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Collection of 10 Nellie patient stories
03 June 2020
The Simple Telehealth Community of Practice is a unique environment harnessing clinical innovation to rapidly expedite the adoption of safe, innovative digital healthcare. Over the past 10 years through the passion and commitment of Community of Practice members, a robust foundation of independent evidence has organically grown.
This wide ranging evidence base, regardless of Flo’s application or patient demographic, consistently demonstrates a direct causal clinical effect and improved efficiency for healthcare providers. Unsurprisingly this has attracted international attention enabling the introduction of her US and Australian cousins (Annie and Nellie.). Although these locations are very different, Flo, Annie and Nellie have all continued to demonstrate the same positive and sustainable outcomes.
Whether using either Flo, Nellie or Clara, people feel that they have a ‘human’ connection to their healthcare provider, making them feel that they are not facing this alone. They have a friend in their pocket who will help to mitigate the significant mental health issues that self-isolation may cause in many patients.
South Eastern Melbourne Primary Health Network (SEMPHN) have shared a selection of short patient stories from across their clinical pathways supported by Nellie bringing this evidence to life. Nellie has been helping South Eastern Melbourne Primary Health Network (SEMPHN) patients to become an active partner in their own health for over two years.
Patient quotes:
" I tend to describe Nellie as a cheerleader to help them stay on track with their action plan. ”
“ So simple, and yet powerful. ”
We have gathered together some short patient stories which capture some of the life changing work.
Case 1: Ruling out hypertensionMrs JW is a 50 year-old woman with pre existing anxiety, occasional mild depression, domestic stress, and chronic pain resulting from a previous workplace injury. As part of her ongoing clinical management, Mrs JW’s blood pressure readings had been routinely taken during consultations at her practice over the past few years and were consistently both erratic and elevated with blood pressure readings up to 190 systolic and 110 diastolic.During an appointment at her practice, Mrs JW explained that she was due to travel to South East Asia in three weeks' time, which was adding to her stress as she was worried about travelling and also the possible risks of being away from home with high blood pressure. With Mrs JW’s history in mind and keen to be able to either diagnose and subsequently treat her possible hypertension, or provide reassurance that it had been excluded before she travelled, Mrs JW's clinician recommended that she accessed Nellie to help her to record daily blood pressure readings. At the end of the period, Mrs JW’s GP was able to review the daily submitted readings and confidently confirm that she did not have hypertension, and she was able to go on holiday with the reassurance she needed. The experience with Nellie was stress free for the patient as there was no requirement to schedule additional appointments for Mrs JW’s blood pressure readings at the practice, or to have to learn how to download and use an app during the short amount of time before her holiday. In addition, Mrs JW was able to send more accurate readings as she was in a more relaxed and familiar environment. Her GP was not involved during those two weeks as they were confident that Nellie would advise the patient to get in touch with the practice if it was appropriate to do so. Mrs JW’s blood pressure readings were simply reviewed by the practice at the end of the two weeks and an informed exclusion of hypertension was able to be made. You can watch this video of Dr Geoff Campbell explaining this story here. Case 2: Helping to take back control with a simple medication reminderMs DM is a 64 year-old woman with a history of acquired brain injury (ABI) following four cerebrovascular accidents in 2014 which affects her short term memory. She also has type 2 diabetes, hypertension and suffers from depression. Ms DM was a new patient to the general practice nurse-led clinic and presented with uncontrolled BP ranging from 150/90 -168/98 and a HbA1c of 8.6%.To help Ms DM remember her medication and take control of her hypertension, Nellie was introduced to her at her care planning session, and she was happy to take up the opportunity for daily prompts to take her morning medication as prescribed. Ms DM was on this program for several weeks and with Nellie’s help, only missed her anti-hypertensive medications on two occasions! As a result, her BP had reduced to 130/85, and her fasting blood glucose levels were also beginning to reduce. Case 3: Preventing cerebrovascular accidents by walking with NellieMr CI is a 69 year-old man with a history of cerebrovascular accidents during the last 18 months. He had recovered well and attended a rehab program yet had found it difficult to maintain his motivation to keep active which was a key component of his recovery. With his weight and blood pressure creeping up, Mr CI was introduced to Nellie and really liked the idea of being accountable for his daily step measurements.On a daily basis for 3 months, Nellie provided Mr Cl with motivational messages to get him moving more and also helped to track his daily step count to maximise his motivation. As a result, Mr Cl was able to maintain his increased activity at a level of 5-6,000 steps a day and consistently demonstrating such positive sustained behaviour change, Mr CI no longer needed Nellie to motivate and prompt him so has been able to be discharged from the program. Case 4: Walking with Nellie helped to save lifeMr and Mrs S are a retired couple and both have chronic health conditions. Mrs S had undergone a knee replacement 3 years ago and has experienced painful knees ever since, which has limited her capacity for physical activity.Mr S was diagnosed with Type 2 diabetes 40 years ago which unfortunately has led to partial blindness. In order to help manage his diabetes, Mr S was treated with 30 units of insulin/d and also has a pacemaker. In a care planning appointment both Mr and Mrs S identified weight loss as a goal for them both and decided to sign up to a walking protocol with Nellie in January 2018. After 3 months of starting with Nellie:
