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Podiatry team prevent deterioration and exacerbations with Flo

posted 19 May 2017, 03:20 by Hollie O'Connell

Pennine Care 
NHS Foundation Trust 

Debra Drury 
Clinical Specialist Podiatrist 

19 May 2017 

(E029) Flo helps diabetic patients care for their feet 

Flo has been supporting patients with diabetes to care for their feet in-between routine clinic visits in Oldham, using her friendly persona to motivate patients to undertake daily foot checks and subsequently providing patients with the capability to identify if, and when, their feet need to be seen by the Specialist Team.

Debra Drury, a Clinical Specialist Podiatrist at Oldham Podiatry Department recently took some time to tell us how Flo is being used to help their patients with diabetes care for their feet. 

"We had heard about Flo through Michelle Flint, who is leading the project in Oldham, and quickly identified an opportunity to support our patients to self care in-between face to face consultations.  We hoped that Flo could help our patients to identify problems with their feet that need our intervention and empower them to seek support sooner, thereby avoiding further deterioration.

What was the challenge?
We know that keeping feet healthy can be difficult for patients with diabetes.  Often patients don’t realise that there is a problem until it has deteriorated as patients can have a loss of sensation in their feet.  In this case, any break in the skin can develop into a foot ulcer and exacerbate quickly, compromising the patient clinically and elongating the treatment plan required.  Sometimes we ask patients ‘How long have you had this wound?’, and they’ll answer ‘8 weeks’, meaning that we are now dealing with a more complex wound that will take longer to treat and have a greater impact on the patient’s lives.  This is very common, patients don’t always recognise the importance of looking after their feet and often think they can put a plaster on and sort it out themselves.

Where did we focus?
Active self care is so important for patients with diabetes.  Many of our patients are gentlemen over the age of 50 who we find can be less engaged and motivated to take on board the foot health education that we have been providing in clinic.  As a team we recognise the importance and actively educate our patients so that they feel confident in their foot care at home.  However, it has proved challenging to generate sufficient engagement for patients to enable them to understand that the condition of their feet needs close attention by them in-between appointments, or even to acknowledge the importance of just attending their routine foot clinic appointments.

We provide paper based education for our patients to take away, however the impact of this is limited and it becomes apparent that it does not always result in helping our patients to become motivated to self care.  We often find it screwed up in their wound dressing bags ourselves when they come in for their appointments!  Therefore we looked to Flo to engage with our patients outside of clinic appointments to provide them with the motivation and capability to self care effectively.

Flo interacts with our patients every evening to remind them to check their feet for any change or damage, along with offering regular advice and information pertinent to their foot care.  We recognised that most patients use their mobile phone regularly, and so we know that Flo is in their pocket rather than in the bottom of a bag!  It’s also reassuring to know that Flo’s messages are recorded on the patient’s phone enabling patients to look back on them at anytime should they need a recap.  The reinforcement that Flo provides around the importance of attending clinic for regular foot checks is also really important, to support an increase in the patient’s motivation and ability to self care in-between.

Here at Oldham Podiatry Department we operate a two tier system: high risk and routine.  When we discharge patients from the high risk clinic to the routine clinic, some patients tell us that they can feel vulnerable, even though they are under shared care where the patient is seen weekly or fortnightly by the high risk team alongside routine follow up with podiatry.  This feeling can be present especially if the patient has had a long-standing foot ulcer and built up a close rapport of trust with specialist staff or if they have had amputation.

Using Flo offers additional support in this transition, patients still have a link to us via Flo which increases patient’s confidence and that feeling of being supported.

What do patients think?
Recently we’ve had a lovely handwritten letter from a gentleman that describes how his feet have “ never been as good as they are now .  The patient goes onto explain how he now applies his cream on at 7 o’clock when Flo tells him to!  Self care can be challenging, and we strive to ensure that we support our patients effectively so that they feel confident and motivated to engage regularly in their foot care; that’s what Flo is helping us to teach them.
Click image to enlarge

Another patient who Flo has helped is Shane.

Shane explained that for him, it was Flo’s friendly, daily message that motivated him to pay more attention to his feet.  Shane didn’t actually use the word 'nagging', but almost!  Shane said that Flo’s reminders to check his feet were useful and he soon found that he was acting on Flo’s prompt in real time. One day, whilst doing his daily foot check, Shane discovered that a wound had developed.  Although Shane choose to not contact the Podiatry Team immediately, when he got his next message a day later from Flo reinforcing his self care advice, Shane thought I'd better do something about it .  Flo’s regular reinforcement was important in making sure that Shane was motivated to take the necessary action and contact us to review his wound before it got any worse.

