daily: two prompts for medication adherence or appointments, and two asking service users to send their wellbeing indicators.

2. Service users develop their own wellbeing indicator based on three individually defined main issues / relapse signs (e.g. sleep, anxiety, voice-hearing intensity).  Depending on the scores, automated response messages designed within Flo’s protocols provide positive feedback, advice and will motivate service users to contact their Care Coordinator to discuss any challenges that they are facing.

3. At any time, service users can send a message to Flo requesting support using a predefined lists of keywords.  In response, the Care Coordinator contacts the service users to understand the nature of the issue further with a view to agreeing appropriate actions to take. 

Emerging evidence suggests that 70% of service users who have used Flo, opt to continue beyond their involvement with the project.  Of those who have opted to discontinue using Flo, their feedback suggests that they do not feel a need for it, rather than feeling that Flo was intrusive or unhelpful.

The project will be formally launched as a QI project in 2018.  Unlike many QI projects, this poses an unusual situation where patients have actively requested this quality improvement measure, rather than being driven by clinicians.

Through learning from other projects through the Health Foundation, it is clear that video feedback is a powerful means to embed and spread an effective intervention.  As a result of this, we have routinely asked participants as a part of follow up assessments whether they would be interested in taking part.  The majority of participants have expressed interest in taking part to promote Flo’s intervention where they found her to be useful.  We are in liaison with the ELFT’s communications team and People Participation Lead with regards to the logistics of creating a service user testimonial video to support further spread and scale up of use.




Paracentesis team "deliver the best, flexible care" for all of their patients with a little help from Flo

posted 12 Apr 2018, 00:46 by Hollie O'Connell   [ updated 8 May 2018, 06:12 by Hannah Mountford ]




Bev Aram 
Paracentesis Assistant Practitioner 


30 April 2018 


Bev Aram, paracentesis assistant practitioner, is part of the paracentesis nursing team at The Queen’s Medical Centre in Nottingham.  The team comprises of Bev and three other nurses, whose main role is to support patients with paracentesis, this can be during phases of exacerbation such as draining ascetic fluid as a form of symptom relief.  Bev recently got in touch to chat about how she and the team have introduced Flo to enhance the care that the team offer to their patients.


What was the service like before Flo? 
Previously, paracentesis care had been doctor led, and this meant that patients were experiencing long waiting times which made them unhappy with the service.  However, the nursing team took over a little over four years ago, which is when Flo was initially introduced.

Why did we want to use Flo?
We wanted to use Flo because she was really easy for us to access, and more importantly for patients to use.  Knowing that Flo was simple for the patients to use was important; if we could use it, then our patients could too!  Another important factor was how easy it was to explain to patients – keeping everything simple was the key for us!

How do we use Flo?
We use Flo to help monitor weight gain in our patients when they’re at home; patients with ascites experience a build-up of fluid in the body, so increase in weight demonstrates that excess fluid is present and needing to be drained.  When we introduce patients to Flo, we weigh them prior to draining excess fluid, and then once again afterwards.  These measures give us a baseline to work with, especially with new patients.  We then take a look at a patient’s weight after the procedure and we tend to add around 5kg to this to give us a maximum weight for the patient to reach.

Patients start with Flo, and she sends prompts three times a week to remind them to send her their weight.  Once they reach the maximum limit we’ve set, they’re asked to get in touch and arrange to see the ascites team to have the fluid drained.

Personalised care for our patients:
We use the 5kg as an initial guide to try to make sure that we can intervene with patients before they reach the stage of being uncomfortable due to fluid build-up.  Sometimes, patients can become uncomfortable before this limit is reached, or the opposite where they reach the upper limit but still do not experience any discomfort.  We always makes sure to explain to our patients to get in touch in either of these circumstances, which allows us to adjust the maximum weight gain limit on a patient-to-patient basis allowing us to offer personalised care.  This is especially helpful if a patient starts using diuretics, as we can change the maximum limit accordingly.   We also make sure they know that the days and times that Flo asks them to send their weight in is flexible to suit them and their day to day lives.

Introducing Flo to patients: 
When we first talk to patients about Flo, we like to keep things nice and simple.  We find that people don’t want to be bogged down with too much information, especially when they’ve only recently been told about the implications of their condition.  We just tell patients that Flo is a tool that we offer to help them monitor their weight, and that the service is free to use – that always seems to be a winner with people!  We explain that Flo keep a record of their weight readings, and that they can use her to help keep track of their weight.
 
Flo’s unique persona 
While we do make sure patients know that Flo is an automated service, many of our patients refer to Flo affectionately as “she” or “her”, which gives the service a human touch.  Doing it this way helps patients to laugh with you, and makes the experience less scary and stressful.  For example, we explain to patients that if Flo doesn’t hear from them for a week or so, she has a bit of a wobble, and tells us to contact them to check everything is okay.  It’s important to make sure that patients know that Flo won’t reply to messages other than patients’ weight readings, so we ensure that they have a contact number for the nurses if they need to get in touch.

Challenges & Learning:
We had a few problems with some patients' messages not being received by Flo, however this was a challenge with mobile network providers rather than Flo.  We got in touch with the Simple Shared Healthcare team and they were able to help us with this, they were able to work through a troubleshooting guide with us, so really the problem was an easy fix.

The other challenge we had was around engaging our patients.  Our patients range in age from their 30’s to 70 plus.  Some of those in the higher age bracket weren’t as comfortable with mobile phones, and some didn’t even have their own mobile.  We give these patients the option of having a relative who is happy to use their phone, receive messages from Flo on their behalf which enabled us to recruit Flo to help them.

Patients are sometimes also concerned about the number of texts they will receive from Flo – they expect to be getting reams of messages and having to send long replies.  When they find out it’s simply 3 messages a week, and that all they have to reply is “WT” followed by their weight, they all say “Oh is that it? That’s so much easier!”, and they are happy to sign up and try Flo.

What benefits do we see? 
Many of our patients tell us that they find Flo really helpful in keeping track of their weight.  From our perspective, this is great because we can see patients becoming more engaged with their health.  When they start on Flo, her prompts often lead to them starting to write down their weight, so they become more aware of their own health and better at managing it – as a clinician you think “Oh this is actually working!”  Some patients are even able to reduce the number of readings they send to Flo as their self-management improves!

For patients with new onset of ascites, we find that they are eager to use Flo, and many say things like “I didn’t realise I had all this fluid, but weighing myself with Flo has helped me to understand my condition and when I need to come in again”.

From our perspective, we find Flo very easy and very simple to use.  The great thing about Flo is that we can choose when to use it or not to, based on our knowledge of our patients.  As I said before, Flo really does allow us to deliver the best, flexible care for all of our patients.  Flo really has helped us to deliver high quality care to our patients, and I would recommend her to other clinicians out there. 
"

'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 ]

simple.uk.net 
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.


Impact
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

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