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Getting started with Flo - Our first 18 months in Powys

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



Victoria Deakins 
Professional Head of Occupational Therapy 

Kathryn Lloyd 
Service Development manager for Therapies and HS 


05 July 2018 


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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.