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Improved Quit Rates with Flo: 6 Month Evaluation of Smoking Cessation Pathway

posted 30 Nov 2020, 01:35 by Hollie O'Connell








30 November 2020 



As reported by the Public Health Agency in Northern Ireland (NI) “Smoking has been identified as the single greatest cause of preventable illness and premature death in Northern Ireland.” Data from 2014 showed that approximately 16% or 1 in 6 of all deaths in NI were attributable to smoking, including cancers, lung disease and circulatory diseases.  Furthermore, in NI it has been estimated the costs of treating smoking-related illness in NI hospitals alone is around £164m a year.  Since 2015, decreasing rates of smoking has remained a priority for improving public health across NI.

Developing the pathway

With this ambition in mind, Northern Health & Social Care Trust (NHSCT) embarked on their journey with Flo, one of their first pathways being developed to help improve quit rates amongst clients who were trying to stop smoking.  The smoking cessation team worked to develop a protocol in Flo that would support and encourage clients on their journey to becoming smoke-free, whilst monitoring throughout for observable behaviour change.

Their pathway included a balance of advice and motivational messages targeted at supporting sustainable behaviour change, such as:

“What have you found good so far about not smoking? Make a list and use this as a regular reminder to keep going. Flo”.

Clients were also asked regularly to rate how hard they were finding it to stay smoke-free and if they had smoked at all during the past week.  The programme of support messages and interactive questions lasts for a total of 12 weeks, with additional evaluation questions to learn more about clients experiences a year after first engaging with the service to ask if they had remained smoke-free.

The first client was enrolled onto the NHSCT Stop Smoking Service on 18th November, and 6 months later an evaluation of the service to date was completed to help the team further develop the support Flo offered clients.  NHSCT have kindly agreed to share their evaluation with other community members via our website.

Findings at 6 months

Within the initial 6 month period, 50 clients were enrolled and 29 opted in to receive messages from Flo - as a first pathway, the team were hoping for an opt-in rate of 50%, but this was exceeded with 58% of clients opting in.  It was hoped that at the 4-week mark 60% of clients on Flo would report staying smoke-free, however, the actual percentage was 69%, beating the target set out by the team.  In comparison, for clients who did not receive support from Flo, 53% reported that they were not smoking at the 4-week point.

Please click image to enlarge
 
Although not all clients completed the evaluation questions, those that did all agreed that Flo was useful in helping them to quit smoking.  Some clients also provided verbal feedback about Flo’s support:

It was helpful
 
It was useful to keep me motivated
 
It was good to keep me on track

NHSCT staff also agreed that Flo provided helpful additional support to their clients, and were pleased to see an improvement in quit rates without the use of excessive clinical time.  The 6-month evaluation concludes:

“ Florence has been a helpful additional aide to help smokers quit.  The quit rate of those using Flo is 16% more than those not using Florence.  It is popular with clients who find the messages useful in their quit attempt.  It has improved quit rates without using up excessive clinical time.  Increased quit rates will reduce medical costs in the short and long term.  

Next Steps

Based on verbal feedback from both staff and clients as well as client evaluation from Flo, the team plan to refine their pathway to further improve the experience.  This will include reducing the number of times patients are asked if they are finding quitting difficult/if they are still smoking, including more practical advice about cravings, changing the wording of the evaluation questions and also discussing with clients at the time of enrolment the importance of answering the evaluation questions at the end of the protocol. 

 Florence has been a useful tool with our clients providing additional support and ultimately improving quit rates. We will continue to use and refine our Florence protocol to help our clients quit this deadly addiction for good and improve their health. 
 
Lynsey McVitty, Health and Wellbeing Officer for Antrim and Ballymena

How Florence is Extending the Reach of Primary Care Remotely During COVID-19

posted 25 Nov 2020, 01:07 by Hollie O'Connell




Rudy Mckinney 
Nurse Practitioner 


25 November 2020 


Rudy Mckinney is a Nurse Practitioner working within Northern Staffordshire CCG who has been implementing Flo during the COVID-19 pandemic.  Rudy has kindly shared her experiences with us.

What is your background and role within your organisation?

I am a Nurse Practitioner working in primary care within North Staffordshire CCG.  Around two years ago I took part in the Digital Nurse Programme which introduces digital technologies, including Flo, into our day to day consulting with patients.  We did some fantastic work as a surgery implementing technology into our daily practices – this resulted in the publication of a journal article that detailed our work and gained digital exemplar status for our surgery.  To read the articles in more detail please click here for The Atlas of Shared Learning - Digital Applications for self-management at Audley Health Centre and here for Digital by choice: becoming part of a digitally ready general practice team.

The recent pandemic has given us the opportunity to strengthen the foundation work that we had in place and our use of technology, in particular Flo, has grown from strength to strength.

How did you first hear about Flo?

I heard about Flo when I attended the Digital Nurse Programme in 2018.  The programme provided digital training and support for 40 primary care nurses; of which I was included, from across Staffordshire who were each tasked with developing action plans on how they would like to use technology with patients.  We were shown innovative practice in the use of social media, apps, Flo and video consultation and then asked to develop our actions plans.

What in particular ignited your passion to develop Flo?

My passion for Flo in particular came from actually using the service with patients.  We now use her in many areas of our consulting, we have found that implementing Flo with patients for medication and injection prompts has been particularly helpful with improving patient compliance.

