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Sharing Experiences and Knowledge: Supporting Asthma Care with Flo in a Rural setting

posted 19 Aug 2019, 02:35 by Hollie O'Connell

Hannah Mountford 
Assistant to Director of Services and Community SSHC 

19 August 2019 

Our Member’s “Network Calls” enable peer to peer sharing across a single area of clinical interest, providing clinicians working within specialist fields the opportunity to hear from their peers to discuss their own experiences and learning with Flo.  The third “Respiratory” Member’s Network Call took place in July featuring Corinne Clark, Respiratory Specialist Nurse from NHS Highland.

What attracted you to integrating Flo into your service?

Corinne gave us an inspirational overview of how she has firmly integrated Flo into her service, helping her to care for patients on the team’s caseload who have been diagnosed with asthma.  Corrine specifically supports patients with Flo whose asthma is poorly controlled which can lead to acute exacerbations, and for some potentially near-fatal asthma attacks.  Corinne explained that there was also a specific group of patients who were not engaged with their healthcare, which puts them at further risk of exacerbation.  Corrine identified that Flo would be able to increase the engagement of these patients to self manage their asthma better, and ultimately lead to an improvement in their asthma outcomes.  Corinne has the additional challenge of rurality, as she is the only specialist covering acute asthma for a large geographical area, where patients may have to take a 5 hour round trip to attend a clinic appointment. 

How does Flo support your patients?

The inclusion criteria for patients accessing Flo as part of NHS Highlands asthma pathway included:
  • The patient has a confirmed diagnosis of asthma;
  • The patient has had a previous hospital admission for acute exacerbation of asthma;
  • Or, the patient had been referred to the Respiratory Community Nurse for specialist input.
  • Patients also need access to a mobile phone to interact with Flo.

Patients are provided with a peak flow meter and a 7 day supply of their prescribed rescue medication.  The protocol that the patient is enrolled onto is assessed by Corrine according to their current best peak flow reading.  Flo then acts as an electronic asthma action plan for the patient, prompting them to take and reply with their peak flow readings.  The patient’s peak flow reading will fall into one of four zones; Flo replies to the patient motivating them to follow the appropriate advice according to each zone. 

What were your outcomes with Flo?

The integration of Flo into the asthma pathway delivers benefits for both Corinne, her patients and the wider health care economy in NHS Highlands, and this is supported by external evaluation by Maria Wolters from the University of Edinburgh. 
  • 100% of patients would recommend Flo.
  • 94% agreed the protocol was easy to understand.
  • 88% agreed that Flo helped them to self manage.
  • Asthma inpatient hospital admission decreased from 129 to 29.
  • The average number of bed days decreased from 52 to 15.
  • GP contacts decreased from 6 to 1.6 per patient.
  • Primary care showed an improvement in the appropriateness of medication reordering.

In addition to the findings from the evaluation, Corinne also reports fewer DNAs to her clinic since implementing Flo.

 Further development & future plans

NHS Highlands have worked to integrate Flo’s Data with SCI Store (an information repository that provides clinicians with secure access to patient information at the point of care), whereby on a monthly basis the data is migrated across so that it is available for all clinicians with access to view the SCI Store.  Corinne has also presented the results of using Flo for Asthma across the country, as well as visiting Milan to talk about her success with Flo at the European Respiratory Society International Congress in 2017.

Looking to the future, Flo will be incorporated into “Near Me” clinics (whereby patients have an appointment with a clinician via a video), which will enable more effective conversations around the patient’s health.  Corinne is always looking to develop and refine the protocols that she has created with Flo, for example, Corrine identified that it would be useful for clinicians to understand the frequency of patients starting their rescue medication.  Flo now prompts the patient asking them to confirm this in order for clinicians to monitor how often this happens and plan any adjustments to treatment accordingly.  Additionally, Corinne and the telehealth team have developed a “Florence Lite” protocol to extend the reach of Flo’s support to the cohort of patients who require less frequent interactions.  The new protocol motivates the patient to take and send two peak flow readings per week over a 3 month period and is then reviewed.  It is hoped that this will be of interest to Primary Care services and will help the spread and adoption of Florence further across NHS Highlands.

