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Shared Learning supports Best Practice: Implementation of Flo for BP Monitoring in Forth Valley

posted 18 Apr 2019, 04:20 by Hollie O'Connell

Colin McGregor  
eHealth Project Officer 

18 April 2019 

Colin McGregor is an eHealth Project Officer at NHS Forth Valley, and has taken a leading role in the expansion of Flo within Forth Valley.  Colin has recently taken some time to discuss his journey with Flo.

Why did we want to use Flo?

Here in NHS Forth Valley, we had 54 GP practices that all had slightly different processes around monitoring the blood pressure of their patients.  Most practices had adopted a light touch form of Home Monitoring by offering their patients a BP monitor to take home with them, and then write down their readings on a piece of paper to hand back into the practice at the end of the week.  This proved challenging for the practice as some patients either lost the piece of paper, or forgot to record their readings, which was subsequently delaying time for a diagnosis or any adjustments that were needed to their medication.

I first heard of Flo from Ann Allison, Technology Enabled Care Lead for Forth Valley.   I had come into post in December 2017, working with the TEC team helping to implement new ways of supporting patients to manage their conditions from home.  Ann’s enthusiasm about Flo sparked me to learn more, and I was impressed at how simple but effective Flo can be in managing a range of conditions.

How did we get started with Flo?

Working with our EPQI (Efficiency, Productivity, Quality and Innovation) team, we were able to create a plan of how we would offer Flo to services.  Due to local need and the strong evidence base that existed already, we decided to focus initially on Blood Pressure Monitoring within primary care and scale up from there.

Other health boards in Scotland who had already established the use of Florence were very happy to share their learning including processes and protocols.  With the potential to scope some regional work we decided to work closely with NHS Ayrshire & Arran to share learning across the two Health Boards.  This was massively beneficial in assisting us to develop our pathways, protocols and documentation.

Our protocols were slightly adapted versions of NHS Ayrshire & Arran’s BP monitoring protocols; Protocol 1 runs for one week for diagnosis or exclusion of hypertension, and Protocol 2 runs for 4 weeks to assist with titration of mediation for patients with an existing hypertension diagnosis.  We developed both protocols with the aim of assisting clinical decision making and reducing the number of appointments needed with clinicians, as well as helping patients feel more in control of their healthcare with helpful prompts to take their readings.

My efforts then turned to trying to engage some GP practices to become our pilot sites.  I attended a variety of meetings with both clinicians and practice managers to demonstrate and talk about Flo.   Five pilot sites came forward, although some still had concerns with regards to how effective they thought Flo would be for their practice.  We purchased 150 BP monitors and a supply of additional large cuffs to give to practices to help them get started.  We also built a helpful ‘practice pack’ which we would give out to practices, containing information for both clinicians and patients.  The packs contained a bundle of patient leaflets, a shared management plan and a clinician’s guide.

I provided practices with training sessions, which gave them information about Flo, how and why she works and how she could support patients to adhere to local clinician’s best practice in NHS Forth Valley.   During the training, I would give staff a run through of Flo, showing them how easy it was to navigate and to add a new patient.  I tried to make the training sessions last no longer than 1 hour, as it was a struggle to get any more time than this with busy clinicians. I feel that the best way to learn about Flo would be by starting your first 2 or 3 patients on a protocol and giving it a go.

How did we keep practices engaged?

We went live in our first five practices, and we were soon getting interest from others, so we decided to continue to work with practices more widely.   I was able to keep practices engaged by visiting them a few months after their go live date to iron out any teething issues.  I would also send out a monthly email to all practice managers to update them on progress with Flo across the Health Board, with an update of how many practices were live and how many patients had benefited in total.

What have we achieved with Flo’s help?

As of March 2019, Flo is currently offered to patients in 21 practices, and we have had over 200 patients interact with our BP monitoring protocols.

Feedback around Flo has been very positive, with one practice reporting they “saved 12 appointments after their first 9 patients.”

Patients have also found Flo very useful, with 100% of patients finding Florence easy to use and 91% saying that Flo helped them to more effectively monitor their blood pressure with helpful reminders.

Where next?