Flo’s inhaler reminders work fantastically for our teenage asthma population that are often poorly compliant with their treatment. We have found that having the reminder nudge sent directly to the patient gives them an increased sense of ownership and has consequently improved compliance, whereas before they had a lot of unwanted nagging from their parents.

Flo has been particularly helpful to both staff and patients during the pandemic.  It has allowed us to facilitate remote consulting more easily – especially with having to limit the number of patients visiting the surgery for face to face appointments.

Flo’s blood pressure pathway has been especially useful for this.  It has allowed us to safely continue prescribing, knowing the patient is supported to submit their blood pressure readings.  We have had excellent feedback from patients – some of whom have been shielding and therefore have been unable to attend the surgery in person.  We also find that our working patients much prefer this type of remote consulting as they often find it hard to attend appointments due to the clash between surgery opening times and their working hours.



Improving medication adherence has been even more important during the pandemic where often housebound and frailer patients are having less input from families / carers due to the restrictions of the lockdown.  We also use the respiratory pathway for monitoring oxygen saturations of some of our more brittle respiratory patients – this has allowed us to monitor them closely and safely when needed, and provided them with peace of mind during such a worrying period.

What improvements did you expect to deliver from integrating Flo?

Flo has allowed our surgery to work more effectively using remote consulting techniques.  During the pandemic, Flo has improved safety as she has allowed us to continue to monitor our patients who we would not have been able to review in the surgery period.

Flo has increased patient compliance and also reported an increase in patient satisfaction.

Implementing Flo has also saved us time – it limits the reminders we need to send to patients as Flo automatically does this for us.  It is also saving us time by reviewing a patient's submitted readings and only contacting them if needed – previously a whole appointment would have been needed for each of our hypertensive patients.  This has in turn increased our appointment capacity for other things that need a face to face appointment.

What were your first steps towards integrating Flo?

To start I would recommend focusing on one area and get used to how Flo works and begin to see the benefits.  Once you are more competent, then see what other patient cohorts could benefit from becoming more active in their self management.  If you have resistance from other staff members then show them the benefits that happen once Flo starts to support your patients and always collate patient feedback.  We found it didn’t take long to get everyone on board once we could share the benefits with them.

Would you recommend Flo to others?

I would strongly recommend Flo to others, particularly at this time during the pandemic - it is a fantastic time to start.

We have found patients that were previously resistant to using technology are now much keener to try.  Patients are often worried to attend healthcare settings, or even leave their house during the pandemic – Flo allows you to continue to offer a fantastic, safe service but remotely.

Proud to be working with Flo; Lisa Taylor reflects on 10 years at SSHC and what’s next

posted 24 Nov 2020, 07:11 by Hollie O'Connell





Lisa Taylor 
Deputy CEO / CCO Simple Shared Health Care 


24 November 2020 



Lisa is now marking her 10th year working with Florence as part of the Simple Shared Health Care team.  With new exciting development and investment brought through the partnership with psHEALTH, Lisa has reflected over these years sharing her thoughts and experiences, as well as what’s next for SSHC.

When and why did you start working with Flo?

2020 marks my 10th year working with Florence, from the very start of her journey in 2010 through to where she is today having helped over 100,000 patients to improve their health outcomes.

My passion was ignited from day one.  Having already worked across the NHS in service redesign roles at local and national level, I often felt like a small cog in a very large wheel, but I could clearly see the potential that Florence had to change real clinical outcomes, for real people, in real everyday life at what can feel like a very vulnerable time.

Empowering patients to become active in their own healthcare fully aligned with my personal objectives, developed during childhood as the daughter of a non-compliant patient.  Watching the clinical and emotional impact of declining health, and how a sense of overwhelment and loss of control quickly removed any motivation to engage in positive health behaviours meant that I was fully committed to help bring Flo, who was just an idea at the time, to life. I knew from my personal experience how individuals can influence their own health outcomes, for the better, or for the worse, and I wanted to help more patients to feel empowered and confident enough to take a more active role.

Most proud moment?

People may think that recognition by the US Government’s Veteran’s Health Administration by inviting a delegation of 16 NHS Clinicians to Washington DC for a two day conference focussed solely on their outcomes with Flo would be my proudest moment; it certainly was one of them.

However, probably my proud moments happen most days, when I hear a brand new patient story or read a service evaluation, case study or publication that I wasn’t aware of - I feel a sense of accomplishment that Flo is delivering what we set out to do all those years ago.  Even after 10 years, I am inspired daily by the commitment of busy clinicians to harness innovative best practice to improve quality and safety for their patients.

Unlike many commercial companies motivated by profit, our goal was never to create dependency on us as a social enterprise.  Our objective has, and always will be to invest our time working in partnership with organisations for the long term.  Focussing on the continual increase in local capability, whilst ensuring that both patients and organisations benefit from evidence based implementations for the lowest possible cost ignites clinical creativity; handing over control of this flexible and adaptable tool allows clinicians to recruit Flo as a member of their own team independently.

Our commitment to do the right thing, for the right reasons for the benefit of patients is what I am most proud of.

Why do you think Flo is so effective?

Thinking back, and of myself as a patient, there is a limit to the impact that even the best practice healthcare can have for me unless I, as a patient, take an active role.  Flo transforms patients from being ‘receivers’ of healthcare to becoming ‘partners’ in their healthcare; from being passive to active.