Simple Shared Healthcare were lucky enough to meet with Mr and Mrs S’s GP in 2019. Their GP said in plain terms that if it hadn't been for this behaviour change towards walking regularly, Mr S would not be here today. Case 5: Informed decision making to reduce BPMs M is a 70 year-old female with Type 1 diabetes, which was diagnosed at the age of 30. She had presented with microvascular complications and more specifically, deteriorating retinopathy. She spoke to her diabetes educator, and her main concern was the potential for losing her eyesight. Her glycaemic control was excellent (reduced to a HbA1c of 6.5% from 8.0% 12 months previously), but she also had a history of hypertension and was on anti-hypertensive medication.At the time of her consultation her blood pressure was 145/85 mmH and her goal was to reduce microvascular risk factors, so she chose to focus on optimising her blood pressure control. It was not clear whether her raised blood pressure was related to suboptimal control or white coat syndrome, so the patient commenced on Nellie with a hypertension protocol. Over the following 4 weeks she measured her BP at home and submitted the results via Nellie. Nellie responded to her raised blood pressure readings to reinforce the target blood pressure range and due to more accurate readings, her GP was able to make a more informed decision to titrate her anti-hypertensive medication and increased her dosage, which resulted in her systolic BP consistently being less than 130mmHg. Nellie’s interactions have helped Ms M to understand how to manage her BP better to reduce the risk of further deterioration of her retinopathy (as well as other vascular risk factors), and has provided her with reassurance that she can continue to control her conditions in future. | After the recent loss of her husband, Mrs J was finding it difficult to motivate herself to go out and exercise. Recognising this, in October her clinician introduced her to Nellie as a friendly nudge towards becoming more active. Nellie first encouraged Mrs J to walk every Monday to Friday, but Mrs J felt that she missed Nellie’s messages at the weekends. Therefore after talking to her clinician about this, her clinician was able to personalise Nellie’s programme for her to provide support 7 days a week. After 1 month, Mrs J had lost 4 kilos and was “ over the moon ” with Nellie for supporting her to get out and be more active, which left her feeling a lot happier within herself. By December, Mrs J had lost 12 kilos! Although this protocol with Nellie was designed just to motivate people to walk more, because of Nellie’s unique persona and supportive messages, it has meant a lot more for Mrs J. Her clinician also commented, saying that “ it’s been lovely to see Mrs J become happier during this difficult time. ” Case 7: Personalisation of messages instrumental to BP managementA patient with multiple chronic conditions identified a lack of motivation to check his blood pressure due to a stressful and demanding job, explaining that he didn’t have the time or mental capacity to remember to check his blood pressure throughout the day. He acknowledged the impact his uncontrolled blood pressure was having on his recently diagnosed Type 2 diabetes, which had also become uncontrolled.After speaking to his clinician, they were able to personalise Nellie’s interactions so that he received them at a time that suited him during his busy day. As the patient knew Nellie would prompt him at a convenient time, he didn’t have added stress about remembering to take his blood pressure readings, and due to these timely prompts, over the next four weeks his blood pressure testing became routine, resulting in his blood pressure being more controlled and feeling empowered to deal with his diabetes. Case 8: Simple inhaler reminder helped patient control and understand their asthmaA 24 year old female patient with chronic asthma often forgot to take her preventer inhaler because of long working hours, which led to frequent exacerbations and the use of her Ventolin (reliever) inhaler almost daily. Due to this, she was suffering from an increased amount of chest infections which understandably was impacting on both her mental and physical health and wellbeing.The patient joined Nellie with a medication reminder protocol, where she received daily prompts to remind her to take her preventer inhaler. The reminder was tailored to her time schedule and specifically told her which inhaler to use, this not only helped her to take her medication but also began to build her health literacy around the treatment of her asthma. Although the patient had only been receiving messages from Nellie for a short amount of time, during the first week healthy habits began to form and she remembered to take her preventer every day and hadn’t needed to use her reliever once, which was a huge improvement. Case 9: Exercising with Nellie and... Dr Who!DA, an overweight 65 year old man with chronic pain and raised blood pressure, struggled to motivate himself to exercise regularly. DA’s Chronic Disease Coordinator suggested introducing Nellie alongside a health coaching program to enhance DA’s motivation to walk, and provide welcome encouragement when he achieved his goal.While walking, DA likes to watch episodes of his favourite TV show, Doctor Who. He even came up with the idea of setting his message tone to the Doctor Who theme when Nellie messaged him. For DA, this linked walking, something that he previously found laborious and boring, with something he truly enjoyed, flipping the negative association to positive. After four months of encouragement from Nellie, DA established a daily routine of waking up in the morning and getting straight on the treadmill. He lost over 7kg of weight and 12cm around his waist by steadily increasing the time he spent on his treadmill, and now has no need for Nellie’s prompts. Over this time, his goal developed from 20 minutes of slow paced walking to over an hour of brisk walking at an incline! He has also committed to an overhaul of his diet, and said “my wife has stopped cooking with salt”. DA now