Treating MS in a rural setting

posted 5 Jun 2019, 03:24 by Hollie O'Connell   [ updated 5 Jun 2019, 05:30 ]

Hannah Mountford 
Assistant to Director of Services and Community SSHC  

05 June 2019 

Flo supports both patients and clinicians in a challenging healthcare environment 

Scotland has the highest prevalence of Multiple Sclerosis (MS) within the United Kingdom, whilst NHS Western Isles is amongst 6 health boards with the highest prevalence nationally.  Clinicians working with the Western Isles face a number of challenges due to the rural island setting, including adverse weather conditions and long travel times.  Flo’s simple and proven methodology is now being used to support patients and clinicians managing MS in these challenging conditions.

In 2012, a specialist MS nurse was appointed to support patients in the Western Isles, covering all nine islands and an area of 3,071km².  Taking into consideration both the challenges of rurality and geographical area to be covered, the MS nurse felt that Flo could provide patients with additional support in between their clinical contacts to improve their confidence to self-manage their condition and adhere to their prescribed treatment.

NHS Western Isles’ MS pathway now includes Flo to specifically support patients who are taking DMDs (Disease Modifying Drugs).  Dependant on the specific drug prescribed for the patient, there is a requirement for regular blood testing fortnightly, monthly, 3 monthly or 6 monthly.  Flo gently prompts patients to book these appointments, which helps to ensure patient safety by improving adherence to clinical guidelines. Having up to date blood test results which are available for review also ensures patient contact is timely and effective, which is especially important given the amount of travelling required for both patients and clinicians in the Western Isles.

Kathleen Smith is a student doctor at the University of Aberdeen, and as part of her 5th year elective, completed an evaluation of patient’s experience of using Flo for MS.  Patients were asked to complete a questionnaire about their experience of using Flo using a rating scale of 1 -10, while also providing any further comments they wished.  Additionally, two healthcare professionals involved in the initial setup and current use of Flo (TEC Project Manager and specialist MS nurse) were involved in the evaluation and completed a separate staff questionnaire.
Patient’s responded very well to Flo, and their feedback reflected how Flo’s simple, supportive messages can make a difference in giving patients the confidence to self-manage their condition:
  • 100% of patients rated Flo as extremely easy to use.
  • 87% of patients rated Flo with the highest score of 10 when asked how useful Flo was in the management of their condition, while the remaining patients rated Flo’s usefulness as 8/10 or higher.
  • 100% felt that Flo was not at all intrusive in their daily lives.
“ Great reminder for management of my MS ”  

Good reminder for my bloods because I often forget until I get texts ”  

I am so happy with ‘Florence’, she is so helpful

Feedback from healthcare professionals was also positive; the MS Nurse responded that Flo was easy to use, was extremely useful in the management of MS, and felt that patients engaged very well with Flo.  They also commented:

[Flo] is such a valuable support for me as a lone working clinician covering a wide geographical area… [Flo is] extremely beneficial in reducing my workload

The TEC Project Manager responded that Flo was easy to initiate in clinical practice, and that protocols are relatively easy to set up, dependent on the type of pathway and its aims.

The use of ‘Florence’ in MS management has overall impacted patient care and healthcare professionals positively.  Patients feel the service is useful and healthcare professionals feel ‘Florence’ has decreased workload.  The service is simple and also provides valuable feedback for patients.   Expansion of ‘Florence’ into other areas of healthcare, and the ability of pathways to be tailored to individual patient needs, will create new uses for the service.

It is fantastic to be able to share this evaluation, and to know that Flo is really making a difference to patient’s lives, as well as supporting clinicians who work in unique and challenging settings to provide high quality patient care.

Flo’s role in upskilling practice nurses - supporting the integration of TECS into everyday practice

posted 30 May 2019, 01:40 by Hollie O'Connell   [ updated 22 Jul 2019, 02:52 ]

Hannah Mountford 
Assistant to Director of Services and Community SSHC 

31 May 2019 

As the NHS works to meet increasing patient demand, Technology Enabled Care Services such as Flo offer a creative solution to help mitigate some of the ongoing pressures.  Flo has been featured in a number of publications that address the need for GP practices and other health care providers to embrace technology as an enabler to improving outcomes, while potentially reducing some pressure from the system. 