You can hear Shane discussing his experience in this video.

Shane has also featured in The Oldham Chronicle.

What’s Next for the Oldham Podiatry Team and Flo?
We’ve now introduced Flo for patients who have undergone nail surgery to support them to self care for their wounds post discharge.  Flo is helping patients to identify any deterioration sooner and motivate them to seek help earlier before the symptoms worsen.  This is a younger patient cohort so Flo has proved very popular with this group, fitting even more easily into their lifestyles.

Moving forward, we hope that even more patients with diabetes are introduced to Flo.  We’ve had patients who’ve come into clinic and given us anecdotal feedback that their feet are in a much better condition, so now our next step is to collect robust clinical evidence to support this.  We’ll be reviewing all of our Flo patients to establish a picture of their condition before Flo and what it’s been like since, regarding ulceration and their presentation at clinic.  I am passionate about taking this forward, because I have seen that Flo is of real benefit to our patients. 

Even if Flo is helping just a quarter of the patients we have on our caseload, that’s massive, it's really is massive.

#Diabetes #Podiatry #Pennine Care

Significant reduction in clinical contacts as Patient's Mental Health is stabilised with Flo.

posted 15 May 2017, 08:14 by Hollie O'Connell   [ updated 15 May 2017, 14:21 ]

South Tyneside 
NHS Foundation Trust  

Helen Thompson 
Safe Care Lead 

15 May 2017 

Patient's mental health is transformed after Flo's help to improve medication adherence  

Helen Thompson, Safe Care Lead and Jan Gorman, Health Care Support Worker from the Learning Disabilities Service at South Tyneside NHS Foundation Trust discusses how intervening with Flo has regained the independence of one of their patients with mild learning difficulties, resulting in their mental health stabilising and removing the need for continuing home visits from their team and the number of Consultant Psychiatrist appointments required. 

“Fred” was an individual with mild Learning Disabilities who had also experienced a decline in his mental health.  Due to this decline, Fred was on the active caseloads of both his Consultant Psychiatrist and Community Learning Disabilities Nursing Team in South Tyneside. 

Emerging from this increased clinical input were concerns regarding Fred’s adherence to his medication regime, the cause of an ongoing decline in his mental health. 

Before using Flo, Fred required several home visits from a Health Care Support worker to prompt him with regards to his medication compliance, and at the time the Community Nurse was also visiting him more often than would normally be required.  In conjunction, Fred’s Consultant Psychiatrist was also offering more regular appointments as a result of symptoms of low mood.  Despite these additional face-to-face interventions, Fred continued to have fluctuating compliance with his medication regime and associated symptoms due to this non-compliance. 

Therefore, the Community Nursing Team felt that Flo would offer Fred an opportunity to receive supportive messages to help guide him towards taking his medication more regularly as prescribed.  

The team hoped that Flo would help to reduce the symptoms that Fred was experiencing associated with his non-compliance and would  maintain his independence, so he would not need to continue receiving the now regular face-to-face interventions.

Following the introduction to Flo's unique persona, Fred was signed up to a protocol designed to support him to improve his medication adherence.  This involved Fred having three messages from Flo each day at key times, reminding him of the need to take his tablets as prescribed. 

With Flo’s helpful reminders, Fred began to change his behaviour to become more complaint with his medication and as a result he started to make good progress, with his compliance improving over a period of several months. 

During the time that Flo was helping Fred, Community Nurse and Health Care Support Worker visits were able to be gradually reduced.  It wasn’t long before Fred also needed less Consultant Psychiatry appointments, with the improvement in his medication compliance resulting in his mental health becoming more stable. 

Now Fred no longer needs Flo to remind him to take his medication – which is a huge success!  Flo has gently helped Fred to establish his own regular routine for taking his medication on time. 

The impact of this improved medication adherence stabilised Fred’s mental health, resulting in him no longer being an open case to Community Learning Disabilities Nursing or his Health Care Support Worker.

Fred now only has his annual outpatient visit to the Psychiatry team for monitoring purposes and is otherwise independently self-managing without any additional intervention required, delivering long term, sustainable benefits.