My GP cannot guarantee that I will take my medication as prescribed, nor can a physiotherapist force me to comply with an exercise plan to prevent exacerbation of my bad back.  My Community Nurse does not know when I need further clinical input if I have not followed my self-management plan and taken action by recognising the signs and symptoms of my deteriorating COPD.  My health literacy dictates if I appreciate the role of diet and exercise in determining if my pre-diabetes turns into a diagnosis or if my unmanaged blood glucose leads to longer term comorbidities.

Flo bridges the gap.

There have never been more available healthcare related gadgets, apps and websites for us all to consume at will and yet adherence is still low.

Florence, or Flo to her friends, “feels” like a person, she interacts with you like a friend about your healthcare via your mobile phone, at times agreed with you.   The guidance she offers is based on you as an individual as prescribed by your healthcare team.  Your clinician can review your readings and/or symptoms at any time and with this extra insight tailor your treatment based on your condition or give you permission to reach out to the right place in your best healthcare interests.

Flo brings self management plans to life, real time nudges gently encourage patients to take action outside of face to face care, the actions that only a patient can take for themselves. Actions that make a significant difference.  Patients feel like they are still connected to their clinical team and levels of accountability increase as Flo starts to interact.

What’s next?

I’m excited for this next phase.  The first 10 years have delivered more than we could have expected thanks to the commitment and passion of NHS clinicians to make this happen.  I am proud to say that Florence is now proven, evidence based and respected amongst clinicians and endorsed at the highest level such as the Kings Fund, Nuffield Trust and Health Foundation.

We started with Florence in the UK, then were asked to work with the Veteran’s Health Administration (VHA) to bring Flo's cousin 'Annie' to life in the USA.  The next generation of Flo's family, ‘Nellie’ in Australia is delivering the same better and faster outcomes for citizens in Melbourne, all enabled by the passion and commitment of our NHS.  Leveraging the last 10 years learning with Florence, aligned with the exact same methodology that activates patients, Nellie uses sophisticated technology and the team in Melbourne are firmly members of our Community of Practice.  The VHA are also active members and as part of their COVID-19 response recognising Annie’s proven techniques in delivering a rapid public health response, have recently published how Annie helped Veterans to monitor their symptoms safely in the Journal of the American Medical Informatics Association delivering both clinical benefit and substantial resource saving.  I am confident that this has helped to expedite similar applications in the NHS with Florence during the pandemic.

Our next phase, partnering with psHEALTH will further develop Florence and bring back into the NHS the capabilities of our third generation platform currently being used in Australia, opening up even more opportunities to accelerate the benefits that Florence brings to patients and clinical teams alike, helping more patients to help themselves.       

Focus On: Clinical Psychologist

posted 23 Oct 2020, 06:20 by Hollie O'Connell   [ updated 27 Oct 2020, 01:36 ]


Sam Malins 
Clinical Psychologist / Honorary Assistant Professor of Clinical Psychology 


26 October 2020 


Sam Malins is a Clinical Psychologist working in Nottinghamshire Healthcare NHS Foundation Trust, University of Nottingham and Nottingham University Hospitals NHS Trust.  Sam has been leading research and development with Flo for psychological therapies over a number of years, and has kindly shared his experience.

What is your background and role within your organisation?

I am a clinical psychologist working at the cross over between physical and mental health with specialist research training.  So I spend my time developing and testing new interventions to improve mental health and delivering psychological therapies in clinical practice.

Where did you hear about & why did you want to use Flo?

In the least likely way!  I happened to be at a presentation where someone was talking about how Flo was used to monitor blood pressure and other health measurements.  Through a bit of thought and a very helpful collaboration between some patient advisors, clinicians, and the people at Simple, we realised that the technology could be adapted to support engagement with psychological therapies.

What did you set out to achieve with Flo and how did you go about it?

Although several psychological therapies are clinically effective, many people who seek help do not experience as much benefit as they could.  Part of the reason for this is that psychological therapies can be hard going and sometimes people stop before they have got the most out of it.  This is especially true for group psychological therapies for people who have long-term health problems.  So we wanted to see if Flo could help people with cancer to get the most from an evidence-based group psychological therapy called Mindfulness-Based Cognitive Therapy (MBCT).

MBCT teaches participants a range of ways to be present to the moment, which can help reduce symptoms of anxiety and depression as well as reducing risk of future problems.  However, MBCT involves around 45 minutes of home practice each day between sessions, which many people find a challenging task.  We developed a way of giving patients tailored messages about the group theme each week and reminders of the home practice, so that they could engage as much or as little with it as they wished including personalised content specific to the group.

In a separate project we tested whether Flo could help people stay well for longer after psychological therapy by asking participants to imagine that they could send text messages to themselves in the future.  We asked patients what advice they would give themselves from what they learnt in therapy if they were 1) doing well 2) experiencing early warning signs of relapse or 3) experiencing full relapse.  We then fed these messages into Flo and asked patients to rate their wellbeing 0 to 5 each week, with 5 being the best and 0 being the worst.  In response they received a message of their own advice tailored to their level of wellbeing.

Were there any surprises?

We were surprised by the size of the effect on dropout.  When we compared the group of patients who used Flo during their group with those who did not, Flo users were much more likely to complete the programme than those who did not.  In fact, the odds of completing MBCT were eight times greater for patients using Flo compared with non‐users.  In addition, Flo users experienced 50% more improvement in symptoms of depression than non-users.


We also interviewed people about the experience afterwards.  We were kind of expecting that people would say that Flo was a good reminder and a prompt, but they also said that it gave a sense of personal connection with the therapists and the group which surprised us.