While the articles (available below) discuss a number of current healthcare delivery challenges, there is an overarching focus on aiming to improve the uptake and use of TECS, specifically by practice nurses, to help to mitigate some of the pressures on the system.  The articles point to a need for general up-skilling amongst practice nurses to enable the adoption of TECS; it is essential that nurses feel confident enough to integrate technology into how they provide care for their patients.  For example, from the patient’s perspective, being introduced to Flo as a tool to support self management by a nurse who is comfortable with Flo is reassuring and motivating, and could potentially lead to improved health outcomes due to better patient engagement in their health. 

Here are some examples of how Flo is making a difference for patients and nurses alike: 

Doing much of the hypertension monitoring using Florence Simple Telehealth has:
  • Improved compliance by sending twice-daily reminders.
  • Saved on appointments, as follow-up of patients can be done by phone.
  • Reduced time wasted on appointments when patients returned without their home readings.
  • Reduced time wasted chasing patients to return their sheets.
Primary Health Care, volume 28, issue 7

Flo telehealth can be a valuable tool to help patients with COPD self-manage at home and can reduce the need for as many surgery visits if the patient’s texted responses trigger advice to take standby medication without delay, improves their compliance with medication, reduces overall anxiety and ultimately avoids hospital attendances or admissions ” 

Practice Nurse, June 2018

Shropshire and Wales Regional Network Event

posted 28 May 2019, 02:29 by Hollie O'Connell   [ updated 29 May 2019, 03:46 ]

Kylie Dentith 
Technology Enabled Care Support Assistant SSHC

29 May 2019 

The Shropshire & Wales Regional Network Event was held of 20th March 2019, hosted by Telford & Wrekin CCG and as usual was an inspiring day for sharing and making new relationships.

Regional events take place across the UK to provide community members with the opportunity to meet and discuss their current and proposed pathways, share best practice and offer the potential for future collaboration and system wide pathway development with member organisations also using Flo nearby.

Regional events are a great opportunity to share and celebrate the clinically driven innovation taking place across the region.  The day was kicked off by Lisa and Karen, who warmly welcomed attendees to the event and gave an update of recent news and events from around the Simple Telehealth Community. 

Lisa and Kylie gave a brief overview of Flo’s role within the NHS England Test Bed at University Hospitals of North Midlands NHS Trust (UHNM) “Smart with Your Heart”, which is based on a successful pilot at UHNM where the cohort demonstrated reduced admissions for patients after discharge when supported by Flo.   With Flo as one of the three digital partners, previous learning is being scaled up and the team at UHNM have developed a pathway that will ask the patients for daily responses about how they are feeling, or about their symptoms in conjunction with their symptom checker to increase awareness and confidence of any actions they need to take.  Patients will be prompted at the end of the pathway to answer four evaluation questions which will support the team in their final evaluation for NHS England, and to inform a sustainable approach to continuing the service.  More information is available here

Hollie O’Connell, Assistant to Chief Innovation Officer and Chairman - Nellie Overview

We then made the most of using technology by joining into a web conferencing platform with Hollie O’Connell.  Hollie gave an introduction to Nellie (our next generation system) and shared the way in which the features and interface have been designed and created to reflect the learning from Flo.

Kath Lloyd, Service Development Manager for Therapies and Health Sciences , Powys Teaching Health Board

Kath kindly gave an overview of Powys’s journey so far with Flo. Powys first introduced Flo with a workshop in 2016 with positive clinical feedback securing Flo from October that year.  The first patient was recruited to Flo on the 31st October 2016, and throughout 2017/2018 interest spread across other clinical teams throughout Powys.
Pathways supported by Flo include: 
  • Falls
  • Respiratory
  • Pulmonary Rehab
  • COPD Maintain and Monitor
  • Diabetes Education
  • Diabetes Non-Metformin
  • Pain Management
  • Blood Glucose in the South of Powys
  • Parkinson’s Disease
Patient feedback from a variety of the above protocols:  

“ Flo encourages me, I like the little tips and reminders ”   

“ I find it very helpful and it has benefited me  

 Flo has improved my diabetes and general wellbeing ” 

 Flo has motivated me and shocked me into making changes. ” 

Feedback from clinicians:  

 I feel the small aspect of Flo has created a large impact   

 The patient, who is on 7 doses of meds per day, is feeling the benefit of Flo after a few days. 