aims to lose another 8kgs over the next 6 months and further improve his diet, limiting less healthy treats to once a week. We’ve been told his wife is relieved he’s now built the habit because she no longer hears that ringtone! Case 10: Nellie as a self-help support for improving mental healthMs S is a 47 year-old woman with a history of Post Traumatic Stress Disorder, fibromyalgia, depression and a few other chronic medical conditions. Her Care Coordinator saw her to review her care plan back in June 2018 and talked about Nellie. Ms S was going to consider Nellie, then rang her Care Coordinator about a month later and decided that she was ready to start.Ms S commenced with Nellie’s mental health protocol and interacted with her each day to self-rate her mood and energy levels in real time. She “ totally loved it " and ended up staying on it for 3 protocol cycles as she was able to re-start the protocol. Ms S even showed her Psychologist her interactions with Nellie on her phone and started sharing her progress with them. She told her Care Coordinator about the story of her grandmother who was called Nellie, so she affectionately named her Granny Nellie. Ms S was living at home with her Mum and was quite withdrawn, socially, and really looked forward to receiving Nellie’s messages every morning, and was happy to follow the instructions and suggestions that Nellie provided in response to her self reported mood and energy scores. She created a diary, which she purchased at one of the later sessions, where she was able to show her Care Coordinator that she’d been documenting all the little activities that she’d been doing as suggested by Nellie, such as making a present for someone, contacting people, writing a letter, listing things she had enjoyed. She loved it and it had really improved her mood over that time. She was on Nellie until December 2018, with a couple of breaks. At the end Ms S was self-rating her energy levels at a 7/10 and her mood at 6/10 and she did start off quite low, at 1’s and 2’s, so she went up and down, but she definitely loved it and having Nellie for support made a big difference. |
Mental Health; Patient Graduates from Nellie after Demonstrating Significant Behaviour Change
Carol Wildey
29 June 2020
With the World Health Organisation citing adherence to therapies as a primary determinant of the effectiveness of treatment1 South Eastern Melbourne Primary Health Network (SEMPHN) clinicians have been harnessing Nellie’s unique ability to motivate and engage patients towards positive behaviour change. Jennifer, age 50 (not real age or name) living with chronic mental health challenges and associated physical health co-morbidities kindly wrote to the SEMPHN team to share the impact of her supportive intervention with Nellie. Jennifer’s clinician, Dr Wild, had targeted Nellie to support the specific medication adherence challenges demonstrated by the patient. Jennifer’s letter described the impact that this made to her physical and mental health and how it enabled her to adopt behaviours to sustain her medication adherence beyond her interventional support from Nellie. The improvements were significant and enabled her to commence cognitive behavioural therapy (CBT) and interpersonal therapy (ITP) programmes. Jennifer’s letter explained that due to her existing medical condition, her clinician had recognised that she was often going to bed forgetting to take her medication despite having a tablet box filled each week by her daughter. Unfortunately, the patient’s suboptimal medication adherence was exacerbating her memory problems, and as a result Nellie was introduced to Jennifer’s daily routine to prompt her before bedtime to provide a real time intervention aimed at improving her adherence and subsequently reducing the physical and mental impact of previous non compliance. With Nellie’s gentle prompts, Jennifer started to take her medication as prescribed, her memory problems began to reduce and her physical and mental health improved; by the time her programme with Nellie had ended she was comfortably in the habit of taking her medication independently as prescribed each evening. Jennifer also explained that as her memory problems had now improved, she had now begun initiating the filling of her tablet box whenever her daughter had forgotten, demonstrating positive behaviour change and a shift to sustainable independence around her medication. | “ As my health improved, so did my memory, and once Nellie’s messages ceased, I was in the habit of taking the nightly dose without being prompted ” Jennifer remains close to being 100% compliant with her medication which far exceeds the average rate of compliance for most patients and is able to increase her independence around managing her condition. Click image to enlarge |
Australia mental health; Nellie makes positive impact with COVID-19 response
Carol Wildey
Peer Facilitator Simple Telehealth “Nellie” South Eastern Melbourne Primary Health Network
05 June 2020
During this unprecedented time of uncertainty with the wide scale introduction of social distancing, and the requirement to reduce face-to-face clinical contact to that of the most urgent need, technology is playing a crucial role in enabling the continuation of safe health care provision during the COVID-19 pandemic around the world.
Flo’s next generation cousin ‘Nellie’ has been helping South Eastern Melbourne Primary Health Network (SEMPHN)’s patients in Australia for over two years now. Recognising Nellie’s proven techniques in delivering a rapid public health response, SEMPHN clinicians were quick to identify the opportunity that Nellie provided to be able to extend their reach remotely, enabling clinicians to continue to provide high quality, safe healthcare. Specific smart-messaging COVID-19 pathways were developed bringing the latest government guidance to life for community members with symptom monitoring (where there were Upper Respiratory Tract infection symptoms) and mental health and wellbeing messages (for any community members, even if they didn’t have symptoms). Carol has kindly shared one patient's experience about how Nellie improved her sense of wellbeing, reduced feelings of anxiety and stress and the wider quality of life impact that this brought.