In recent months we have begun to use Flo to assist the Dietetics team with their weight management pathways and our Respiratory teams for COPD.  We are excited to continue working with Flo to ensure patients receive the best quality care through using innovative TEC solutions.

Ann Allison & Colin McGregor

Focus on: A Midwife's role with Flo

posted 3 Apr 2019, 05:24 by Hollie O'Connell   [ updated 5 Apr 2019, 00:17 ]

Anne Webb 

03 April 2019 

Anne Webb is a Midwife at Great Western Hospitals NHS Foundation Trust.  Anne has kindly taken some time to share with us her experiences of working with Flo as a clinician, for our new “Focus on Evaluation Project”.

What is your background and role within your organisation?

“I work in the Day Assessment Unit (DAU)/Antenatal Clinic as a midwife caring for women with raised blood pressure/symptoms of pre-eclampsia.”

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

“Our aim in offering Flo was to be able to provide our pregnant mums with the opportunity to safely take their own blood pressure readings at home, saving them from needing to attend the DAU for routine blood pressure check appointments.  We envisaged that this would have a significant impact, especially to those ladies prescribed medications that required twice weekly appointments.  When checking their blood pressure at home, ladies are more likely to be relaxed and record an accurate blood pressure reading.  This avoids the implications of either white coat hypertension, or raised blood pressure as a result of environmental factors associated with their journey or visit to the clinic.

Being able to send their blood pressure readings via Flo saves on childcare, parking costs, and ladies having to take time off work. Also, we all like using our phones, so it is easy to send their readings in to Flo.

Ladies are only prompted by Flo on Fridays to send their reading in.  We also have an antenatal clinic on a Friday specifically for blood pressure, so it’s easy to identify ladies for Flo.”

Were there any surprises?

“Flo is a different way of having an appointment; some colleagues have not been keen to change their way of working and are not always comfortable with having women take responsibility of looking after themselves.

However, most women record better readings for their blood pressure when taken at home, compared to clinic readings.  They also like the freedom of being able to do it at home with Flo, but they know they can phone if they have any problems.”

How do your patients feel about Flo?

“On our post trial survey, 100% of women would recommend Flo to their friends and are happy to be involved.  Ladies also check their blood pressure on other days (rather than just Friday when they are prompted to), as they have a machine at home to do it, and will phone the DAU if their readings are high.  This indicates an improved understanding of the implications of their blood pressure and provides an opportunity to intervene earlier with a change in treatment if required.

Gaining feedback has also been easier - as our ladies are already interacting with Flo, they are more likely to respond.”

What can you do more/less/differently with Flo?

“We will hopefully continue with Flo on a Friday as it appears to be successful.  Integrating Flo into our pathway has picked up ladies who are developing PET (pre-eclamptic toxaemia)/rising BP, where before they may not have sought medical help, or just waited to see their community midwife before getting reviewed.

We still review the ladies’ readings, even though Flo will ask them to phone the DAU if there are any concerns.  Sometimes the readings are borderline normal, so we use Flo to send our ladies a message to ask them to repeat their BP/retest urine sample.”

What are your future plans with Flo?

“We are going to use Flo with Elecys (a blood test to determine if a woman is at risk of developing pre-eclampsia); if the blood results are borderline, the ladies will then use Flo to monitor their BP/urine.”

Focus on: Primary Care Reception + Flo Lead

posted 22 Mar 2019, 05:08 by Hollie O'Connell

Beverley Holland 
Reception Lead 

22 March 2019 

Roundwood Surgery recruited Flo as a member of the practice team a few years ago, here is a video where Dr Milind Tadpatrikar and COPD patient Jim McCabe discuss how the surgery use Flo in General Practice.  In Roundwood’s 2015 CQC visit, the report cites their use of 'Flo' demonstrating that pragmatic telehealth solutions can be successfully implemented in General Practice and even contributed to their attainment of an Outstanding CQC rating.

Beverley Holland is the Reception Lead at Roundwood Surgery in Nottinghamshire.  Beverley’s role with Flo is quite innovative and whilst her role within the surgery is not clinical, Beverley works directly with patients, introducing them to Flo and helping them to get started.

