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Significant reduction in diabetes health risks through self-management

posted 18 Dec 2017, 00:15 by Hollie O'Connell   [ updated 15 Jan 2018, 01:49 ]

South Tyneside 
NHS Foundation Trust 
Alison Stewart 
 Safe Care Lead Diabetes 

15 January 2018 

Patient self-management is significantly reducing short and long term health risks associated with diabetes 

By recruiting Flo as part of the team, patients in South Tyneside are becoming more capable and confident to self-manage meaning clinic appointments are able to be reduced, and glycaemic control is demonstrating significant improvement reducing both short and long term associated health risks.  Alison explains what Flo means for her patients and her service.

What do South Tyneside Diabetes Specialist Nurses do?  

Diabetes Specialist Nurses (DSN) are qualified nurses with special expertise in the care and treatment of people with diabetes.  In South Tyneside we have 4.4 whole time equivalent DSNs delivering a broad range of services from specialist nurse-led inpatient and outpatient care to pre-pregnancy clinics and patient education.

A patient with type 2 diabetes was referred to the Diabetes Specialist Nurse Service demonstrating poor glycaemic control resulting in a change to her oral medication and basal insulin to twice daily mixed insulin.  However, the patient’s high glucose levels carried short term risks for her of increased tiredness and lethargy and thirst plus polyuria and a more likely risk of infection.  Equally as significant for the patient are her long term complications due to her diabetes remaining uncontrolled such as heart attack and stroke, retinopathy, maculopathy, kidney disease, damage to her nerves and circulation in her feet, and also her autonomic nervous system.

The lady’s HbA1c at the outset was 94 mmol/mol, recognising the importance of supporting her to self-manage her diabetes better, we introduced her to Florence.  The patient agreed and began receiving messages from Flo targeting at motivating her towards lifestyle changes that she could make to support a reduction in her HbA1c.  The patient also replied to Flo 4 times a day with her blood glucose reading, enabling her to act on Flo’s advice, encouraging her to improve her capability and confidence to self-manage.  These are the kinds of interactions that she had with Florence;

  • “As your sugar levels improve your symptoms should reduce, Flo” 
  • “Hi it’s Flo, have you looked at your sugar levels and made any changes?” 
  • “Have you managed to increase your activity levels, take care, Flo” 
  • “Hi Flo here, please do not forget to change your needles, take care”
Initially I decided to set time aside to review her readings and to make contact twice weekly via Flo for targeted intervention; for example to advise her to increase her insulin.  However once there was a noticeable improvement in her glycaemic control, I was able to reduce my contact to once a week and reduce Flo’s interactions around testing to once daily.

What did the patient think?  

The patient was previously seen in Sunderland, but in the 7 month period since she started using Flo, she only needed 4 clinic appointments.  The patient feedback was that being able to be supported by Flo was a major benefit for her, not only as she had regained control of her condition, but that she had previously had to rely on her husband to bring her to her clinic appointments and as he worked shifts, it wasn’t always convenient.  The patient also commented that she found texting Flo to be helpful in improving her self-management of her diabetes.

What are the benefits? 

There are a number of benefits of using Flo from my perspective as a Diabetic Specialist Nurse.  Firstly, using Flo has certainly freed up clinic appointments, and as the number of referrals we receive increases, this is an important consideration.  Importantly though, using Flo also meant the patient was now being regularly reviewed in order to support her aim of improving glycaemic control.  This lady’s HbA1c dramatically improved as indicated by an HbA1c of 52mmol/mol, and she has now significantly lowered her risk of long term diabetes related complications.  I would recommend Flo to other clinicians and feel that many would find using Flo helpful.

Single Point of Access reduces need for home visits

posted 15 Aug 2017, 03:32 by Hollie O'Connell   [ updated 16 Oct 2017, 02:32 ]

Sheffield Teaching Hospitals 
NHS Foundation Trust 

Jayne Stocks 
Clinical Lead Assistive Technology 

Jeanette Deslandes 
Telehealth Nurse 

Joanne Sellers 
Health Care Assistant 

15 August 2017 

The Single Point of Access (SPA) is a one stop shop for referrals between Sheffield Teaching Hospitals' acute and community services.  SPA is an appointment-booking service 
working in partnership with social workers, mental health nurses and out of hours services, facilitating discharges and avoidance of hospital admissions where possible.