In the relapse prevention project we thought that Flo might prevent relapse, but results suggested that in some areas it encouraged ongoing improvement in health, which we weren’t expecting.

How does Flo fit with your organisational vision/current strategies?

I am really keen to lower the bar for engagement with any behavioural change intervention.  What I mean by that is that the people who actually seek help from services are a small proportion of the people who could benefit, but it takes a lot of effort and courage to go and ask for help.  So my vision is that Flo can be both a bridge to help for people who would not otherwise get it and a way for everyone to get the most from their psychological care through personalisation of Flo messages, to the most meaningful information for the individual patient.

What do you consider your biggest success with Flo?

I really would not like to say! Mainly, because I feel like we have just scratched the surface with the work we have done so far and I feel we could do much, much more.  In particular, I am excited by the potential to lengthen the benefits from psychological therapy so that they go far beyond the time of seeing a therapist.  I also feel we can help many more people to stick with what can be a tough journey through psychological therapy, so that they can reap the benefits at the end.

How do you engage your clinicians and wider organisation with Flo?

I really think practice-based evidence is absolutely key.  What I mean by that is collecting data on the most important outcomes in your service routinely and using it to see where Flo is making a difference.  Showing this evidence has been the best way of engaging people and it is really at the heart of what I want to know as a clinician and a researcher.

What are the future plans with Flo?

We are currently putting together a proposal to see if we can link together the different ways we have used Flo in psychological therapies to run a clinical trial.  Then we can see if it helps more people recover from anxiety and depression, long-term and how clinicians find using Flo in this way.

NHS Test Bed: ‘Smart with your Heart’ Reducing Readmission Rate for Heart Failure Patients at the Royal Stoke University Hospital: A Telehealth Coordinators Perspective

posted 16 Oct 2020, 02:49 by Hollie O'Connell



Kylie Dentith 
Technology Enabled Care Senior Support Assistant - Simple Share Healthcare 


16 October 2020 


Following a successful pilot demonstrating a significant reduction in readmissions for patients admitted with heart failure, Florence was chosen to be part of the NHS Test Beds Programme at Royal Stoke University Hospital called ‘Smart with your Heart” in October 2018.  Florence, along with two other digital technologies were combined and have now been scaled up, with the aim of further reducing the readmission of patients with chronic long-term heart failure through community-based clinical interventions and remote support, to better self-manage their condition post-discharge.

The “Smart with your Heart” project also aimed to improve patient’s health literacy and their capability to safely ‘self-care’, using bespoke patient-education materials and referrals to appropriate third-sector services.  The project has now come to an end and is in the evaluation phase to produce a final report for wider sharing.

Dr Duwarakan Satchithananda, Consultant Cardiologist and Clinical Lead for the project, commented 

Patients felt supported by the combinatorial nature of the project – not just with the combination of digital products, but with the combination of the digital products and a human face to help patients get to the appropriate team that could help them” 

In the pathway designed by Dr Duwarakan Satchithananda, patients were prompted by Flo to reply every 2 days as to whether they felt better, worse or the same compared to their previous response, in order to identify any early deterioration in their condition and facilitate early intervention.  The patient was then guided by Flo to check how their symptoms matched against the heart failure symptom checker that they were provided with and reply with Red, Amber or Green accordingly.  Along with interactions around symptoms, Flo also provided patients with tips and information about managing their condition, as well as links to the other digital technologies. 

In the prevention of readmission, it was clinically relevant for the team to review any patients who were experiencing worsening symptoms and to be able to intervene quickly.  Flo notified the Telehealth Coordinators, and the team would then review any patients clinically indicated and intervene with a phone call to the patient to ask some further questions, and advise what appropriate course of action the patient was required to take.  As part of the Smart with your Heart project the team also developed a patient tracker to record patient details, crucial dates, call notes and patient ID’s for each of the technologies used as part of the pathway.  The responses from patient phone calls including the main points of the discussion could then be noted and added to the patient tracker, which the Telehealth Coordinators had access to should this be required to support the team based approach.



Nicola Antrobus was one of the Telehealth Coordinators for the Smart with your Heart Test Bed Project
and has kindly shared her perspective of how her role supported the project.  Nicola worked directly with patients and focused on their engagement with the new pathway; if a patient met the criteria, Nicola would advise how the project would support them and the expected benefits associated with the likelihood of reducing the potential need for readmission. 

The SHINE Clinic was a key resource for the project, acting as an Ambulatory Heart Failure Clinic offering heart failure treatment such as intravenous diuretics on an out-patient basis, meaning that patients requiring treatment can have this delivered to them as an outpatient without the need to stay in hospital.  As one of the Telehealth Coordinators, Nicola visited the SHINE Clinic on a daily basis to talk to patients about the Smart with your Heart project, and ensured that patients knew they could approach her for more information, advice or to have a general chat about everyday life.

Nicola found that patients were more engaged in the project after receiving the face to face visits where she explained what was involved and how Flo could support them.  Nicola felt that the first introduction was important in building the relationship with the patient, and told them her name and job title, how she was a part of the Smart with your Heart project and that the patient had been referred by one of the consultants or the heart failure nurse.  If needed, Nicola also helped patients to opt in to receive messages from Flo, would provide them with information around useful websites and talk through the symptom checker to ensure the patient understood what to do.  Nicola and the team would always be willing to call or visit the patient again to offer further support.