The team are now looking to introduce Flo within GP Practices to use with their hypertensive patients and also with their local CAMHS team.  The team are also looking to recruit a Telehealth Coordinator for 3 days a week to support the rest of the team to spread the use of Flo across the health board. For more information please see here

Kath Fackrell, Voluntary Services Link, Shropshire Community Health NHS Trust

Kath, along with Wrekin Housing Trust and the Carers Centre have collaborated on working on a pathway for patients that are discharged from the hospital, to go back home and recover with the support of a carer. 

Kath shared a few of Flo’s interactions that are included in the pathway such as messages with contact numbers for further support, information on discounts they can get at venues like the Theatre for example, and general information on keeping well.  To ensure the patients and carers are fully informed with all relevant information, the team created a patient information leaflet, which includes information on free-to-use texts, what Flo is and what the patients will receive once enrolled onto Flo.  Some of the patients that will be introduced to Flo may not have their mobile phone with them at the time of enrolment, so the team has also added what to do if this is the case to the leaflet.

The team also created a consent form which all patients will be required to complete before being able to be enrolled onto Flo.  The information that is on the patient information leaflet is also covered on the consent form. 

Maximising the Impact of the Initial Introduction to Flo

Karen and Lisa delivered a lively session on maximising the impact that the initial conversation between patient and clinician has on patient engagement when introducing Flo, a session suggested at the previous meeting.

The importance of the patient's initial introduction to Flo by their clinician cannot be underestimated.  While still relatively new within healthcare, supported self management with technology as an enabler can be a relatively new concept to both patient and clinician, and one that certainly becomes more natural with experience, particularly as clinicians begin to see and feel the impact that Flo’s interactions have on the behaviour of their patients. 

Learning from across the Simple Telehealth Community of Practice demonstrates that for some clinicians, discussions with their first few patients when introducing them to Flo can be the most difficult as they begin to familiarise themselves with not only the concept of technology as part of healthcare management, but the cultural shift in motivating the patient to take more responsibility for their self care outside of the routine face to face clinical environment. 

Similarly for the patient, the same cultural shift needs to take place.  The most powerful positive influence around this is derived from the confidence demonstrated by the patient’s own trusted clinician in this initial conversation.  Where a clinician understands and articulates to the patient the benefits that additional support to their self management can bring, the rate of acceptance and subsequent engagement substantially increases.

Confidence in the clinician can be assured by focussing on a few factors.  Often where a clinician has been involved in the design of the new pathway from the start, this confidence is apparent much sooner as a result of their depth of understanding both of the rationale and process.  However as the number of clinicians integrating Flo into their clinical management spreads for example across a team, it’s vital to dedicate time up front with new clinicians to assure the depth of understanding also spreads. 

Once a clinician begins to experience the anticipated benefits within their own patients, a unique opportunity develops, and new initial conversations organically start to feature context from the clinicians previous experiences when their patients have been supported by Flo, which is then very easy for the patient to understand. 

To bring this to life, Karen and Kath Fackrell used role-play to demonstrate a scenario with Karen being a clinician and Kath a patient.  The scenario demonstrated clearly the correlation between the patient’s acceptance of Flo and their clinicians confidence both in the rationale for use and explaining what the patient should expect, and what they may need to do. 

The role play ignited a discussion on how to enhance the way clinicians approach to this initial conversation.