Made up of 50 Administrators, 13 Nurse Advisors, Social Care Managers and a Business Management Team, Sheffield’s SPA Contact Centre is located at Community House, Northern General Hospital Campus and opens 0800 to 2200 hours, seven days a week (out-of-hours cover is provided by the GP Collaborative).

In Sheffield Flo has been recruited to optimise community resources and support patients to self-manage their long-term condition(s) better.  SPA nurses triage patient contacts where they are being supported via Flo.  

SPA nurses have a wealth of telephone triage experience and are usually able to deal with the presenting situation over the phone and only request  community nurse visits where clinically necessary.  Flo is well positioned to integrate into the SPA model with patient’s contacting the SPA as prompted by Flo should their condition deteriorate.

Role of the Telehealth Team:
The team facilitate the Telehealth pathway and help clinicians within Sheffield Teaching Hospitals Community Services to use the pathway with Flo.  Flo is currently used within community services; however, there are emerging opportunities to expand this to acute pathways in the future.

Flo is currently being used by the District Nursing and Community Matron teams to enable patients to self-monitor their long term conditions; for example to send prompts and reminders to take insulin or other medications.  The community falls teams: Integrated Care Team Therapy (ICT Therapy) and Assessment & Rehabilitation Centre (ARC) also use Flo to send prompts and reminders to help patients follow their exercise plan.

The Telehealth Team role also includes administration of the Flo system which enables us to keep clinical access to the system up to date.


An 83-year-old patient with type 2 diabetes recently commenced with Flo following a referral from their community nurse team.  The patient had recently started on insulin and a course of steroids following a recent hospital admission.

While in hospital, the patient was taught how to self-administer their own insulin and following this was discharged into the care of the community nurse team for them to provide on-going support with self-administration and monitoring at home.

The patient’s Diabetic Specialist Nurse (DSN) felt that the patient’s insulin dose would need to be reviewed and as the patient was on a reducing dose of steroids, the insulin dose needed to be titrated accordingly to ensure the best outcome for the patient.

Initially community nurses were visiting the patient twice a day to supervise the patient’s self-administration of their insulin, as well as monitoring the patient’s blood sugar levels.  The community nurses were gradually able to reduce the number of visits as the patient became more confident.  At this point the patient began to receive phone call prompts from the community nurses, but soon after they were referred to Flo for on-going support.

Following referral, our Telehealth Nurse visited the patient to explain how Flo could support them and agree with the patient their shared management plan.  On the same visit, the Telehealth Nurse was able to set Flo up and the patient opted in, Flo was now ready to provide ongoing support for the patient by recording and offering advice according to the patient’s blood sugar readings along with prompts to take their insulin as prescribed. 

The patient was supported by Flo for just over a month.  In that time, the patient felt that they were more confident in managing their insulin regime.

The patient’s evening blood sugars did remain high during this time.  Initially these increased levels caused Flo to prompt the patient to phone the SPA (Single Point of Access, a service that manages patient referrals), and each time the patient phoned the SPA the patient felt that their anxiety levels increased demonstrating the importance of providing the patient with a clear self-management plan at home.

Through the readings sent to Flo, we were able to establish that the patient needed a review by the Community Diabetic Specialist Nurse.  The patient’s DSN gave the patient further guidelines on their diabetes management and provided the patient with information about who to contact, and when, if they were concerned.

Both the patient and DSN felt that the patient had gained confidence in their diabetes management, resulting in the patient being able to self-manage without the need for further support from Flo, which was a great success!

The outcome from the patient’s experience with Flo was that
  • The patient now feels confident in taking their own blood sugar readings 
  • The patient now feels confident in administering their insulin 
  • The patient’s sense of independence has improved 
  • The patient’s awareness of, and ability to manage their diabetes has improved 

The community nursing team have been able to empower the patient to self-manage their insulin regime with the help of Flo, and this has resulted in a reduction of nurse visits to the patient yet an overall increase in the amount of interaction and support the patient had with their diabetes.