" Nina (anonomysed) reached out to us at SEMPHN to say that she wanted to give us some feedback about her experience of Nellie’s COVID-19 pathway. I made contact with her and here is her story: Nina is a lady in her early 60s who lives alone and has recently moved back into the suburb where she grew up. Nina has been seeing her GP regularly as she has a history of mental ill health, and from a brochure at her GP surgery was initially introduced to how Nellie could support her wellbeing during COVID-19. Designed with personalised tracking which adapts to each patient’s individual journey within the prescribed protocol at any particular time, the self-subscribe feature within Nellie was chosen for community members accessing this pathway to enable them to easily self-enrol and avoid the need to make contact with their clinician. Therefore Nina was able to go home and look at information on the SEMPHN Nellie web page, and she could decide if the service was right for her. Once Nina felt ready, she was able to activate the service by simply sending a designated keyword to Nellie’s specific mobile number to start receiving messages. Nina told us that she liked knowing that Nellie’s service was time-limited, as she thought that, given the purpose of Nellie’s use during COVID-19, that this would maintain engagement and interest. Nina also liked that Nellie’s messages came at different times of the day. She said that some people with a mental health diagnosis might become obsessive if they were anticipating a message at the same time each day. She had noticed and appreciated the fact that this wasn’t the case for Nellie, because the messages were set up to be sent at varied times. We hadn’t really thought about the timing of the messages in this way. We had simply designed Nellie’s schedule with what time felt appropriate for a particular interaction. It’s definitely something we’ve taken on board! | “ Wow, I know Nellie isn’t a real person (and that’s part of the magic). It feels like it’s a real person who cares about you, but you don’t have to worry about them ” Once again, we hadn’t fully considered the anxiety experienced by people in relation to their loved ones, and it was clear that it was comforting for Nina to know that Nellie is not a real person that she needs to worry about, but still receives the non-judgmental advice and reassurance she needed. Nina also said that she had found Nellie really easy to use, and that she liked that she could reply to Nellie’s wellbeing check-in messages and get appropriate feedback and tips. However, she also said, “ you didn’t have to reply at all if you didn’t want to and it didn’t matter ” which was important for this patient cohort Importantly Nina said that she felt that she could trust what Nellie was saying. Even though she knew that Nellie wasn’t a real person, she knew that there were real health professionals who had approved the Nellie program and the information was based on the latest Government advice. One of the things that Nina told me was that Nellie had a positive ripple effect in her family. Nina explained that she would often call her brother when she was experiencing stress and anxiety, but Nellie’s guidance had helped her to feel calmer and more in control. As Nina was feeling less stressed, she didn’t need to call her brother as often for support, but when they did speak, the conversations were more relaxed and positive which allowed her brother to feel confident that Nina was ok and didn’t get as worried when she did call. Nina’s closing quote was, " I like to think of Nellie as a special robot who is looking after me ” " |
Supporting respiratory care in Powys: A Patient Story
Jo Allen
Respiratory Specialist Nurse Team Leader
15 November 2019
Jo Allen is the Respiratory Specialist Nurse Team Leader at Welshpool Hospital. Jo was first introduced to Flo a number of years ago, and has been using Flo to support patients who have a variety of respiratory conditions. She has recently taken some time to share one of her patient’s stories with us.
“ I have a patient who I’m supporting with his respiratory condition. He has COPD and bronchiectasis, and he has had a number of admissions for Type 2 respiratory failure. He is hypoxic due to his condition and is on long term oxygen and ambulatory oxygen to try to help with this. He’s also waiting for a sleep assessment at Wrexham hospital to try to support his breathing and better sleep at nighttime. The gentleman becomes breathless after minimal activity or exertion. He is limited in terms of what he’s able to do before becoming breathless and needing to stop and rest, and as such he can’t walk further than around 50 metres. Consequently, he has become very reliant on his wife for help and support in his day to day life. As you can imagine, my patient found that it was a big adjustment to start using oxygen at home and also to have to rely on his wife so much. He was not engaged with his health, which was a cause for some concern. I wanted to find a way to help my patient by improving his confidence around his health and ensuring a link to myself and other clinicians, in a way which would not seem intrusive. I thought Flo could really help my patient, and he had actually already heard about Flo from our team. I discussed with him how I thought Flo could help, and we decided to give it a go. I explained what Flo would ask him to do, and also how to use some simple equipment to take his readings. Flo sends my patient a friendly prompt twice a week to reply with his blood oxygen saturation levels, and also his temperature. Depending on the readings he sends in, Flo will then provide some guidance based on the agreed care between myself and the patient. If his readings are either too low or too high too many times over a certain period, I will get a notification on his patient record in Flo’s system. Flo also sends him some additional advice and motivation messages each week, for example, advice around staying active, breathing exercises and so on. | I think that from my patients perspective Flo has been really helpful in supporting him to better self-manage his condition. He has told me that he finds Flo easy to use, and her messages are useful because they remind him that there is someone there to support him, and he also feels less isolated. He has told me that he worries a little less now about his condition, and would recommend her to others with similar health concerns to him, as she helps him to stay focused. I am really pleased with the improvement I have seen in my patient’s health. I can tell that he is more confident in the management of his condition and that his knowledge and understanding has improved. I think this is evidenced by the noticeable reduction in admissions we have seen for this gentleman. From my perspective as a clinician, I have found Flo to be a really useful tool for us. When I have introduced patients to Flo, their feedback has always been very positive. I think Flo is able to offer patients some additional reassurance, which gives them the confidence to self-manage & engage with their health. Not only do patients benefit from this, but their family and friends do too, as they feel reassured that their loved one is receiving the support they need. Although where we have used Flo we have had some fantastic results, we would like to be able to introduce her to more patients and improve uptake. We now have a new Healthcare Support Worker working with us, and our physiotherapist has re-joined us, and I think that increased capacity will really help us to be able to take Flo forwards and reach more patients. ” |
If you would like more information about how Jo is implementing Flo to support her patients with respiratory conditions, please contact her at Joanne.Allen2@wales.nhs.uk
#COPD #Bronchiectasis #Respiratory # Welshpool Hospital #Powys Teaching Health Board #Wales #TotallyUnique
Hypertension and Flo in General Practice; exploring evidence supporting sustainable scale-up of services
Hollie O'Connell
Innovation Support Officer
Karen Moore
Advanced Capability Lead
30 August 2019
Since the early days of our Community of Practice, hypertension has proved to be the most successfully evaluated pathway with Florence. Following our recent news of Scotland’s £1.2 million Scale-up BP Initiative which will see Flo rolled out nationally over the coming 2 years, we’ve compiled below some key articles and case studies which demonstrate the many sustainable benefits of supporting hypertension pathways with Flo. These publications have been contributed from all corners of the community and include evidence for the release of appointment capacity and standardisation of care, along with the positive outcomes for patients with better disease control, which has been achieved by combining Simple Shared Healthcare’s unique methodology, Flo’s persona and the utilisation of local clinical best practice.