I work at Roundwood Surgery as a member of the Reception Team.  My day to day role mainly focuses on the front reception desk, handling patient requirements, telephone calls, prescriptions, subject access requests and scanning, just to name a few things.

I was first introduced to Flo a couple of years ago while working as a part-time Receptionist; I was asked if I would like the opportunity to help patients get started on the Flo programme when we first launched Flo.

I was a bit apprehensive at first, as the appointments with patients were face-to-face, which was all new to me as usually I would have my colleagues with me in reception.  Sometimes patients would ask me clinical questions which I didn’t have the answers for straight away; however, I work with our Senior Nurse, Ian Jackson, who is also the clinician for Flo, and I make sure I get a reply to them following the appointment. 

Working Alongside Flo

In my current role, I work with Flo for two hours on Monday mornings, and also on Tuesday afternoons.  During this time, I will on average see 2 or 3 patients who have been referred through for Flo monitoring, usually due to having recorded high blood pressure.  I demonstrate how to use the Blood Pressure machine by putting the cuff on myself (I am not able to put the cuff on the patient due to me not being a clinician).

I then explain how Flo will interact, and how they should reply to her.  I also go through all of the ‘do’s and don’ts’ with the programme and explain to the patients how readings sent to Flo will be reviewed by the Surgery.  I finally check that they have understood the process and are happy to join the programme.  Patients are provided with an information pack to take home confirming everything that we have gone through, and I always add my name and Ian’s name so that they have a contact at the surgery.

After the appointment with the patient, I create their record in Flo and check that they have replied the same day to their first opt-in welcome message.  This ensures that the patients are up and running ready for their prompt the next day asking for their first Blood Pressure reading.

Once a month I liaise with Ian and give him a list of all of our patients on Flo.  Depending on their readings, Ian may ask me to adjust protocols for specific patients; for example if they can be switched from daily to weekly, to fortnightly and eventually to monthly once their hypertension has been stabilised through improved self-management.  Ian also has time set aside each week when he will access the patient’s readings and check how things are going for them.   For example if any patients have recorded particularly high readings, Ian is then able to intervene and provide care accordingly, such as sending the patient a message through Flo to ask them to book an appointment with him.  He is then able to check their readings against the surgery blood pressure monitors and decide if any medication is required or needs to be adjusted.

The Difference for Roundwood Surgery

I can honestly say that Flo is helping so many of our patients by having access to the hypertension programme and self-monitoring.  With Flo prompting patients to follow self-management guidance, readings are available in real time at the practice which means that patients do not need to make time and attend in person It is such an easy to use process, and only takes a couple of minutes of the patients’ time - and obviously Flo doesn’t cost the patient a penny.

I also have a number of patients using Flo to support their Asthma and COPD.  We use a similar process as with hypertension, but I demonstrate the relevant equipment.  The equipment provided for each chronic disease monitoring is all free for the patient.

I’ve also extended the Flo service to include DMARD (Disease-modifying antirheumatic drugs) patients who are on regular blood monitoring for antirheumatic medication, such as Methotrexate.  I asked our Flo System Administrators to design a protocol to assist with this for one, two, and three monthly blood monitoring, Flo will also nudge the patient to book a blood test at the surgery.  This is also proving to be excellent service for the patient.

Moving forwards, I have plans to develop protocols to support those patients who need regularly scheduled injections at the surgery, for example Depo and Vitamin B12.  This is with the aim of helping patients adhere to their treatment schedule, as sometimes appointments are not able to be booked that far in advance, so patients will receive a reminder prompt from Flo asking them to book an appointment at the surgery. 

Focus on: Technology Enabled Care Lead

posted 22 Mar 2019, 05:07 by Hollie O'Connell

Shona Burge 
Home and Mobile Health Monitoring Project Manager 

22 March 2019 

Shona Burge is the Home and Mobile Health Monitoring Project Manager at Angus Health & Social Care Partnership.  Shona has kindly taken some time to share her experiences of working with Flo from a Lead perspective with us for our new “Focus on Evaluation Project”.

What is your background and role within your organisation?