Due to the high level of interaction required with the patient for this project, Nicola explained that having effective communication skills within her role was crucial.  As well as explaining the project in a clear and informative way, Nicola also needed to be sensitive and understanding of each patient's situation, and due to the personal information required to take part in the project, it was essential that Nicola built trust with the patient and their family so that they felt comfortable and reassured that their information was going to be used in an appropriate and secure way.

Not only was communication key while introducing patients to the project, it was also important to Nicola that she helped patients feel at ease and to grow their trust in her.  Throughout the pathway, if a patient responded to their daily prompt saying they felt worse, the Telehealth Coordinators would call the patient and it was extremely important that the patient was open and honest about why they were feeling worse, as this would then help to guide the Coordinators on what the most clinically appropriate advice or action was for the patient based on the pathway.  As these calls could often be sensitive and concerning for the patient, it was imperative that Nicola was understanding and communicated effectively.
This level of adaptable communication enabled patients to fully utilise and benefit from the pathway by reducing any barriers that could have been present when encouraging patients to take part in the project, and when developing working relationships with others involved.

Nicola explained that the role was not without its challenges, one of which was the introduction of new ways of working within the heart failure patient cohort and engaging clinicians in wanting to introduce digital technologies to their patients as part of their post-discharge care.  Subsequently, it was important that the Telehealth Coordinators worked closely with the wider clinical team, supporting them to take an active role in the project and providing a reference point.  The Telehealth Coordinators would always try to work with the clinicians as much as possible and would attend the weekly heart failure meetings to provide more information and initial feedback on the project, as well as guide clinicians as to what was required from them to help the uptake of the project.  One of the main issues was that it took quite a bit of time to get approval for clinical governance, which was raised at many meetings.  If there had been any resistance from the wider team this could have proved difficult to recruit patients to the project, however, everyone involved was supportive and worked cooperatively to overcome any issues and make this project successful.  The Telehealth Coordinators also linked in with the Heart Failure Nurses’ monthly meetings which were across the Trust and with the Community Heart Failure Nurses.  This helped to build up working relationships with those outside of the Trust and keep them informed about the project.

Nicola felt that the role exceeded her expectations as she enjoyed the variety of responsibilities each day brought, and she also really enjoyed the interactions with the patients, Community Heart Failure Nurses and the team.  Nicola found Flo very easy to use for herself and was simple and easy to understand for the patients too.  Whilst being a part of the project Nicola learnt that patients didn’t really know what signs that they were looking for around a deterioration in their condition, by using Flo and being prompted to look at the symptoms on the symptom checker, the patients became more educated and clearer on what to look out for and why it was important in helping to prevent any health deterioration.  Nicola also thought it was great to see patients who had a fear of a mobile phone become more confident and comfortable in using technology and in some instances start to use it more to contact family members.

When asked what advice Nicola would give to others she replied 

Don’t be put off by any resistance in the departments you are dealing with, learn and understand as much as you can and grow the relationships with your patients and colleagues and support each other

Focus on: Peer Facilitator - Nellie

posted 5 Aug 2020, 02:56 by Hollie O'Connell


Carol Wildey 
Peer Facilitator, Simple Telehealth - Nellie 


05 August 2020 



Carol has been working in the South Eastern Melbourne Primary Health Network (SEMPHN) for nearly 3 years.  She uses her previous knowledge and experience in healthcare, alongside drawing on the learning and evidence-based psychology behind Flo, to help support successful implementation of ‘Nellie’ (Flo’s Australian cousin) to primary care teams.   Carol has kindly shared her experience of being a Peer Facilitator for Nellie.

What is your background and role within your organisation?

My role with SEMPHN is Peer Facilitator, Simple Telehealth – Nellie.  I started working at SEMPHN at the end of 2017 when Nellie was just starting to be rolled out in our Primary Health Networks catchment in South Eastern Melbourne.  Prior to moving to Melbourne from the UK in 2011, I had worked for the NHS as a dietitian for over 20 years in various positions.  I mainly worked in the area of diabetes education with a focus on supporting patient self-management, patient-centred care, and care and support planning for long-term conditions (chronic disease).  When I moved to Australia I worked as a research project manager across a diverse range of research projects including diabetes prevention for women post-Gestational Diabetes, cancer and health literacy.

My role at SEMPHN involves working with primary care teams to identify where Nellie can be used to supplement existing models of care (by fitting in easily with them) in new and innovative ways to benefit the team and patients.  E.g. this, from the published paper: “… can be implemented into routine primary care at scale with little impact on clinician workload…”.

What did you set out to achieve with Nellie and how did you go about it?

We set out to establish whether Nellie was a valid, useful and effective tool to use within the Australian primary health care context.  It’s always challenging to introduce new interventions and tools to busy general practices and evidence suggests that it takes up to 17 years to embed new evidence-based interventions in health care.  Okay, so we didn’t have 17 years up our sleeves, but the SSHC Community of Practice has been a valuable factor by being able to draw on others' experiences and pathways with Flo and Annie.

We used our PHN communications channels to talk about Nellie and asked for teams to contact us if they were interested.  We visited interested practices and gave them a live demo of Nellie.  Most of these teams were excited about the prospect of using Nellie and immediately thought about specific patients and cohorts who they thought Nellie’s friendly messages and interactions could help.  Many of them also identified how they thought that Nellie could make their work lives easier, especially with Nellie’s intuitive interface – this provided crucial motivation for them to embed Nellie in their workflow.