The community nurse team were asked to visit a 65-year-old patient who had a history of Alzheimer's disease and over the previous 6-9 months had been frequently forgetting to take their insulin at home.

The patient had been on a pre-meal insulin regime, which they were beginning to struggle to maintain.  The patient’s concordance with their medication had been deteriorating, and as a result their HbA1c had increased over this period.  Due to this, the patient’s daughter had been phoning to prompt them to take their insulin, however this was difficult for her to do regularly.

The district nurses were asked by the Diabetic Specialist Nurse to visit the patient to supervise a new twice daily regime, and to check the patient's blood glucose levels to titrate the doses of insulin.  Within two weeks the nurses felt that the patient was managing well with the new regime, and they referred them to the Florence Telehealth Team.  The team suggested that the patient should receive twice daily messages via Flo to check that they were continuing to manage their diabetes.  The patient was set up with Flo to prompt them twice daily to take their insulin, as well as to request twice daily blood sugar readings, twice a week.

Initially, the patient was anxious about using their mobile phone, particularly around sending in readings in to Flo.  However, following a discussion with their daughter, the team was able to reassure the patient that they would not need to reply to the twice daily prompts to take insulin, and that their daughter could support them to send in the blood sugar readings twice a week.  The patient continues to use Flo, self-managing even with a titration in the dose of insulin.

Flo can improve medication concordance, as well as support remote monitoring so that both patients and clinicians can feel confident that the patient has the right support in place when it is needed.

The community nurse is able to review the blood sugar readings on a regular basis, with a view to liaising with the Diabetic Specialist nurse if it is required.

For this patient, community nurse interventions have been reduced.  There is no longer the need to phone the patient twice a day, the independence of the patient has also increased and the patient is compliant with their treatment regime.

The District Nursing Service was asked to visit a 41 year old patient who required supervision to self-administer their insulin and take blood glucose readings to monitor their diabetes.  The patient had ongoing problems with anxiety and depression, and was finding it increasingly difficult to remember to take their insulin twice daily.  The patient was reviewed by the Diabetic Specialist Nurse, who was concerned that they were forgetting both doses of insulin as a result the patient’s blood sugars were elevated, leading to further complications.

The patient was referred to the district nurse service for once daily supervision of self-administration of insulin, initially for 7 days.  Following the week of supervision, the patient was referred to the Florence Telehealth Team and in the meantime, the district nurses used phone calls to prompt the patient to take their insulin once a day until Flo was set up.  The referral for Flo included monitoring blood glucose twice a day, and to have twice daily prompts to take their insulin and to confirm to Flo once this was completed.

On the second day of being supported by Flo, the patient’s blood sugar was outside of the parameters set by their clinician and the patient was prompted to contact the Single Point of Access (SPA).  The patient phoned into SPA as requested and following which they were triaged and reviewed by a GP, and given antibiotics for a chest infection.

The patient continues to use Flo to monitor their diabetes.  The readings captured by Flo indicate when the patient has missed any doses of insulin, and when their blood sugars are outside of the acceptable parameters.  Importantly, this information is available to the patient’s Community Matron, which enables efficient review of the patient’s care management plan.

The outcome for this patient is that they are once again independent with their insulin administration, and the community nurses no longer have to phone the patient to prompt them to administer their insulin.  The patient continues to have support from the Community Matron and Diabetic Specialist Nurse, who find the patient’s reading captured by Flo is valuable in aiding their clinical decision making with regards to the patient’s ongoing care.

A 65 year old patient with Type 1 Diabetes and ongoing mental health issues was finding it increasingly difficult to manage their diabetes.  In April 2016 the community nurses were phoning to prompt the patient to self-administer insulin and to take blood sugar readings.  The patient was then referred to the Florence Telehealth Team to help support them in monitoring their blood sugars regularly via Flo.

The patient’s blood sugars were erratic, with two admissions in the past 12 months for hyperglycaemia, as well as two paramedic calls for hypoglycaemia in the same time period.

The patient now uses Flo prompt and motivate them to monitor their blood sugar levels, as well as receiving regular support from the Community Matron.  The Community Matron is able to view the readings the patient sends to Flo, and then liaise with the Diabetic Specialist Nurse to inform the continuing management of the patient’s diabetes.