Intermittent Claudication with Flo motivates patients and increases clinic capacity

posted 10 May 2017, 03:12 by Philip O'Connell   [ updated 10 May 2017, 10:03 by Hollie O'Connell ]

Mairi Ross 
Vascular Physiotherapist 

10 May 2017 

(SCO NHS NHI) Patients feel less isolated and more motivated to improve Intermittent Claudication with Flo's help

Intermittent Claudication (IC) is a symptom of peripheral arterial disease (PAD) where pain is experienced in the main muscle groups of the leg when exercising and walking.  Patients with IC need to push further into their leg pain when exercising and walking to gain any benefit from physiotherapy – this develops the collateral circulation allowing the blood to follow a natural bypass to the affected muscles and therefore reducing the pain felt thus increasing the pain free walking distance. 

NHS Highland (NHSH) is the largest Health Board in Scotland covering 32 500km2 serving a population of 320,000. 2.3% of adults over the age of 16 will be affected by IC – this equates approximately to 4,420 adults in NHSH.  The geography of this area is one of the biggest challenges to delivering patient care.  A large number of patients are very remote and rural, making the journey to Inverness long and tiring.  If we can treat and assess these patients in their homes then the geography challenge will no longer be an issue. 

With an ever-increasing population there should be no need to review clinically stable claudicants especially if telehealth can be used for remote monitoring. 

“If we can treat and assess this cohort of patients in their homes, then the geography challenge will no longer be an issue bringing great benefit to patients and clinicians alike whilst deriving greater value from NHS resources and creating clinic capacity for patients who do require face-to-face review.”

Welcoming Flo

The opportunity for us to use Flo to enable us to remotely gather information regarding their condition and ability, and also to encourage and motivate these patients to continue with their exercise regime and daily walking went live with IC patients in Jan 2016. 

At the patient’s initial assessment, they undergo a treadmill test measuring the pain onset distance (POD), maximum walking distance (MWD) and the reason for having to stop walking. Patients are then given a home exercise programme and advised to push into their pain level a little more than they normally would. Some of these patients will attend a weekly exercise class at Raigmore Hospital (Inverness).

Patients who consent are enrolled with Flo at the end of the initial physiotherapy assessment, The session is extended by 15 minutes to allow for the actions below:
  • To explain what Flo is and how she can benefit the patient whilst they are at home
  • To provide a patient information leaflet with time to read this 
  • To explain consent and for the patient to sign the consent form 
  • To loan the patient a pedometer and show them how it works 
  • To register the patient with Flo and send consent form to TEC

Flo’s Interactions with our IC Patients

Patients receive regular interaction with Flo’s friendly persona around key elements involved in their treatment plan. This helps to educate and motivate patients to become more confident and engaged with their self care, examples include:
  • Understanding the number of steps the patient can take before having to stop and the reasons for stopping walking 
  • Interaction around physiotherapy exercise 
  • Patient reported impact of symptoms on daily activities 
  • Medicine compliance for aspirin or clopidogrel 
  • Smoking status 
  • Compliance with diabetes management 
  • Patients report their daily step count registered on their pedometer 

Patients are then re-assessed after 3 months when they repeat the initial treadmill test.

Early pulmonary rehabilitation - Sheffield Teaching Hospitals NHS Foundation Trust increase adherence and safety for patients

posted 29 Mar 2017, 07:20 by Philip O'Connell   [ updated 25 Apr 2017, 03:32 by Hollie O'Connell ]

Cath O'Connor 
Clinical Specialist Respiratory Physiotherapist 

Jayne Stocks 
Clinical Lead Assistive Technology 

Katie Biggs 
Lead Trial Manager CTRU 

30 March 2017 

'Making Change Happen' National Showcase; Early pulmonary rehabilitation following AECOPD 

Click image to enlarge

Community resources optimised as Flo helps clinicians to deliver care "right first time" through Single Point of Access

posted 29 Mar 2017, 05:18 by Philip O'Connell   [ updated 25 Apr 2017, 03:36 by Hollie O'Connell ]

Jayne Stocks 
Clinical Lead Assistive Technology 

Janice Renner 
Nurse Adviser 

30 March 2017 

'Making Change Happen' National Showcase; Single Point of Access  

Flo supports Carers in Sunderland

posted 23 Feb 2017, 04:38 by Philip O'Connell   [ updated 25 Apr 2017, 03:36 by Hollie O'Connell ]