The key message was always, start small.  We worked with clinicians to identify how they thought they would like to use Nellie and collaboratively designed suitable pathways.  Some teams were more interested in using Nellie to monitor their patients remotely, such as using a Blood Pressure monitoring protocol.  Others were much more interested in how Nellie could help their patients establish healthier habits through sustained behaviour change, such as by increasing their physical activity.  As Nellie uses basic SMS messaging, she is easily accessible and familiar to most people, however we always emphasised the importance of making sure they screened their patients for their capacity to use and interact with Nellie, but also the importance of assessing an agreed health-related goal which was important to the patient.  A key element to creating sustained change is that the clinician must work together with the patient to help them identify an action plan to achieve their goal, and one that the patient felt confident they could achieve and were ready to commit to.  The Nellie protocol to support this action plan is then highly likely to be both helpful and effective.

We now have around 50 teams actively using Nellie with good feedback from both patients and clinicians.  As part of evaluation for pathways and patient experience, we build Net Promoter Scores into most pathways where we are able to measure patient feedback.  The results remain good!  We are also using Nellie to measure Patient Reported Outcomes Measures, or PROMs, using a tool called howru from R-Outcomes to track patient status measures over time.

Were there any surprises?

Patients often think of Nellie as “she” or “her” - as if she is a friend looking out for them.  During a time where there are many different health apps available, I have been amazed that something as simple as a persona-based SMS service can have such a profound impact on patient outcomes.  I spent many years as a clinician, struggling to help my patients to change certain behaviours such as their diet, activity levels, smoking status, alcohol intake, engagement with medication regimens etc etc etc.  Change is hard.  Change is especially hard for people with complex health needs, but Nellie is something unique!  I now hear stories about how Nellie has helped people who may have been struggling for many years.  Small changes can lead to huge improvements in people’s quality of life, and that’s what’s really important.
 

How does Nellie fit with your organisational vision/current strategies?

I work in the digital health team.  Our organisation’s strategy has digital health as one of its core pillars, and Nellie is a perfect fit.  It underpins the work across the entire organisation.  One strategic aim is to reduce the number of potentially preventable hospitalisations.  Nellie has already helped many primary care patients to better self-manage their health at home, with better outcomes through her persona-based messages.
 

What do you consider your biggest success with Nellie?

Having so many primary care teams use Nellie without any financial incentives!  We have great feedback from patients across a broad range of different protocols used.  They have really appreciated the extension of clinician-led care that Nellie provides in their day-to-day lives in a friendly and non-judgemental way.
 

How do you engage your clinicians and wider organisation with Nellie?

We have a Nellie page on our website and use ‘Basecamp’ for our local community of practice, as well as regular communications with practices via our regular SEMPHN newsletters.  One of the key drivers for implementing Nellie is understanding how using Nellie can make clinicians’ lives easier.  Talking to clinicians, with a focus on the quadruple aim of better outcomes, improved patient experience, lower cost and importantly, improved clinician experience, helps us to frame Nellie in a way that engages clinicians in thinking about how they might use Nellie – and it’s different for every team.
 

What are the future plans with Nellie?

We will continue to work with our primary care teams to make improvements where we can to deliver an even better program.  We’re also thinking about engaging with local partners to use Nellie to improve the integration of health services and reduce organisational barriers in areas such as shared care, hospital discharge, mental health and addiction services.  Watch this space!

Focus On: Advanced Diabetes Nurse

posted 28 Nov 2019, 02:45 by Hollie O'Connell


Seonaid Morrison  
Advanced Diabetes Nurse 


29 November 2019 


Diabetes - Self-management support 
   


Seonaid Morrison is an Advanced Diabetes Nurse for Argyll & Bute Health & Social Care Partnership.   Seonaid has kindly taken some time to share with us her experiences of working with Flo as part of our “Focus on Evaluation Project”.


What is your background and role within your organisation? 
I’ve been in the NHS since 1984; my background is nursing and my roles have changed over the years I have been practicing.  I have worked within the ward situation as well as being a diabetes specialist nurse and doing some management posts. 

What did you set out to achieve with Flo and how did you go about it?
We set out to use Flo as an addition to our diabetes education programmes.  We have been extremely lucky in Argyll & Bute to have a great team who informed us of how Flo’s methodology of subtle psychology can help with the ongoing care of our patients.  The reason we decided to use Flo was to enhance our structured education programmes and support people to be more motivated to continue to make lifestyle changes and self-manage their diabetes.

Were there any surprises?
No, we haven’t had any surprises, but we are very happy that a number of our patients have used the service and had a positive experience based on the feedback that we have received.  All of the feedback from Flo has been positive and people like to receive Flo’s prompts as they remind them of the goals they have set and encourage them to take forward their goals.

Change can be difficult; if you experienced any resistance within your team, how did you overcome this?
As we are part of a very small team we are all very motivated and believe that change can be a positive rather than a negative, so we have not had any difficulties with this.





What do your clinicians like about Flo?
As a clinician, Flo is very easy to use. Flo is used in addition to our structured education programmes; we would not routinely follow up those patients who had taken part, and they are later invited to yearly review sessions.  We have therefore implemented Flo as an additional tool to support and act as a prompt to assist people to think about their self-management between the initial education we provide, and the yearly follow-up.  Flo has been a positive tool for us, and all our educators believe this is beneficial for both patients and themselves in their practice. 

An additional benefit is that where there were previously no structured education programmes available in Argyll & Bute, we are now offering them to patients and Flo supports us with this.