One of the earliest publications evidencing the influence that Flo had on patients hypertension management was published by NICE in 2012, where key findings were not only a significant reduction in patients BP readings, but also through Flo’s interactions and unique persona, patients benefited from an “improvement in education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur”. A service evaluation was also published in 2012 as a BMJ paper with 10 General Practices in Stoke-on-Trent volunteering to measure the acceptability, satisfaction and ease of use when using Flo for hypertension management in primary care. Overall satisfaction with Flo was very high, scoring 4.81/5.00 at week 13 of the programme with “feelings of control and support” and patients finding Flo easy to use. Along with this, it was concluded that Flo should be considered for wide-spread implementation for hypertension as “a large number of meaningful readings can be obtained from many patients in a prompt, efficient, interactive and acceptable way.” Another BMJ paper published in 2012 examined “how efficiently an innovative, simple and interactive blood pressure (BP) management intervention improves BP control in general practice.” This study gathered data from patients who received treatment as usual and patients who received Flo as an intervention. Results showed that intervention patients had a greater reduction in their BP readings and due to there being significantly more readings, there were more medication changes as clinicians were able to access more accurate readings and titrate medication appropriately. However the highlight of this study was seen when Flo’s intervention stopped. Patients from the control group not using Flo, over time returned to their baseline uncontrolled BP readings, whilst those who had received an intervention from Flo continued to control their BP (as shown in diagram below), demonstrating sustainable behaviour change and continued self-management of their hypertension. | Later in 2015, a further BMJ paper was published focussing on the AIM (Advice and Interactive messages) project which included 425 primary care practices in England evaluating a number of pathways in Flo including medication reminders, smoking cessation and hypertension diagnosis/monitoring, where the impact and acceptance of Flo for patients and professional users was assessed with positive results. Highlands also evaluated a number of applications in Flo which included their use of hypertension diagnosis, where:
NHS Lanarkshire’s large-scale implementation of Florence was supported initially by a 90 day rapid improvement study focussing on Flo’s impact on appointment capacity and clinical decision making. This study along with the soon to be published outcomes of NHS Lothians Scale UP BP programme provided valuable evidence to support the decision for Scotland to scale-up with Flo nationally. Some of the benefits found included:
| Alongside the substantial quantitative evaluation, qualitative evaluation has also been captured by a number of organisations capturing how patients and users feel about their experience of Flo. Jane Freeman - Health Secretary Scotland commented: “This technology [Flo] brings significant benefits to patients. It enables them to have more control over how they manage their condition, and greatly cuts down on the number of appointments they have to attend.” Below is a selection of patient comments about their experience of using Flo and how she has contributed to better management of their hypertension: “The system [Flo] is so easy to use and has made all the difference to me and my family” “I have found using Flo really good, the reminder and what to do with blood pressure is too high is very useful as there are times when you forget that it is time to check the blood pressure and you get a gentle reminder. Doing the BP at home is less stressful as it is a more relaxed environment” “I liked being in control of my monitoring. I also know a lot more about blood pressure” “Being offered the use of Florence was a brilliant alternative [to attending appointments] – and I think the hassle free-nature of it, without having to commute and take time out of a busy day, probably gave a truer reflection of my day-to-day readings.” |
Focus on COPD: Improving quality of life in the Highlands
20 December 2018
COPD - Supporting patients to take personal responsibility
You may have previously read the inspirational report published by NHS Highland providing a comprehensive analysis of Flo’s impact across a number of services throughout the Highlands region, including hypertension, asthma, low FODMAP diet and weight loss.
Feedback around NHS Highland’s COPD pathway has been fantastic. Patients interacted with Flo and as a result felt supported to take personal responsibility for their health, which in turn improved their quality of life through better self-management. We would therefore like to share a more in-depth focus on this area with you.
NHS Highlands developed a local COPD pathway towards the end of 2016 incorporating Flo, which was specifically developed to help improve their patients motivation and confidence to self-manage. Flo interacts with patients with support and advice, whilst providing the opportunity for them to participate in remote monitoring of their COPD by bringing their electronic action plan to life. When patients report readings to Flo, her responses are based on the Chest, Heart and Stroke Scotland (CHSS) COPD Traffic Lights. For example, if a patient who uses Flo reports that they are currently within a ‘red traffic light’ based on their SATS and symptoms readings, Flo will prompt the patient to take their rescue medication and to confirm that the action has been taken. As the patient confirms via Flo, a notification will be sent to the clinician informing them that the patient has initiated their treatment. A number of anticipated outcomes were identified at the start of the project, including:
It was also acknowledged that achieving these outcomes would contribute significantly to improved cost effectiveness, access to services and staff engagement, as well as reduced waiting times for patients. Feedback gathered by NHS Highlands was overwhelmingly positive, from both clinicians and patients alike. | In addition to these comments, NHS Highland also utilised Flo and traditional paper questionnaires to collect evaluation data at the end of the protocol, finding that:
Outcomes:As well as producing their own evaluation of Flo services, NHS Highlands approach was also included in Service Evaluation by Dr Maria Wolters, Edinburgh University, which focused on telehealth use for COPD, Asthma & Heart Failure. The evaluation found evidence that the COPD pathway integrating Flo:
If you would like to take an in-depth look at Dr Wolter’s Service Evaluation, then click here. |
Case study:
Mrs Smith is 60 years old and has a confirmed diagnosis of COPD. Before being introduced to Flo, she contacted the respiratory department on a regular basis, as she was very anxious about her condition.