  • The value of training was highlighted as an area that can be reinforced locally to provide assurance and confidence around the rationale for introducing Flo, and also to reduce any personal fear of technology that the clinician may bring.
  • Specifically highlighting the importance of this initial patient to clinician conversation was also suggested as a dedicated topic to cover within routine training. This was also raised as an effective method to be able to unpick any additional gaps in knowledge or skills that can be supported early on.
  • The group discussed how insufficient understanding can often be enough to deter clinicians from introducing Flo to their patients, or can result in a poor quality discussion. Offering the clinician a prompt or guide on what to remember can motivate them to embark with those first few patient discussions. This can often reassure clinicians enough to make a start with recruiting patients.
  • The conversation between the clinician and the patient needs to be informative for the patient but simple enough for them to understand what they need to do and when, and what Flo means for supporting their condition.
  • It is optimal to be able to add the patient to Flo during this initial discussion as it assures the patient’s competency around their use of Flo demonstrated by them replying to her to opt in, that they have provided the correct mobile phone number and reassure the clinician that the patient will start to receive Flo’s support. A shared management plan and patient information leaflet reinforces this conversation and allows the patient to reflect and compound their understanding in the first few days of Flo’s support. For patients who wish to reflect on whether they want to join in, patient leaflets can provide a good overview of Flo, who she is, how she works and explain what to do if they do decide to join.

Flo Focus On: Strategic Leads

posted 13 May 2019, 05:25 by Hollie O'Connell

Janet Davies 
NHS Test Bed Programme Manager 

13 May 2019 

Janet Davies was the Test Bed Programme Manager for the LCIA Test Bed during wave 1 in 2016-18, and wave 1.5 in 2018-19.  Janet has kindly taken some time to share with us her experiences of working with Flo for our new “Focus on Evaluation Project”.

What is your background and role within your organisation?

I have over 12 years’ experience in a senior management role, and 26 years of operational management.  During the past 16 years this experience has been within the NHS, however I have undertaken management roles in Private, Voluntary and Statutory sectors.  As Test Bed Programme Manager, I have responsibility for the delivery of the Testbed programme. I report to the Programme Board and the Programme SRO.

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

Flo was one of 7 technology partners chosen to work with the Test Bed to implement and evaluate a combination of technologies and practices aimed at supporting older people (aged 55 +) with long term conditions (LTC) to remain well in the community, avoiding unnecessary hospital admissions.  The combinatorial health technologies were designed to better enable older people with LTC to self-care at home and to improve patient activation.  The LTC included COPD, heart failure and dementia.

The LCIA Test Bed was delivered through two neighbouring Vanguard sites – the Fylde Coast Local Health Economy and Morecambe Bay Health Community (Better Care Together), located in Lancashire and South Cumbria.

Both our Vanguards were focused on population-based new models of care that were central to delivering the vision of the NHS Five Year Forward View: integrated primary and acute care systems (PACSs) and multi-specialty community providers (MCPs) whose focus was on integration.  The MCP model was designed to dissolve the historical divide between health and social care.  It involves redesigning care around the health of the population, irrespective of existing institutional arrangements. Blackpool Fylde and Wyre (Your care, Our priority) was a MCP Vanguard.  Better Care Together was a PACS Vanguard. PACS were based on GP registered lists with the aim of improving the physical, mental and social health and wellbeing of the local population and reducing inequalities.  PACS were designed to bring together health and care providers with shared goals and incentives, so they could focus on what is best for the local population.  Critically, the general practice was at its core.

Patients with LTCs were recruited to one of three cohorts depending on their level of risk of hospital admission (Cohort 1 being the highest risk category); individuals with mild to moderate dementia were recruited to an additional Cohort 4.  The combination of technologies each patient received was dependent on their level of risk and their primary LTC.  Flo was used within Cohort 2 in which patients had a risk score of 10% - 25%. Protocols were developed with clinicians for Falls, COPD, Heart Failure and carers.

Patients were recruited to the Test Bed through the clinical teams within the Vanguard, which for Better Care Together was GP led, and were taken from the patients lists using risk stratification through Aristotle.  In Fylde Coast, patients were identified by teams e.g. Pulmonary Rehab and Falls Team. 

Were there any surprises?