What do you consider your biggest success with Flo?
I think that our biggest success is having patients report back to us that Flo has been helpful as a reminder to self-manage their condition.  Patients who have used Flo tell us that she has kept them on track with changes in their diet and/or exercise, which can really improve their long-term health outcomes

What are the future plans with Flo?
We plan to keep using Flo for diabetes education; at the moment, whenever we change any of our patient education we update the information on Flo to maintain continuity.  If we develop any further education for patients we would look to incorporating Flo in addition to our practice.

How do your patients feel about Flo?
Any patients that have utilised the service have provided positive feedback about the addition of Flo.  We have seen examples of various positive outcomes including weight loss, reduced blood pressure and blood glucose levels, which is fantastic.

What can you do more/less/differently with Flo?
I don’t think we can do anything differently at the moment, as Flo is successfully enhancing the education available for patients in Argyll & Bute.



Mental Health Member’s Network; Beating the Blues with NHS Highland

posted 2 Oct 2019, 02:30 by Hollie O'Connell   [ updated 2 Oct 2019, 03:10 ]


Hannah Mountford 
Support Officer - Technology Enabled Care SSHC 



02 October 2019 



Our Mental Health Member’s Network has recently been launched to support learning and sharing amongst community of practice members, with the first network call taking place on 17th August.  Kylie Dentith, Senior Support Officer for Technology Enabled Care SSHC, began the call by giving an overview of the aims of the Member’s Network, and some of the current applications of Flo for mental health.  If you would like to read an overview of these, please take a look at our blog.

Following this, Kylie introduced the call’s featured clinician, Iona McMurdo, who is a CBT Project Support Officer with the TEC team at NHS Highland.  Iona joined us to share her experiences of supporting the implementation of Flo with Beating the Blues (BtB). 


BtB is an online cognitive behavioural therapy course, used for the treatment of low to moderate anxiety and depression.  The course aims to help people to challenge and change their thinking patterns, understand their feelings and learn how to overcome negative thoughts by the use of interactive tools.  Case studies have shown that CBT is just as effective in treating anxiety and depression as antidepressants, with the added benefit of helping to prevent symptoms returning.

Previously, BtB had to be accessed using a PC, but updates have now allowed service users to access modules via mobile devices such as phones and tablets, making the course more accessible.  BtB comprises of 8 sessions, each with 3-4 modules, and on average it takes 10-14 weeks to complete.  Flo provides additional support to those completing the BtB course between sessions to encourage people to continue with and complete the course.

NHS Highland first implemented BtB with Florence in 2017, and data gathered indicates that service users are 30% more likely to complete the course if they opt into Flo also.  Initial engagement is also improved, as they are able to receive the link to BtB from Flo, and then start the first module directly thanks to the update allowing mobile devices to access the course.  Flo’s messages can also be reassuring for those living alone with anxiety or depression, as they make people feel as if someone cares about them.  NHS Highland aims to focus on inactive and pending users to encourage them to activate the course, and this is something Flo is able to support in her gentle & friendly manner. 


As with any implementation, Iona and the team did experience some challenges initially, including poor mobile signal in rural areas, service users on multiple protocols having a few too many messages from Flo, and some unfounded concerns around a charge for opting into Flo.  

Iona’s key advice here is to educate and inform patients from the start, so that they have a better understanding of how the system works, including that it is free to use and their confidence around it is improved.  Part of this includes a phone call from Iona after referral, allowing service users to be as informed as possible around the benefits of engaging with both BtB & Flo. 

Iona was also able to share some fantastic patient feedback:

“This is an amazing course that has really helped me. I feel it should be part of the education curriculum! It is so helpful and so beneficial and I can see how my thinking errors started quite young. I have told everyone and anyone who was prepared to listen of the benefits of Beating the Blues/CBT”

“Beating the Blues was a brilliant course, and my GP has been a fantastic support… Really I couldn’t be more grateful to you all. Feel Saved!”

Iona finished by discussing some of the next steps for Flo & BtB in NHS Highland:


  • Ensure better communication with service users as they begin their journey with BtB, and provide more information around Flo to help them make an informed decision.
  • Improve how the team measures outcomes to assess the impact of the programme.
  • Focus on activation, drop-out and completion rates to explore contributing factors; for example, patients who opt into Flo compared to those who don’t.
  • To meet with and communicate with the wider BtB team to discuss challenges and share learning, with the aim of continually improving service delivery moving forward.

Following Iona’s presentation, community members who had joined the call had the chance to discuss and ask Iona some questions.   The group discussed improved use of technology in older populations.  It is often thought that technology such as Flo may not be suitable for older users, but increasingly this is found to be inaccurate as tech literacy improves.  

Other discussion topics included: the addition of evaluation questions in Flo protocols, how to evaluate cost-effectiveness of programmes such as BtB, choosing the best language for your patient cohort and how clinician confidence when discussing Flo can improve patient engagement. 



Flo: improving Patient Safety through technology

posted 18 Sept 2019, 05:22 by Hollie O'Connell   [ updated 18 Sept 2019, 05:34 ]

Hannah Mountford 
Support Officer - Technology Enabled Care SSHC 


18 September 2019 

In July 2019, NHS Improvement published the first-ever NHS Patient Safety Strategy.  The strategy outlines three main aims:
  • Insight: improving understanding of safety by drawing intelligence from multiple sources of patient safety information.
  • Involvement: equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system.
  • Improvement: designing and supporting programmes that deliver effective and sustainable change in the most important areas.
Investing in new technology to support improved patient safety features throughout the strategy, and Flo with her solid track record of improving patient engagement and adherence to best practice clinical care is in a fantastic position to further support the Patient Safety initiative moving forwards.  We have many examples of where she has already helped clinicians to ensure patient safety and improve the outcomes of best practice care.