When she was enrolled on Flo, Mrs Smith initially had increased contact with clinical staff. However, as her understanding of Flo grew, so too did her understanding of her COPD. Mrs Smith became more confident in her ability to self-manage her condition, and the contact with clinical staff became less frequent.
By the final third of the protocol Mrs Smith was contacting the clinical team far less frequently than before her introduction to Flo, and since being on Flo she is willing to submit sputum samples, which previously she was uncomfortable doing.
Mrs Smith is now less anxious about her COPD, and Flo has made her feel reassured that she has the support she needs to manage her own health. Furthermore, this feeling of improved confidence has continued beyond the end of the protocol, demonstrating that Flo’s proven psychology can help to effect long term health behaviours.
For more information, please contact
Providing a "convenient" and "relaxed environment" to help patients stabilise blood pressure
Sandwell and West Birmingham Hospitals
NHS Trust
Dr De
Consultant Physician and Clinical Lead in Diabetes and Endocrinology
30 May 2018
Compliance is a major issue in any chronic disease management, combined with the high prevalence of diabetes across Sandwell and West Birmingham, compliance to treatment is a particular challenge to patient’s achieving their optimum disease control and preventing or delaying further deterioration to their health.
Through his clinical practice, Dr Parijat De recognised the impact that poor compliance to self-management and treatment was having on his patient’s disease control. Given the compliance issues faced, together with poor blood pressure control amongst high risk patients with diabetes and renal disease, Dr De accepted the challenge to address this in order to improve the clinical outcomes and quality of life for his patients.
Consequently, Dr De harnessed Flo as a tool to integrate into his treatment planning, aimed at specifically improving his patient’s adherence to their blood pressure treatment. Flo’s interactions were designed to gently educate and motivate patients to become more engaged and confident to self-manage their blood pressure outside of face to face care, with regular encouragement to follow their treatment plan. Some sphygmomanometers were made available to lend to hypertensive patients, however most patients purchased their own blood pressure machines after the team explained how Flo’s support could help them. Read more here.
Dr De has shared three patient stories.
" Patient OneA 72 year old lady with type 1 diabetes, hypertension and a background history of Conn’s syndrome (diagnosed in 2008) was referred to me for her uncontrolled blood pressure and resulting symptoms. Given her resistant hypertension and an endocrine cause for her high blood pressure, this patient’s blood pressure needed to be monitored very carefully. The patient was already taking Amlodipine 5mg, Indapamide SR 2.5mg and Losartan 100mg daily, was not able to tolerate Doxazosin and empirically was treated medically for her Conn’s syndrome with Spironolactone. The patient had demonstrated that she needed to be reminded initially to check her own blood pressure readings on a regular basis, and needed both hospital and primary care monitoring for this which she found very difficult to cope with given all her complex endocrinology investigations that were being carried out simultaneously alongside. So we introduced Flo to the patient specifically to support her blood pressure management. With Flo’s interactions, the patient’s blood pressure ranged between 140-150/60-80. Given that the patient had successfully stabilised her blood pressure during monitoring with Flo’s regular two-way dialogue, she was then able to reduce Flo’s interactions to once or twice a week. The patient was quite happy with the feedback received from Flo on a regular basis and she explained that this helped her to feel more confident. This model of care proved to be more convenient for the patient as she did not have to travel to hospital or her GP surgery clinics for this regular blood pressure monitoring. Given her complex endocrinological condition and resistant hypertension, the patient continues with active Flo support on an ongoing basis and is currently very pleased. " I found using Flo very good as a reminder and a discipline for remote monitoring of my BP. Obviously more convenient than travelling to the GP or hospital " Patient Two A renal patient with associated diabetes and resistant hypertension is under my care having been treated with four different blood pressure medications previously. Acknowledging the co-morbidities experienced by the patient, we recruited Flo to support the patient specifically around improving the frequency of their home blood pressure monitoring, and the confidence to act on the advice agreed in their shared management plan. Flo began to prompt the patient to take their blood pressure and send the reading back to her, where Flo would give appropriate advice, the patient was also reminded to take their medication as prescribed. With these friendly prompts and guidance the patient sent regular readings in and enabled the team to accurately titrate their medication. With the patient taking their medication more accurately, the team were able to more closely monitor the resulting impact on their blood pressure. As a result, the patient’s blood pressure control improved significantly in this very high cardiovascular risk patient. " I have found using Flo really good, the reminder and what to do with blood pressure is too high is very useful as there are times when you forget that it is time to check the blood pressure and you get a gentle reminder. Doing the BP at home is less stressful as it is a more relaxed environment " | Patient Three I have been treating a 72 year old gentleman with type 2 diabetes, anaemia, hypertension, depression, hypercholesterolemia and previous history of drug induced hyponatraemia. The patient’s blood pressure had been fluctuating with low sodium levels since May 2017, and a number of his blood pressure medications had to be stopped including Lisinopril prescribed for his for low sodium levels. The