“Having spent 10 years in the voluntary sector while completing my degree, I moved to NHS Tayside in 2009.   My first post was within the Health Improvement Team working on a community led health project to support the nutrition of the under fives.  In 2016 my role changed, and as an employee of NHS Tayside I began to work for Angus Health & Social Care Partnership (HSCP) as the Home & Mobile Health Monitoring Manager.  My role within that post has largely been to introduce Florence to various services across Tayside, and also involves some work in the spread of Attend Anywhere and Video Conferencing.”

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

“We set out to meet our recruitment target of 350 patients recruited to Flo by the end of our 2 year TEC funded period, and managed to just surpass that.  You can find out how we did that in my other blog; Five steps to Florence"

Were there any surprises?

“I think the only surprise was some of the reluctance coming from some clinicians to adopt a new technology.  Not having a clinical background, I was surprised at how important it was for clinicians to be able to access patient data in the systems they were already used to.  Having worked with many different services now, I can see how busy their jobs are and can understand the need to know exactly which button to click when, so I try to make it as easy as possible for Flo to fit in and help out! 

It was also surprising to see how quickly patients personalise Flo by thinking of her as a person (referring to Flo by saying ‘she says’ or ‘her texts’), but at the same time value the anonymity that she gives them.  For example, one of our weight management patients said, She’s that friend you’ll tell your weight to’.”

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

"The three Health and Social Care Partnerships in Tayside, Angus, Dundee and Perth & Kinross have made a strategic commitment to Technology Enabled Care (TEC) within their respective Strategic Commissioning Plans.  Each are using TEC to act as a catalyst to the transformation of health and care services with the aim that technology becomes integrated as ‘business as usual’, thereby allowing more delivery of services at home and in community settings. 

In April 2018 NHS Tayside published their ambitious Integrated Clinical Strategy which makes a commitment to invest resources in our infrastructure, in eHealth, in technology and information systems that optimise our capacity and delivery of care.  Providing technology that enables community-based support, independent living and health monitoring solutions is identified as one of the factors critical to success.”

What do you consider your biggest success with Flo?

“Our biggest success would be preventing hospital admission for 4 of our Heart Failure patients.

Our Heart Failure Liaison Nurse using Flo reported that 4 patients had contacted the clinic before there was an exacerbation of their condition and that without Flo the patients would likely have remained at home until their condition warranted re-admission.

Each hospital readmission for this condition commonly averages out at a 4 day stay at a cost of £700/ day (based on 2015 costings).   This means that at least £28,000 was saved by Flo in that service alone – not to mention the patient benefit in staying well and not having to be readmitted to hospital.  This is something we’d certainly like to replicate.”

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

“We now find that Flo finds us; through word of mouth.  We do have enthusiastic advocates across Tayside who promote Flo, and as the Flo co-ordinator I go out to services to provide Flo demos and chat about the potential of Flo for service users and services alike.  We also have a Flo Newsletter that goes out approximately three times per year and this always generates a wave of interest from potential Flo users.”

What are the future plans with Flo?

“We would like to build on the areas that demonstrated most patient benefit while having a time/cost saving, for example areas like Heart Failure - and we hope we can engage GPs in this.  We are keen too however, to gain the same benefits for BP monitoring as some of our counterparts in other areas and have bid into the Scottish Government National Scale-Up BP Programme.  If successful in this, we will certainly be kept busy over the next few months and we think this could really change the tide in terms of how clinicians and patients alike perceive the role of technology in their own health care and enabling, and empowering people to take more control of their own health and well being.”

East Renfrewshire GPs go with Flo - 2018 evaluation

posted 15 Jan 2019, 02:17 by Hollie O'Connell

Joanne McKeeve 
Home and Mobile Health Monitoring Nurse 

15 January 2019 

At East Renfrewshire Health & Social Care Partnership we first introduced Flo in September 2017.  We are using Flo to assist in the management of hypertension – including diagnosis, titration of medication, and long-term management of the condition.  We have also started to implement Flo to assist in the management of COPD.