Flo has helped the patient to increase their independence, by prompting them to take their readings at times convenient to them.  Flo also enables the clinicians managing the patient’s care to view the readings regularly, allowing visits and phone calls to be better timed to meet the patient’s needs.  Flo supports both patients and clinicians with diabetes management by providing individualised, patient centred care.

Asthma - "Very positive results"

posted 31 Jul 2017, 00:52 by Hollie O'Connell   [ updated 5 Dec 2017, 05:00 by Hannah Mountford ]

Corinne Clark 
Respiratory Specialist Nurse 

07 September 2017 

Many of Corinne’s patients suffer from severe asthma, which requires careful management to avoid asthma attacks that, in the most serious instances, can be life-threatening.  Corinne often worried about her asthmatic patients, specifically how well they were handling their condition, and wanted to do something about this.  Research suggests that patients who have a written asthma plan are 4 times less likely to be hospitalised due to asthma attacks.  Corinne enlisted the help of the health board’s TEC team to create an electronic Asthma Action Plan (eAPP) using Florence.

 There was certainly a cohort of asthma patients who I was losing sleep over!  I was worried about how they were self-managing their condition.  What we needed to do as healthcare professionals was really think outside the box: how we could get our patients to engage with us more effectively?  How do we best motivate patients to look after their condition through self-management?  And perhaps most importantly, how do we support patients to recognise when it is appropriate for them to seek urgent medical attention for their asthma? 

How do we use Flo? 
When I found out about Flo, I realised that she could really help to address some of the issues we’d been having.  We developed a protocol whereby Flo sends messages to the patient twice a day, asking for patient’s peak flow reading.  Flo records these readings, so I can map trends in their condition over the weeks and months.  This is really useful, as I can pick up on any points of concern, and then send them a text message directly via Flo from myself.  The patients we’ve identified as potentially benefiting from using Flo have all had previous admissions to hospital for acute exacerbation of asthma, or had been referred to the Respiratory Clinical Nurse Specialist (RCNS) by their GP or consultant.  In order for them to use Flo, these patients needed to have access to a mobile phone, and they were supplied with a peak flow meter and an emergency supply of rescue prednisolone.

The clever part of Flo for the patients is that she acts as an electronic asthma plan in the background for them.  When patients send their peak flow reading to Flo, the reading will fall into one of four zones, dependant on what their highest recorded peak flow reading is:
  • Zone 1 for readings above 80% of patient’s highest peak flow 
  • Zone 2 for readings between 60% and 80% 
  • Zone 3 for readings between 50% and 60% 
  • Zone 4 is for readings below 50% of the patient’s best peak flow 
So, depending on the patient’s reading sent to Flo, the patient will receive a confirmation message with advice that is appropriate to their current peak flow reading.

In addition, patients receive various support and information messages, and even reminders to book and attend their asthma reviews!  We do stress to our patients though that Flo isn’t an emergency response service – she’s a tool to help them to self-manage their asthma.  After all, patients are the ones that know their symptoms the best.

What differences has Flo made? 
When we first introduced Flo to our patients at the end of February 2016, we initially had 50 patients sign up, and this has now built up to a total of 88 patients so far.  A few patients have dropped out, either having opted out themselves, or being discharged from the service due to not sending their readings to Flo.

Amongst our active users we’ve seen some very positive results from using Flo.  Amongst the cohort we’ve seen only 4 acute admissions, all of which experienced exacerbations compounded with positive cultures of either influenza or pertussis.  In all of these cases however, the patients acted appropriately when there was deterioration in their symptoms and sought urgent medical attention in a timely manner. 

We also see that these patients have become more engaged with their own health and the specialist services on offer to them and importantly none of these patients have failed to turn up for their clinic appointments with their respiratory nurse specialist.  My colleagues across the country will tell you that asthma patients often don’t attend their clinic appointments, so for us to see such an improvement using Flo is wonderful.

From my perspective as a clinician, Flo is an amazing tool.  She allows me to monitor my patient’s remotely, and I find it reassuring to know that they are all managing their asthma well with Flo’s help.  Another benefit of being able to remotely monitor my patients’ readings with Flo is that they no longer have to attend as many appointments at the clinic.  Given how precious clinic appointments are, not having to see patients who are on Flo as often has really freed up some capacity for us. 