patient had undergone twenty-four hour ambulatory blood pressure readings which confirmed a persistent high blood pressure and as a consequence, Lisinopril was reintroduced along with Indapamide and Amlodipine 5mg once a day; Doxazosin was also added which we later discovered the patient could not tolerate. At this point we felt that Flo could offer support to the patient in managing his blood pressure and becoming more complaint with his treatment plan. We discussed this and the patient was happy to receive Flo’s support via his son, who was active in his Father’s care, sending his Father’s readings. We also felt that recruiting Flo to gently remind the patient of the lifestyle changes that we had previously discussed with him, would continue the conversation beyond his hospital appointment and motivate him to take the required actions. With friendly prompts reminding the patient to take his blood pressure readings and the motivation to act on the advice, Flo helped the patient ensure that his systolic blood pressure became more stable, ranging between 125-145 and diastolic 80-92 mm mercury. As you can see, the patient had multiple medical co-morbidities. The patient’s blood pressure control was not being helped by them feeling very weak, lethargic and quite depressed resulting in the patient’s blood pressure remaining high and volatile. Now with Flo’s help, the patient’s blood pressure is stable and he is sending blood pressure readings via Flo once a week. The patient’s son, who regularly keeps an eye on his Father’s blood pressure and also sends his reading to Flo commented: " Florence has been definitely beneficial to my father and it is very helpful to take blood pressure readings at home in a familiar and relaxed environment especially as his blood pressure is always high when he visits the hospital or GP. It also avoids lots of further journeys which means he can use this time saved in a different way. More importantly he has peace of mind that his blood pressure is being monitored and that he would be notified if there was an issue that needed action. Although he is quite disciplined in the way we keep an eye on his blood pressure, Florence reminders are also very useful in following exercise and diet. I would definitely recommend this service " " |
Removal of gastrostomy tube, independence and education are some of the goals achieved by Adult Cystic Fibrosis patient with Flo's tips and support
Alison Marshall
Adult Cystic Fibrosis Specialist Dietitian
26 April 2018
Alison Marshall is an Adult Cystic Fibrosis (CF) Specialist Dietitian working within the Tayside Adult CF service. The team is based at Ninewells Hospital, Dundee, and they are committed to providing specialist care for young people and adults with CF, as well as supporting families of young people with the condition. The team is made up of specialist multidisciplinary clinicians, including consultants, nurses and physiotherapists to promote all aspects of physical and mental health and well-being.
One of Alison’s patients is Adam; they were introduced just as Adam turned 16. Adam lives with cystic fibrosis and like most cystic fibrosis patients, has to work hard to keep up his calorie intake to ensure that he is getting the correct nutrients and that he maintains a healthy weight. Alison and Adam have worked closely together to improve his nutrition, with the aim of increasing his weight up to the point where he would no longer need to rely on his gastrostomy feeding tube. With the aim of no longer being dependant on the gastrostomy tube, both Adam and Alison worked together to increase his oral nutrition and supplements whilst simultaneously decreasing Adam’s use of the gastrostomy tube, and within a space of six months made good progress. It was around this time that Alison asked Adam if he’d like to try Flo to help him with this. Adam, “I didn’t really have a system for managing my diet. I would just eat whatever I wanted to and tried to remember to eat snacks in between meals. I would also just try to remember tips from my dietitian such as adding cream to my milkshakes in the morning. I also never weighed myself at home.” | Flo helped Adam to embed the strategies that he discussed with Alison into his daily life by sending regular friendly messages and asking Adam to record his weight periodically too. “My dietitian asked me if I wanted to try Flo and I said yes, because there’s no harm in trying something that might help. I’ve been using Flo to give me tips on how to put on weight, remind me to eat snacks, and also to monitor how much weight I’m putting on and I have found her fairly helpful - I now remember much better to eat my snacks and also have a broad range of tips for putting on extra weight.” In addition to the educational messages that Flo sends him, Adam also used Flo’s ideas and methods to set up extra prompts and reminders of his own to help him even more. |
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Diabetes; Flo improves efficacy of best practice care - a collection of ten patient stories
Derbyshire Community Health Services
NHS Foundation Trust
Michelle Denyer
Lead Community Diabetes Specialist Nurse
16 February 2018
The Diabetes Specialist Nursing (DSN) Team at Derbyshire Community Health Services NHS Foundation Trust (DCHS) provides services for patients with Type 1 & Type 2 diabetes in the north of Derbyshire. The team supports patients with overall management of their condition, helping to avoid both short and long term complications. The DSN team assist patients by altering existing treatment plans and initiating new ones, as well as providing advice around lifestyle, diet and so on. The team also provides a selection of short educational courses to patients and other practitioners & care staff to improve knowledge and understanding of diabetes.
Michelle Denyer, Lead Specialist Nurse with the DSN team has captured some of her patient’s experiences to share with the Simple Telehealth Community.The stories below highlight examples of how clinicians have used Flo to augment best practice care, the positive impact this has had on patient’s lives and the value that Flo adds to the team as an enabling tool to support their patients in a different way.