14 March 2017 

'Making Change Happen' National Showcase; Carers Connect Service 

NHS Lanarkshire increases smoking quit rate with Flo

posted 23 Feb 2017, 02:50 by Philip O'Connell   [ updated 1 May 2017, 06:46 by Hollie O'Connell ]

Cheryl Baker 
Specialist Nurse 

23 February 2017 

'Making Change Happen' National Showcase; Stop Smoking Service

Urinary Continence; Dramatically better outcomes with Flo

posted 11 Nov 2016, 05:41 by Philip O'Connell   [ updated 30 Mar 2017, 02:57 by Hollie O'Connell ]

NHS Western Isles  
Iain Trayner 
TEC Project Manager 

14 November 2016 

Urinary Continence: Using Florence to improve the lives of local people 

The NHS Western Isles Continence service provides advice and support to people living with the condition in these islands. 

Continence can be a very difficult condition to live with and many people can feel trapped, with everyday life becoming a strain for them and their families.

One of the tools used by the service is a pelvic floor improvement programme.  This requires the person to perform pelvic floor exercises up to 8 times a day.  Although very beneficial it can be difficult for patients, remembering to do the exercises in itself is a challenge and tracking progress is almost impossible.

Florence, a web based text messaging clinical interface is now being used to help people who suffer with this sensitive condition.

Florence (Flo) works by sending reminders to patients to do their pelvic floor exercises.  Flo also sends early morning texts each day to encourage fluid intake and then a text in the evening that requires a reply to monitor compliance.

Using Flo to support the patient ensures that the prescribed programme gets the best chance of success.  The regular discreet messages act as a reminder for the patient and the response question allows the specialist nurse to track progress.

“ The text reminders are brilliant, I would never remember to do the exercises if I was not getting them, I hear the ping on my phone, look at the clock and I know it’s time to do them 

Although still in its infancy, using Flo to support the service has proved to be very beneficial for those patients who have signed up for it.

Patient overview
The very first patient to use Flo on this programme had no pelvic floor sensation and had been told by the Urologist that nothing more could be done for them.  Consequently, this person has suffered for many years with the complications that accompany this condition.

After receiving the messages for just 3 days, the patient began to notice an improvement.  After 2 months, they now have normal pelvic floor sensation and life has changed dramatically for the better. 

“ I can now feel my pelvic floor! I’m amazed because they told me at the hospital there was nothing else they could do ”

Rosemary MacRitchie, Tissue Viability Lead and Continence Advisor is very enthusiastic about using Flo to help support her patients. 

“ Florence offers regular prompts and also lets me see how things are going, keeping up with a pelvic floor programme can be difficult and Flo is an excellent option to help people along the way 

Weight management; Patients show demonstrable behavioural changes with Flo

posted 3 Nov 2016, 02:50 by Philip O'Connell   [ updated 30 Jan 2017, 07:15 by Hollie O'Connell ]

Laura Bell  
Dietetic Assistant Practitioner

15 November 2016 

Laura has led on the pilot of Florence in the weight loss maintenance stage of the Lothian programme and uses Flo to improve patient commitment and adherence to weight management programmes.

“ I was about to get something from the fridge and a text message came through. It made me stop and think do I actually need this....   NO! So I walked away ”

Offering patients a choice, through a combination of motivational messaging and/or weekly weight checks, the team offers Flo to their patients to provide a complete ‘person’ package in-between face-to-face consultations. 

To establish sustained behaviour change, patients opting for motivational support and encouragement to help them engage better with the existing weight management  programme are supported by Flo for eight weeks.
The interactive programme provides motivational messages and validated signposting about where to access reliable and up to date information on healthy eating & activity, obesity related conditions, and mental health support.  Patients can also report their weight weekly.  

Flo’s timely interactions help patients to maintain focus on the journey towards their agreed target weight whilst at the same time recording progress through weekly weight readings.

By understanding what motivates each patient, a choice of protocols are available with either a focus on weight loss, or weight gain - Flo’s replies are tailored to either context.
Improved engagement with the patient’s own weight management programme not only improves clinical outcomes but increases patient attendance at existing group sessions and 1:1 appointments ensuring that clinical time is used efficiently.

"60% of patients chose to sign-up, and more d
emonstrable behavioural changes were seen in
patients on the Florence service."