The feedback from patients so far has been very promising; they find Flo reassuring, and they’ve really noticed an improvement in the stability of their condition.  We have one patient, Kyle, who was regularly in hospital due to his asthma as he struggled to manage his condition.  Since he’s been using Flo though, he’s noticed that his breathing has improved, and that his peak flow readings are far more consistent.   

You can find out more about Kyle’s experience of using Flo to support his asthma management in this video

Comments from patients about Flo include:
  • After being in hospital I felt Flo was a support
  • Flo reminds me to check my peak flow.  I have a very busy job and I tend to forget to take my readings. 
  • I found it much easier to monitor my asthma on a daily basis 
  • I liked how I could keep a more accurate record of my peak flow 
  • Regular contact and advice
  • Easy and helpful 
  • For those who are unsure how to manage asthma, Flo provides simple, structured guidelines.  Flo provides the clinician with a clear overview for am and pm. 
  • Gets me to keep a check on my peak flow scores and be more aware of how my breathing is - whether it's zone 1 or zone 2 
  • It’s reassuring that even if my PF falls slightly due to a cold that I shouldn't be worried 
  • Reminded me to keep on top of my medication 
  • Consistent prompts for info makes me think about my health.  Reminders about changing treatment in response to data provided. 
  • Good monitoring, makes you complete your peak flows everyday.  Excellent that it can be monitored. 
  • Reminds you to check lung function and records function on phone.  You can look back 6 months if you want. Great! 
  • Flo lets me know when I need to change my medication 
  • Easy to use and understand 
  • Convenient helpful and easy to use
  • Flo shows you visually how your asthma is being managed and liaises with the hospital
  • Flo sends back information and records ups and downs, so finding further insight into illness is gained resulting in better control and treatment plans. 
  • I find that Flo keeps me looking at my PF when before I would not have checked it.
  • Reminds me morning and night to take my preventer inhaler (symbicort) because of the times I receive the text messages

Where are we headed?
We are currently in the process of having an external audit completed by an academic from Edinburgh University to look into both the clinical effectiveness and cost effectiveness of this specific Flo protocol.  This is using a number of sources, including Florence system reports, hospital and GP records, evaluation questionnaires and interviews with both the RCNS and patients, to find out what they really think about using Flo.  Although this is ongoing, early results are encouraging, and we hope that the final result will really allow us to shout about how good Flo is.

Earlier this year I submitted an abstract for consideration to the European Respiratory Society (ERS) around the asthma protocol.  I have recently been informed that my abstract has been successful and the ERS has invited me to give an oral presentation at their conference in Milan in September around Florence home health monitoring for asthma patients..... so exciting times!   "

For more information please contact corrineelaine.clark@nhs.net

Mental health; Flo reinforces coping techniques

posted 23 Jun 2017, 01:50 by Hollie O'Connell   [ updated 16 Oct 2017, 02:33 ]

Kathryn Sumner 
Safe Care Lead / CBT Therapist 

26 June 2017 

Gateshead Talking Therapies offers a confidential service to people wishing to overcome problems triggered by feeling low, depressed, stressed or anxious focussing on helping people experiencing mild, moderately severe and first onset severe problems.  The team specialises in working with people aged 16 or over who have recently developed a problem and helping them to understand it, and prevent it from becoming more severe and disrupting their lives.  As well as offering a selection of courses and 1:1 therapy providing interventions recommended by NICE for a range of mental health difficulties – such as anxiety, depression, trauma, stress, bereavement, low self esteem and other emotional issues.

Upon GP or self-referral, the team delivers therapies according to identified needs including Cognitive Behaviour Therapy (CBT), Cognitive Analytical Therapy (CAT), Eye Movement Desensitisation and Reprocessing (EMDR), Interpersonal Therapy (IPT), Mindfulness, Primary Care Mental Health and short courses and Supported Self Help (4-6 weeks).

The team identified that they could extend their reach to support clients after of face-to-face appointments by recruiting Flo as one of the team.  Flo’s personal feel was well placed to interact with patients to consolidate the techniques discussed previously and provide a real time nudge to put them into action. 