Engagement with staff was sometimes challenging and we experienced some resistance from teams to using technologies including Flo, with capacity being the most frequently cited barrier.  Due to the nature of testbeds being proof of concept rather than an introduction of new working practices, teams were required to continue with their traditional pathways alongside the new technologies we were asking them to try.  This sometimes meant that information was available in both existing pathways and new technologies, and so using new technologies for monitoring was often not a priority in an already busy workload.

Self-management as a concept is also relatively new and demands a real shift in thinking for teams in respect of delivery of care, which has historically been clinician led. As a team we were able to meet each concern as we went along, working closely with teams to break down barriers whether this be related to capacity or something more practical in nature such as the supply of handsets for patients who didn’t own a mobile phone. However as with any change in practice, there were of course some teams who were unable to overcome their local challenges to be able to fully engage with the testbed. 

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

Flo was an integral Partner in the LCIA Test Bed.  While that programme has now concluded, the knowledge and understanding of Flo will however remain with the Test Bed leadership Team, who are now working with Healthier Lancashire and South Cumbria Integrated Care System to take forward the Technology Enabled Care agenda, starting with a Digital Discharge Bag.

What do you consider your biggest success with Flo?

Most patients interviewed in Cohort 2 experienced an increase in confidence in relation to their health as a result of taking part in the Test Bed.  This was linked to an increase in knowledge and skills, resulting in people being better able to self-manage their health.

  • 83% of Cohort 2 indicated an increased confidence about their health.
  • 94% with a risk score 10% - 25% indicated increased knowledge and skills enabling self-management of LTC.

The majority of Phase 2 patients in Cohort 2 had COPD.  Most found participation in the Test Bed programme helped them to learn about their condition and how to better manage it.  Participation in the Test Bed programme also had a positive influence on daily activities for some participants, with the biggest impact occurring in Cohort 2.

In addition, there was an overall total cost saving for Cohort 2 participants using Flo of approximately £133 per patient. 

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

To help us to engage with clinicians, we set up ‘Use of Clinical Operation Groups’ for each area (Better Care Together, Fylde Coast and Dementia), as well as providing a number of updates to encourage use of Flo and other TEC in the Test Bed, including: Innovator monthly updates, reporting as part of Board updates, as well as weekly updates for those using Flo and other TEC within the test bed. 

What are the future plans with Flo?

Despite the Test Bed ending, we have learnt a great deal and improved our understanding of Flo and how her unique persona can support patients with LTC improve their self-management and in turn their long-term outcomes.  The Test Bed leadership Team‘s experience and learning with Flo will support our work as we take forward the Technology Enabled Care agenda with Healthier Lancashire and South Cumbria Integrated Care System, beginning with the Digital Discharge Bag as I previously mentioned.

Information regarding the impact of FLO as part of a combinatorial approach to managing long term conditions has been reported as part of the Phase 1 and 1.5 evaluations, and you can find out more about the test bed here.

Focus On: Clinical Applications

posted 7 May 2019, 03:08 by Hollie O'Connell

Ann Hughes 
Practice Nurse / Telehealth Facilitator 

07 May 2019 

Ann Hughes is a practice nurse working within Northern Staffordshire CCGs.  As part of our “Focus on Evaluation” project, Ann has shared with us her experience of using Flo as a Clinician, but also her Role as a Flo Champion to support spread and adoption of Flo, first locally and now at a national level.

What is your background and role within your organisation?

"I have been a nurse for many years; early in my career I primarily focused on acute care areas, but gradually moved over to primary care some 16 years ago.

For the last few years I have been sharing my time between my patients at the surgery and our Digital Nurse Programme, supporting other clinicians across our organisation to introduce a range of technologies, including Flo.  Having used Flo myself for a number of years I have been able to share both my own and my patient’s experiences with colleagues to promote better management of common long term conditions.  More recently Staffordshire’s Digital Nurse Programme has been commissioned nationally so I have been travelling across England to share my experiences via our Action Learning Events."

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

"I set out to offer patients another way of managing their condition; whether that be a simple text reminder so as not to be late with, or miss taking their prescribed medication, or a pathway of simple health advice messages from Flo that help them adhere to their shared management plan around their condition.