The decision to introduce Telehealth in East Renfrewshire was made several years ago when East Renfrewshire had a small part to play in the United4Health European project.  The United4Health Project was set up to assist European countries to meet the growing demands for healthcare services, and ran from January 2012 to December 2015.  It focused on finding ways to maximise new technology, such as telehealth solutions, to help improve healthcare, access to care, self-management and resource utilisation.  Following on from U4H, when Flo’s success was evidenced in other areas, such as Lanarkshire and Lothian, it was decided Flo would be used by East Renfrewshire as part of the National TEC Programme.

East Renfrewshire got off to a slow start in its implementation of Home and Mobile Health Monitoring (HMHM).  Several different models were looked at.  One suggested model was to have the Advanced Nurse Practitioners lead on HMHM, however, their already heavy workload prevented this model from going forward.  Our HMHM journey finally got underway when a designated clinical lead was recruited.  We created a new Flo hypertension pathway which was easy for our primary care partners to adopt, and developed a simple protocol which is user friendly for practitioners.  We are now proud to be able to share that 87% of East Renfrewshire’s GP practices have signed up and are trained to recruit patients to Flo, and 100% of GP practices have agreed to use Flo to assist in the management of hypertension.

We have recently carried out an evaluation of Flo’s impact when used to assist in the management of hypertension.  This was done as part of the national evaluation undertaken by Dr Helen Alexander, the purpose of which was to assess the outcomes achieved by Years 1-3 of Scotland’s Home and Mobile Health Monitoring Programme, and its success with scale-up, spread and sustainability.

The findings of our contribution to the national evaluation have shown some fantastic benefits for both patients and staff following the implementation of Flo, and the feedback from both groups has also been great.  For example, we have found that: 
  • 42% of patients were able to stabilise their hypertension with Flo’s help. 
  • Monitoring and titration with Flo has saved around 1400 face-to-face appointments as of the end of November 2018.  This means that our clinicians are able to ease some of the pressure on their caseload, and see more patients during their working hours.
A random selection of patients were surveyed about their experience using Flo, and we found that:
  • 100% of patients felt that Flo helped them to understand their health condition.
  • 100% of patients felt that Flo helped them to comply with health advice.
  • 93% of patients felt that Flo helped them to control their symptoms.
  • 73% of patients felt that Flo helped them to make lifestyle changes.
  • 80% of patients felt that Flo helped them to recognise when their condition was getting worse and when they needed to take action.
  • 86% of patients felt that Flo reduced the need for them to attend clinic appointments.
  • 100% of patients felt that Flo had been a positive experience for them.
As well as receiving such fantastic feedback, patient comments also gave us a further insight into the impact that Flo had for them:

It was excellent not having to miss work to attend the nurse to have my blood pressure checked.

It was fantastic. It really reassured me because of my family history of high blood pressure.

Alongside patients, a smaller number of health professionals were also surveyed; again, the results were fantastic, with 100% of those asked responding positively to the questions asked, including:
  • Flo aided better conversations with patients.
  • Flo aided better clinical decision making.
  • Flo aided patients to avoid unrequired/unwanted appointments.

The evaluation also includes two case studies of patients who used Flo to monitor their blood pressure at home, and in both cases the outcomes for the patient was significantly improved.  Both patients replied to Flo registering high blood pressure readings, upon which Flo advised them to seek out of hours help.  Had the patients not sought further appropriate medical support on Flo’s advice, then the consequences may have been considerably worse, including the potential risk of stroke.  If you would like to read about these case studies in more depth, then please take a look at the full evaluation below (membership required).

Post-discharge reassurance and support for patients and carers

posted 8 Nov 2018, 11:49 by Hollie O'Connell

Agnieszka Belz  
Pharmacy Technician Carer Support Worker 

08 November 2018 

Agnieszka Belz is a Prescribing Support Pharmacy Technician at NHS Lothian.  Agnieszka was first introduced to Flo as part of her role as a Pharmacy Technician Carer Support Worker within the Edinburgh Carer Support Team.  The team recruited Flo to continue the conversation and provide patients with additional advice and signposting after being discharged from hospital.  Agnieszka employed Flo as a medication prompting tool and has shared her experiences of how Flo has motivated her patients to increase adherence with their medication during this key transition from hospital to home.

How did I hear about Flo?