Victoria Rathour, Primary Care Mental Health Worker with Gateshead Talking Therapies Service part of South Tyneside NHS FT has shared some recent case studies from her clients that have been introduced to Flo.

Not feeling alone, overcoming worry and low self-esteem

A client was referred to the Gateshead Talking Therapies experiencing worry and low self-esteem following a relationship break up.  These feelings were being exacerbated by some challenging family relationships, especially the client’s sister who she had struggled to build a relationship with as she was in touch and worked with her ex partners’ old girlfriend.

The team identified that extended reach support via Flo could extend the team’s support to the client once she had gone back to her daily life after their appointment.  The team discussed Flo, and how she may be able to help at the client’s first appointment.  Victoria Rathour as the client’s Primary Care Mental Health Worker gave the client Flo’s service information leaflet that had been developed by the team and used this as a basis to explain how Flo could help.

The client left the appointment ready to receive Flo’s first message later that day once she had returned home.

How Flo helped
Flo’s timely interactions supported the client to help identify her own coping strategies and to start to rationalise her own thoughts, particularly around the low self-esteem and worry that she had been experiencing and discussing with the team.  The client fed back that by receiving Flo’s messages it made her feel she that she wasn’t the only one suffering from mental health problems which was a significant milestone towards her recovery
The client explained that she found Flo, 

"very helpful and often looked forward to receiving texts from Flo" 

When the time came for the client to be discharged, she was in recovery having started to implement the tools and techniques advocated by the team and Flo to improve her self-esteem issues, and she began to make positive changes in her life. The client was very pleased with the service and stated that she may be interested in joining further courses or groups in the future.

Putting best practice care into practice

The team received a referral for a client who was a full time carer for her daughter and was hoping to develop techniques to help her overcome the depression and anxiety that she had been experiencing.

The client was finding herself mentally and physically drained from looking after her daughter, and was feeling an extreme amount of pressure and stress from having to liaise with other professionals to ensure that her daughter was receiving the treatment she needed.

At the client’s first appointment with the Gateshead Talking Therapies Team, Flo was introduced to extend the impact of the tools and techniques that had been discussed at the appointment to support the client in developing and using her coping strategies once she left the appointment and was back in her caring role.

For the client, Flo would be able to regularly interact with her to bring to life the themes discussed at the previous appointment, gently motivating her to reflect and put into practice what she had learned and feel supported and not alone.

The client found Flo very helpful and enjoyed receiving her messages.  In particular the client found the messages learning about mindfulness useful, and appreciated Flo’s prompts and encouragement to use the coping strategies that she knew she had, but didn’t always use when she needed too.  This real time intervention was able to extend the best practice care delivered by the team into the client’s everyday life.

Upon being discharged from the team, the client was in recovery and had started really picking up on mindfulness techniques and making plans of activities to do with her husband outside of being a carer for her daughter, which was something she really valued.

Liverpool Health Trainers and home blood pressure monitoring

posted 25 May 2017, 06:00 by Hollie O'Connell   [ updated 16 Oct 2017, 02:33 ]

Sharon Poll 
Liverpool CCG - GPN Lead 

30 May 2017  

Hypertension case studies 

Liverpool Health Trainers is managed by Person Shaped Support, they help to empower and enable referred patients to manage their health better through education and support.  They have been using Florence to help monitor blood pressure and have shared some of their case studies. 

Patient X was referred to their Health Trainer via their GP practice.  The patient had been experiencing strain from their overall health issues combined with a high blood pressure reading which may have been making the patient feel worse. 

The patient’s GP identified an opportunity for the patient to be introduced to Flo to facilitate the collection of short term home blood pressure readings.  The patient’s GP was keen to understand if there was any change in the patient’s blood pressure at home from that recorded at the surgery to inform a diagnosis or exclusion of hypertension, and to ensure the most appropriate treatment plan was arranged for the patient. 

The Health Trainer provided the patient with a hypertension diagnosis shared management plan, and explained to them how Flo would prompt them to send in their blood pressure and also offer advice dependent upon the patient’s reported readings as agreed with their GP.  These readings would then be reviewed at the surgery to inform on-going treatment. 

The patient left their appointment with their Health Trainer reassured and enrolled onto Flo, awaiting their first request for their blood pressure reading. 