Some of my patients require additional support from one of Flo’s interactive message protocols.  For example, a 7-day hypertension diagnosis protocol, or for patients with already diagnosed long term conditions, protocols such as COPD self-management supports them to take their rescue medication more efficiently and improves their confidence to self-manage their condition."

Were there any surprises?

"I was surprised by how much impact a simple text message from Flo can have on patients, supporting them to self-manage their health and improve their long-term outcomes."

How do your patients feel about Flo?

"The majority of my patients like or love Flo, but I think that when you first start out, picking the right patients to promote Flo can be really helpful too.

The only occasional negative comment was that there were too many messages sent on certain protocols, but that could be rectified by editing the protocol alongside the patient to remove the unwanted messages.   It can be difficult to judge, as some patients benefit from the extra support the additional messages could provide, but Flo’s flexibility really helps to tailor protocols to each patient."

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

"With Flo I am able to support patients with timely reminders to make often essential regular appointments, whether that is for routine B12 vaccinations, or essential cancer medication for the control of the disease.  Flo helps me to support patients to take their medications as prescribed or attend appointments to achieve better control and outcomes.

Reminding patients to make and attend appointments has helped to free up capacity by reducing missed appointments, and she also helps me to make quicker, more informed decisions when it comes to diagnosing and treating patients.  For example, I can quickly diagnose patients with hypertension using a 7-day protocol with Flo, compared to the standard practice which would mean the patient making several visits to the surgery amongst other things. "

What are your future plans with Flo?

"I will of course be continuing to support the spread of Flo in my role as Telehealth Facilitator across the Staffordshire area to support local adoption, but I’m really excited to be able to share my experiences more widely via our Action Learning Events which will be taking place all over the country this year. "

Breastfeeding Support in Dudley: Sharing learning and best practice across our Maternity Members Network

posted 2 May 2019, 01:22 by Hollie O'Connell   [ updated 2 May 2019, 06:13 ]

Kylie Dentith 
Technology Enabled Care Support Assistant 
Simple Shared Healthcare 

02 May 2019 

The latest Maternity Members Network Call featured Dudley Metropolitan Borough Council’s Breastfeeding Support Team, sharing their learning and experience since they recruited Flo to their team around 12 months ago.

Where it began with Flo:

Over the last 3 years, the team had been delivering a phone based service for their patients with an administrator calling mums post discharge from hospital, to see how they were getting on and to direct them to services new mums may find helpful.  Whilst looking for a sustainable approach to delivering this service that could meet the needs of their new mums in the changing climate, Helen Fidgeon (Senior Health Improvement Practitioner) discovered Flo. 

After reviewing outcomes delivered by other breastfeeding support teams who had recruited Flo, the team at Dudley were inspired to read how Flo was seen as a “Friend” to mums, and felt that this would offer a perfect transition from the current service which was highly regarded.  Flo’s persona was an incredibly important element to ensure that the personal touch appreciated by mums remained; the team understood that they could not replace the current phone service with “just: an automated messaging service”.

Next steps and implementation:

Once the decision had been made to move forward with Flo, the next step was to develop a robust business case to their Senior Management team capturing the team’s ideas and utilising evidence collated from the Simple Telehealth Community of Practice, which to their delight was approved.  Throughout the early stages of planning and implementation, the team worked alongside the Maternity and Health Visiting Service which proved to be key to the success of implementing Flo quickly.  The team also benefited from significant support via the Maternity Clinical Lead, who assisted with clinical governance assurance and ensuring that the aim of the new service, and how Flo would interact with mums, supported local hospital policies.

During the planning stages, the staff who had been identified as most appropriate to introduce mums to Flo were in fact 3rd party employees.  This presented the team with a challenge to comply with local Information & Governance policies.  However with the support of the senior team and their governance lead, this was quickly overcome and the team were able to continue their progress.

The team’s specific aim in using Flo was to increase both breastfeeding initiation and subsequent continuation rates for between 6 and 8 weeks, whilst still offering mums a personable approach to the support they needed.