Hypertension Diagnosis:

One of the most widely used applications of Flo is in the diagnosis of hypertension.  Patients who demonstrate a high blood pressure during an appointment at their GP surgery can be added to Flo’s hypertension diagnosis pathway, which asks for several readings over the course of the week to help clinicians to diagnose or rule out hypertension.  Patient safety is improved by reaching a quicker decision about diagnosis, without waiting for ambulatory monitoring, or making multiple trips to the surgery.  Those who have hypertension can begin treatment in a timely manner, whilst those who may have exhibited white-coat symptoms, or who are not hypertensive are quickly identified.  Flo’s application across hypertension, including diagnosis and monitoring, has been so successful that the Scottish Government have made a £1.2m investment to scale up their hypertension services with Flo nationally; you can find out more about this here.

Medication Concordance:

Flo has supported many patients to adhere to their medication regime, including taking insulin and inhalers, as prescribed.  Ensuring medication regimes are followed is key to patient safety, as it helps to both treat and stabilise health conditions, avoiding exacerbations and flare-ups.  Find out more about how Flo has helped patients stay on track with their medication:

Medication Titration:

As well as ensuring patients take medications on time, Flo can also support medication titration to make sure dosage is appropriate and correct, improving patient safety.
  • Hypertension: Properly tracking blood pressure after diagnosis provides regular data which clinicians are able to use to safely and accurately titrate blood pressure medications to ensure condition control.
  • Tacrolimus for renal transplant patients: Flo interacts with the patients about their dose adjustment following their most recent appointment.  Flo asks patients to reply to ensure that they had read and understood the changes to their medication, thus improving patient safety.


Timely response to changes in condition:

Many patients who are introduced to Flo can send readings in to support them with self-management of their condition.  Flo helps patients to improve their understanding of and ability to recognise changes in their condition, allowing them to take action or seek clinical help as appropriate.  Pathways with Flo draw on pre-existing local best practice support with additional clinician input; any responses Flo sends to patients following receiving their reading contain the clinician’s advice in conjunction with the patient’s shared management plan.  Implementing shared management plans with Flo can also have the added benefit of helping to standardise care as they can be used with all patients, regardless of whether they have been enrolled with Flo or not.  Here are some examples where Flo’s support is helping to improve patient safety:
  • Maternity: Flo has been used to support ladies with pregnancy-induced hypertension and gestational diabetes.  If blood pressure or blood glucose readings are not within range, ladies are advised to contact their midwife, ensuring that any required intervention is timely.
  • Diabetes: Similar to gestational diabetes pathways, patients with both type 1 and type 2 diabetes are provided with advice or asked to contact their specialist nurse.  This potentially avoids hypo or hyperglycemic episodes, improving long-term outcomes and patient safety.
  • Oncology: Patients at the University Hospital North Midlands who were receiving chemotherapy sent temperature readings to Flo.  Raised temperature can be a sign of infection; patients recording high temperature readings would be asked to attend the Emergency Assessment Bay, ensuring a prompt action to counteract any potential infection was taken.
  • COPD: Patients with COPD may be asked to send readings in about a variety of symptoms, including breathlessness score, sputum colour or cough.  For example; If the symptoms suggest a worsening in condition, Flo can prompt patients to follow their shared clinical management plan and start to take their rescue medication and contact their respiratory nurse.  By starting medications in a timely fashion, patient safety is improved by potentially avoiding more severe exacerbations.

As you can see, innovations with Flo have already helped many clinicians ensure that their patients take an active role in improving the safety of best-practice care through better engagement and adherence to shared clinical management plans.  If you would like to read more about the NHS Patient Safety Strategy, please follow this link (Membership required).  For more information about how Flo can help support you in ensuring high levels of patient safety, please get in touch with a member of the team:
Karen.Moore@simple.uk.net   Lisa.Taylor@simple.uk.net   Kylie.Dentith@simple.uk.net   Hannah.Mountford@simple.uk.net

New to Flo or need to refresh your skills? Access our on-line training for Clinicians

posted 16 Sept 2019, 02:05 by Hollie O'Connell   [ updated 16 Sept 2019, 03:33 ]




Kylie Dentith 
Senior Support Officer SSHC 


16 September 2019 

Florence on-line Training 

The Florence Clinician Training sessions have been created to help and support clinicians to become more capable and knowledgeable when implementing Flo into practice with their patients.

Delivered by one of the team here at Simple Shared Healthcare Ltd the sessions are scheduled to take place monthly.  Additional sessions can also be arranged by request either on a one to one basis, for teams or for those clinicians who are unable to join on the scheduled dates and times.

Delivered remotely via a web conference platform the session consists of a short presentation, a live demonstration of Flo via screen sharing and covers the following clinician activities in Flo:
  • How to add a patient
  • Adding protocols
  • Personalising protocols for patients
  • Reviewing readings and notifications
  • Patient discharge/transfers
  • Managing your clinician account preferences

Feedback from delegates so far has been that the sessions are easy to book with a good choice of dates, and they have recommended to colleagues who are new to Flo or wish to refresh their existing skills.






To sign up or find out about our upcoming dates please click here.  If you would like more information or would like to request a session for your local team then please email Kylie.Dentith@Simple.uk.net

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