I already had some knowledge that local clinicians were innovating with Flo across NHS Lothian.  They were experiencing really positive outcomes that were being demonstrated across various aspects of patient’s health.   I had identified a cohort of patients under my care, who would benefit from some support aimed at improving their adherence to their medication regime.  As I was searching for a tool to support this, Flo sounded like a great match as an opportunistic tool for the patients and carers I supported.   Therefore, the Edinburgh Carer Support Team chose to innovate with Flo to support unpaid carers in their roles relating to medication compliance.

Why did I want to use Flo?

My passion is to support patients and their carers with their medication during and after their hospital discharge, which can understandably be a difficult time.  So far I have learned that discharges, and the changes associated with leaving hospital, bring lots of anxiety and uncertainty to family members and friends.  Family and friends often undertake the role of unpaid carers and they shared with me some of the issues which they experience:

“ How will I remember to remind my loved one to take their new medication? 

“ Will I be able to leave the house without worrying that my loved one will take their medication or will I have to stay with him during medication administration times? ” 

Locally, I shared my idea with Elizabeth Payne, who was my line manager and the Project Development Manager at the time.  Elizabeth was more than happy to support me in implementing Flo as a remote medication prompt for my patients and their carers.

What stood out for me about Flo?

Probably that I could easily create a medication reminder prompts specific to the patient or carer’s individual needs, and even include additional advice for specific medications that was meaningful, e.g. “take out of the fridge”, or “take with full glass of water”, which for some patients is very important and makes adherence more likely.

What were the potential benefits of using Flo?

Once we began to introduce Flo to our patients, I found that there were many potential benefits for my patients and their carers, including:

  • Helping to prevent hospital readmission through the correct administration of medication
  • Safer use of medication due to improved compliance
  • The ability to provide updated information in the reminders when medication changed, or allowing me to make an opportunity to discuss their medication over the phone 
  • Improving independence with no need for a package of care with medication prompts upon discharge
  • Reduced stress for patients and their carers
  • Allowing patients and carers to take part in ‘out of house’ activities, for example carer going to work or on holiday
There were also additional benefits that became apparent for my own clinical practice:

  • I was able to learn more about certain medication regimens which in turn allowed me to provide enhanced care for patients. My learning came about from creating and agreeing the times for medication prompts with the patient and carer.  I found that the routine at home after discharge was different to that while in hospital, so I had to take patient’s lifestyle and habits into consideration.   When creating prompts for the specific agreed times, I had to consider how certain medication worked in relation to food and storage, for example if the medication required refrigeration, how long could it be left unrefrigerated to support the patient’s routine and compliance?  When working with one patient, I researched more about their medication storage, and found out that in certain quantities it was ok to store it at room temperature for number of days.   This meant that the patient could keep it together with other medication, having it all ready when Flo’s prompt arrived.  Identifying issues like this and applying the learning from it helped to improve other patients’ compliance.

What were my first steps with Flo?

One of the first protocols that I developed was aimed at supporting a specific patient who had been diagnosed with Parkinson’s disease, and her sister who lived with her and acted as her carer.  Due to the nature of the condition, the times that the patient’s medication needed to be administered are very specific; if patients with Parkinson’s Disease do not receive their medication on time, their ability to manage their symptoms may be lost.  Therefore I had to consult with the Parkinson’s Nurse in the Western General Hospital for additional input to ensure that the protocol design was accurate.  I decided to use a general medication reminder protocol, and then was able to personalise the protocol for this patient matching Flo’s interactions with the patient’s medication regime.  I found that integrating Flo was quick and easy to manage, and I received great support from the Flo team.

"The Power of Social Media" with Joan Pons Laplana

posted 5 Nov 2018, 01:50 by Hollie O'Connell   [ updated 6 Nov 2018, 00:33 ]

Hannah Mountford 
Assistant to Director of Services and Community 

05 November 2018 

The Simple Telehealth Community of Practice is at the heart of Simple Shared Healthcare’s model.  Supporting members to embed sustainable innovative practice is our primary objective by investing in organisations to support a continual increase in capability to ensure both patients, and the organisation benefit from evidence based implementations for the lowest possible cost.  Through discussions with Community Members, a focussed session concentrating on the abi
lity of social media to not only engage, but to share and recognise innovative clinical practice was arranged.  Simple Shared Healthcare were thrilled to host this exciting learning opportunity.