In addition to supporting safe weight loss, other benefits of the programme include a reduction in further medical interventions, reduction in GP visits and reduction of prescribed medication. 

from the initial pilot

  • Patients have given positive feedback with 85% of patients reporting that they liked using Flo as part of their weight management programme.
  • 83% would recommend using Flo for additional support when on a Weight Management programme. 
  • The programme will now be used widely across NHS Lothian’s weight management services.

COPD patient avoids A&E and acute admissions through self-management with Flo

posted 22 Oct 2016, 02:21 by Philip O'Connell   [ updated 26 Oct 2016, 02:09 by Hollie O'Connell ]

Blythe Bridge Surgery  
Tean and Blythe Bridge Primary Care  

Ann Hughes  
Practice Nurse 

25 October 2016 

Flo Helps COPD Patient with a High Frequency of Acute Admissions  
to Self-Manage and Stay Well 

Chronic Obstructive Pulmonary Disease (COPD) describes a number of conditions including emphysema and chronic bronchitis.  It is a condition where the airways become inflamed and the air sacs in your lungs are damaged causing the airways to become narrower making it harder to breathe in and out. 

COPD patients are usually on a variety of medications to manage their condition including ‘rescue medication’ for use at home during an exacerbation.  Patients typically have a COPD self-management plan, agreed with their clinician, advising them what action and/ or medication to take, according to their symptoms.  Delay in identifying exacerbations and taking action, including using the correct rescue medication, can lead to emergency admission to hospital. 

As a consequence, patients often need to be seen in the primary care setting to have checks and to review their treatment along with seeking reassurance and advice.  These visits can often be difficult for patients as their poor breathing can lead to reduced mobility and having to sit in waiting rooms can expose patients to the risk of further infection.  Florence (Flo) can be a very valuable tool to help patients with COPD self-manage at home and can reduce the need for as many surgery visits, improve their compliance with medication, reduce overall anxiety and ultimately avoidable hospital attendances or admissions.

One patient who was helped in this way, is Pat who was on the 'Admission Avoidance Care Plan Scheme', Pat had had four attendances at A&E via 999 and had been supported by 'Hospital at Home'.   As well as two hospital stays during a three month period. Pat had also attended the GP surgery on many occasions for rescue medication. 

In order to help Pat better cope with her COPD I decided to introduce her to Flo to provide support and guidance.  Pat was equipped with an oxygen saturation monitor and a thermometer to take home to use when prompted via Flo, in conjunction with her COPD Management Plan. 

Flo prompts Pat to send in her oxygen saturation level and will then advise her what further steps, if any, are necessary depending on this information, using parameters set by the clinician.  Flo also coaches patients through the correct use of rescue medication, if it is deemed appropriate according to symptoms reported.  In my experience, when the need arises for a patient to use rescue medication, this can make them panic and take everything just hoping that this will alleviate their symptoms.  Flo ensures patients take the right amount, of the right medication at the right time.

Importantly Flo has given Pat more confidence to self-manage leading to an improved quality of life.

The daily recording of oxygen saturation levels and the guidance from Flo have reassured Pat.

By enabling Pat to self-manage her COPD, if her oxygen level is low she knows to check her temperature, and if this is fine then she knows she doesn't need take any further action.

Flo has had a marked impact in reducing surgery visits and preventing exacerbations from reaching the point of needing to call 999 and hospital admission;
Indeed Pat has not attended A&E since she was introduced to Flo on August 2nd 2016 and her only contact with the surgery has been an occasional telephone call from us to check that all is well.  Since using Flo she has not had to use her steroids (prednisolone) and has not collected her prescriptions for this. 

As Pat is now in control of her COPD it has allowed her to use her exercise bike and identify the difference between when her breathlessness is safe and when it isn't.  Along with this Pat is able to help her daughter with moving the plates and washing up at her porta cabin [cafe].  Pat commented on how her daughter has also recognised the change Flo has made to her life:

"My daughter said, there's something different about you mother.  I was a bit worried about you at first, but you've managed quite well."

When Pat was asked if there was anything she didn't like about Flo she replied: 

"The only thing I don't like is the fact that you might ring me to come off Flo"

After using flo

  • Not only has time been released in the GP surgery, but by motivating Pat to follow her COPD Management plan,  Flo has provided a significant cost saving.
  • Flo has given the patient the opportunity and motivation to improve her capability to self manage her COPD at home, and has demonstrated a reduction in her emergency admissions via an improved use of her prescribed rescue medication; allowing capacity to be focused on other areas of patient care.

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