The breastfeeding rates in Dudley are some of the lowest in the country, so it was particularly important for the team to be able to engage with pregnant ladies as early as possible.  It was felt that by integrating Flo into their service they would be able to reach out to pregnant women as well as mums who had recently delivered their babies.

Whilst increasing breastfeeding rates was the main aim of the pathway, rather than just concentrate on this alone, the team were keen to develop a holistic approach with antenatal protocols.  These protocols helped to build relationships between the team and mums in their care, whilst providing education about the changes their babies would go through during the first few days following birth.  Along with this, mums were signposted to the local support available to them.

Following their in depth review of the existing use of Flo for breastfeeding support across the Community of Practice, the team felt confident in developing their own local pathway.  At this stage the local administrator's knowledge and experience (gained from listening to new mums stories) became invaluable.  The team were able to integrate this knowledge into Flo's interactions to maximise the relevance and personal nature of the service.

Flo’s interactions were therefore designed around “Dudley Mums” experiences and their specific support needs which the team were able to identify following their discharge from hospital.  Finally all of the pathways developed by the team were reviewed and approved by the Maternity Clinical Lead ensuring compliance with local governance and hospital policies.

Introducing Flo to patients:

The task of introducing Flo was very much a team effort and to support the service, bespoke patient leaflets were developed with input from the whole service.

Ladies were identified and consented for Flo opportunistically via three routes, the first being Community Midwives who consented mums-to-be on to the antenatal pathway from 28 weeks onwards, secondly, post delivery the Maternity Infant Feeding Assistants (MIFA) discussed and consented new mums on hospital wards.  Both teams received training around the initial discussion to introduce Flo to patients, as well as patient consent.  Once the training was completed, the team were able to complete consent forms with mums across the community and wards, these were then passed on to the dedicated Flo administrator who would create a Flo record and enrol patients on to an appropriate pathway.

Lastly, mums were introduced to Flo via the antenatal clinic at the local hospital with a joint approach between midwives and the Flo administrator.  Midwives would lead the initial discussion in clinic, and then refer mums to a separate clinic area where the Flo administrator would take them through what to expect and to complete their consent form before finally enrolling them into the service.  Often mums attending the antenatal clinics would opt in at this stage if they had their mobile phone with them.  By utilising the Flo administrator for this initial face to face appointment, the team were able to provide a very personalised service antenatally whilst saving time in their clinical appointments.


After local testing within the team it became apparent that some of the testers with android handsets had been receiving automated notifications from the mobile network provider to warn against possible charges for messaging.

Flo is a free service for patients to use in the UK.  However with shortcode numbers often being used for promotional activities at premium rates, some providers inappropriately send out blanket notifications to their customers wherever any shortcode number is used, even in the case of Flo’s free to text shortcode.  The team identified this as a potential barrier to mums using the service, and to overcome this they incorporated guidance into their patient information leaflet to provide assurance that all interactions with Flo are free to patients in the UK.  They also ensured that the midwives and MIFA’s were made aware of the incorrect network shortcode notices so that it became part of the discussion with the patient during their initial contact.

Specifically for antenatal enrolment, the question of how the team would identify when a mum delivered needed to be addressed.  To tackle this, the team were able to use Flo to their advantage by creating a message within the antenatal pathway asking mum’s to share their baby’s birthday with Flo.  Flo then notified the Flo Administrator who could then easily assign the appropriate postnatal pathway to the patient.

The team created a variety of different postnatal pathways to support this approach, ensuring that mums were able to be assigned to an appropriate postnatal pathway for up to 5 days after giving birth.  Each pathway ensured that mums received educational messages which were relevant to the age of their new born baby.

Early in their journey with Flo, the administrator was only able to enrol patients from her desktop PC, which on some occasions resulted in mums who had consented to Flo experiencing a few days delay in receiving their opt in message.

This meant they were potentially missing out on some of the valuable early education and information about changes in their babies within their first few days.  To better support mums and to ensure they could be enrolled onto Flo as soon as possible, the team purchased a wi-fi enabled tablet which allowed the Flo administrator to have mobile access to Flo to enrol mums more quickly, and often within the clinic at the time of their initial contact.

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 7 May 2019, 02:59 ]

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. 

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