Joan Pons Laplana kindly took the time to deliver a webinar called “The Power of Social Media” to our community members.   Joan has been a nurse for over 20 years, and is now a clinical fellow at NHS Digital.  Joan is passionate about empowering both staff and patients; he is a champion for using social media in healthcare, and wants to inspire others to embrace it.  Joan has won a number of awards for his innovative approach to healthcare, including the Nursing Times Nurse Tweeter of Year 2014, and the BJN “Nurse of the Year” Award 2018.

After being introduced by Kylie, Joan started the webinar by discussing some of the issues around how the NHS shares and communicates with both staff and the public.   Joan shared that within a busy NHS workplace, despite the associated issues of missed emails and inbox backlog, email still remains the main method of communication and sharing across organisations.  Joan feels that many NHS Communications teams would benefit in engaging with frontline staff, and that even the best campaign can fail if it does not reach the intended audience.

Why go social?

The use of social media has massively increased over the past decade; people connect to social media multiple times a day, and almost 60% of smartphone users don’t go an hour without checking their phones.  For young people, social media plays an even greater role in their day to day lives. Joan then showed us a short video called “The Social Media Revolution 2017”, which shared further statistics about social media use worldwide, including:
  • Facebook added over 2 million users in less than a year
  • 80% of companies use social media for recruitment
  • 50% of the UK’s mobile internet traffic is for Facebook
Social media has allowed people to connect with others on a global scale; we no longer work in silos, and we can organise our lives from the palm of our hands.

However, despite this development, the NHS has not yet kept pace with change, and Joan believes that this needs to change;

The question isn’t ‘Do we need to do social media’, it should be ‘How well are we going to do social media?’

Joan went on to discuss how using social media has changed how he works and cares for people.  He feels that it has opened a lot of doors for him, and has put him in contact with great projects and people.  Social media has given Joan a platform to share his passion leading him to meet important individuals in the healthcare sector, speak at large rallies and conferences, and even appear on television.  Joan feels that if it were not for the extended reach he has gained from an active social media presence, then he wouldn’t have been able to do any of this.  Although social media has come about through developments in technology, Joan strongly believes that social media is about the people “behind the screen” and the connections and relationships they are able to make through sharing and networking with others.

Another great bit of advice from Joan is to make use of data analytics about your social media accounts.  This allows you to see who you are reaching, what sort of posts are more viewed compared to others etc.  This can help you to improve how you use social media for your campaigns; using social media to its full potential allows you to reach a much larger audience, especially if it goes viral!

Framing your projects

As Joan pointed out, 
successful campaigns and projects commonly create branding.  For example, a hashtag will make any posts easily searchable, while logos provide an easily recognisable visual aid. Joan highly recommends framing any project like this to help it succeed.  Joan also believes that you should try to make your campaign fun.  Frontline NHS staff are very busy, and may often find themselves bombarded by information.  However, if you make your campaign fun, then they are far more likely to engage with the project.


Click image to enlarge 


Joan created the hashtag #FloMania whilst working as the telehealth lead at Derbyshire Community Health Services.  #FloMania continues to be used when sharing Flo news, and is used both nationally and internationally, helping Flo users discover, share and connect with other Flo users more easily.

Social Media is a very powerful tool, that if used correctly, has endless possibilities.  Never underestimate the power of twitter.

Joan's “10 Commandments for Social Media”

  • Create an account in multiple platforms – many of them connect with each other to make sharing easy, and they are free!
  • Read the Code of Conduct from your Professional body before posting.
  • Brand your campaign. Logos and hashtags help to make your campaign more memorable and engaging, and make sure you know your audience.
  • Add pictures or short videos to your content – when browsing social media people pay more attention to these kinds of post compared to just text.
  • Tag people and organisations to improve the reach of your posts.
  • Remember that social media is not just broadcasting – it’s a two-way system and you have to engage with people who contact you as a result of your posts.
  • Remember to network and create links by following like minded people.
  • Avoid conflicts and agree to disagree with people.
  • Always make the journey fun.
  • Maintain a positive attitude.

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.

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