Upon further review of the patient’s blood pressure readings, their average blood pressure was within the normal range compared to readings taken solely at the practice, and a diagnosis of hypertension was excluded by the GP. 

The Health Trainer commented that having the time to discuss Flo and how she can support the patient’s on-going treatment plan was useful.  The patient reported that on the day he had his blood pressure taken in surgery, his shirt had been tight and he was anxious which may have impacted on a false high reading.  Using Flo provided the patient with reassurance that their real time home blood pressure readings could be reviewed to provide data for an accurate diagnosis without the impact of external influences brought about by attending the surgery. 

The Health Trainer commented;

" Florence totally sorted this out as the patient was more relaxed and not rushed doing it at home. The patient now feels far more reassured. "

Patient X with uncontrolled hypertension was referred to their Health Trainer by their GP to use Flo.  The aim was to support the patient in improving compliance with their hypertensive medication and for education and motivation to adopt a healthier lifestyle in support of gaining better control of their blood pressure. 

On meeting the patient, the Health Trainer discussed Flo and how she can support the patient’s on-going treatment plan.  The patient was quickly enrolled onto an 8 week programme with Flo supported by a shared management plan and guidance on how to take home blood pressure readings. 

The Health Visitor offered to create a Personal Health Plan for the patient, however the patient was keen to follow Flo’s programme and to make the necessary lifestyle changes. 

Over the 8 weeks since being introduced to Flo, the patient’s blood pressure control has significantly improved 
  • Week 1 - average BP 163/122 
  • Week 8 - average BP 142/98 

The patient was thankful for Flo’s additional support and commented that Flo was " a real help to him and kept him on track " and explained to his Health Trainer how he could see the improvements in his blood pressure and the difference it was making for him. 

Importantly, the patient is now also more aware of the importance of taking his medication as prescribed and aims to continue to make further lifestyle improvements.

Patient X was referred to her Health Trainer by her practice nurse. The patient’s blood pressure was remaining high regardless of prescribed medication aimed to control it.  The nurse had identified using Flo as a tool to compliment the care already being given, helping to motivate and educate the patient to adopt a healthier lifestyle in support of gaining better blood pressure control. 

Flo was discussed with the patient and the Health Trainer explained what the patient could expect over the next week of home blood pressure monitoring.  A demonstration of how to use the blood pressure monitor was provided and a shared management plan was agreed with the patient. 

The Health Trainer explained the risks associated with high blood pressure and provided brief information regarding how lifestyle improvements can help to control and reduce high blood pressure. 

The patient visited her GP a few days later and through a discussion around her blood pressure realised she should have been taking three tablets rather than two.  The patient’s GP advised her to increase her medication to the prescribed dosage, and to continue to report her blood pressure to Flo for a further two weeks.  With the patients improved medication adherence, the GP could review the impact of the new dosage.

On review and after increasing her medication to the prescribed dose the patient’s average week reading was 151/98 mmHg.  The patient continued to take her blood pressure at home and send them to Flo for a further two weeks.

In the meantime the Health Trainer sent the patient’s blood pressure readings that had been reported to Flo to her GP.  Having reviewed the readings, the patient’s GP called her to ask that she return to the surgery to discuss her medication.

Based on the patient’s reported home blood pressure readings via Flo, the GP was able to intervene earlier upon identifying that the patient’s blood pressure medication needed to be increased; the GP subsequently requested that the patient continue to send Flo her home readings for a further week.

At the patient’s last review, the benefits of leading a healthy lifestyle were recapped, and information on the Health Trainer service was provided for any help or support to make lifestyle changes.  The patient’s average blood pressure at the end of the home monitoring via Flo had fallen to 118/84 mmHg and the GP was now confident that her antihypertensive medication had been titrated accurately.

Podiatry team prevent deterioration and exacerbations with Flo

posted 19 May 2017, 03:20 by Hollie O'Connell   [ updated 16 Oct 2017, 02:33 ]

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 #TotallyUnique

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 16 Oct 2017, 02:34 ]

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 16 Oct 2017, 02:34 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 16 Oct 2017, 02:36 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 16 Oct 2017, 02:36 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  

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