Case study 1 BG remote monitoring results in no further hospital admissions or ambulance call outs Patient 1 was a 77 year old with type 2 diabetes. The patient lived in a residential care home, and their diabetes was difficult to control, with blood glucose readings anywhere between 2mmol and 30mmol being recorded. This poor control led to the patient being hospitalised for a total of four weeks from 14th August 2017, while various methods were attempted to control their blood glucose. The patient’s HbA1c in June 2017 was 8.4%. Upon discharge and returning to the residential home, it was requested by the hospital that the patients’ blood glucose be monitored four times a day, and these readings continued to fluctuate. To counteract high blood glucose levels, the home was advised to administer quick acting insulin. The diabetes specialist nurse visited the care home and found that the patient’s care plan was very complicated, and felt somewhat uneasy about this. The patients’ blood glucose before going bed was around 2.4mmol, and this rose to between 24-30mmol in the morning – no explanation could be found for this as the patient had no access to food during the night time. As of 18th September, the patient’s blood glucose remained unstable, leading to an ambulance being called out and a subsequent hospital admission on 20th September. The patient began a basal bolus regime, which meant that the patient was having 4 injections daily – not particularly ideal for a patient of this age. At this point, the DSN spoke to the patient’s son about having a mobile phone to use with Florence, and also spoke to the care home about telehealth. The patient was set up on Flo via a telephone call, and the patient’s son did the initial text confirmation to opt in. The patient was put on to a simple protocol which asked for readings and recorded them. This enabled the DSN to remotely monitor the patient’s blood glucose levels, and contact the care home to provide advice and support when necessary. The care home staff reacted positively to the use of Florence, as they felt reassured that a clinician was checking the patient’s readings remotely. From the clinician’s perspective, using Flo has created time savings, as they can now log into Florence and check the patient’s readings. If the readings are within range the DSN nurse doesn’t need to contact the home, whereas before this was necessary to find out what the readings were. On the other hand, if the DSN sees that the readings are too high or low, they can intervene in a timely manner, and avoid further ambulance call outs or hospital admissions for the patient. There have been no further admissions or ambulance call outs to the patient to date. Main benefits:
Case study 2 BG control allowed surgery to go ahead as planned The patient was a 53 year old with type 2 diabetes, who was found to have a tumour in their bladder. Surgery was scheduled for 29th August 2017 to remove the tumour, and the patient began to take insulin. As the patient was going in for surgery, it was key that their blood glucose was kept within tight targets. At this time, the patient’s HbA1c was 9%. The DSN did not need to arrange any face to face appointments with the patient due to the fact that she was able to remotely monitor their readings using Florence. Instead, the DSN made three phone calls to the patient to give them extra advice based on their readings. This saved time for the DSN, and also meant that the patient didn’t need to go to further appointments, which was more convenient for them. The patient has also commented that using Florence was helpful and reassuring for them. Main benefits:
Case study 3 Carers and DSN help patient to reduce hypoglycaemia episodes and as a result reduce ambulance call outs The patient was a 53 year old with type 1 diabetes. The patient lived in a supported unit, and had previously had problems with alcohol. They were experiencing episodes of hypoglycaemia leading to unconsciousness. Staff at the supported unit would then have to handle these incidents. The patient’s HbA1c was measured at 6.4%. The patient began to use Flo in July 2015 and initially carers were texting Florence on their behalf. The carers found using Florence to be a positive experience; they felt reassured that the diabetes specialist nurse could monitor the results, and that Florence would let them know if they should contact the DSN. They also found the advice such as when to check for ketones, or treatment of hypos helpful. Prior to using Florence the ambulance service had attended the patient during their episodes of hypoglycaemia, but since using Florence this has not been necessary as the DSN can react to the patient’s readings and provide support. Recently the DSN and carers have been looking into providing the patient with their own phone to text Florence to increase their independence. The DSN still has face to face appointments with the patient, as it can be difficult communicating with carers, but these are appropriate, and resources are being saved by the fact that paramedics are no longer having to be called to the patient. Further investigation into weight loss lead to supplements being used which raised the glucose level significantly, which the DSN has been able to monitor remotely and alter insulin doses as needed. Main benefits:
| Case study 4 Improved medication compliance results in BG within target range and avoidance of insulin The patient was a 52 year old woman with type 2 diabetes. She was seen jointly by the GP and the diabetes specialist nurse. The GP wanted the patient to start taking either GLP-1 or insulin, but the GLP1 medication can cause nausea. At the time of the consultation, the patient’s HbA1c was 10.3%. The patient was set up on Florence for medication reminders, as she were having difficulty remembering to take her tablets during the day. The patient did not want to use Florence to monitor their blood glucose levels, so they were set up on a meter to monitor this, which would automatically download to the patient’s mobile phone, these readings could then be sent to DSN. The DSN has received 2 sets of readings for the patient since the beginning of August. Having used Florence to improve medication adherence, the patient’s BG readings have been below 10mmol, which was within her target range, HbA1c 7.6% within 3 months. The patient has also started to remember to take her medication, as shown by her blood glucose being within the target range. The patient’s blood glucose is mostly controlled now thanks to the medication prompts from Florence. This means that there is a cost saving as the lady has not needed to start taking insulin or GLP-1. Additionally, the patient feels that having Florence is like having someone keeping an eye on her and her health. Main benefits:
Case study 5 Timely and appropriate intervention reduces A&E admissions and consultations
Case study 6 Patient caring for her sister regains control of her diabetes leading to a stop in taking insulin, weight loss and enabling her to live a healthier life DSN: “Many patients with type 2 diabetes are treated with insulin; the doses are increased over a period of time and patients fall into a cycle of more insulin, increasing weight and increasing insulin. The change in Diane’s confidence has been amazing; she felt very supported with the telehealth system [Flo] and having both her Practice Nurse, Louise, for support in surgery and having regular phone calls from DSN. She was delighted when she stopped insulin. The outcomes are not just about improved HbA1c and the associated health benefits of this, but also the quality of patients’ lives. When I spoke to Diane this week she told me how thrilled she was as she had been able to repaint her own garden fence; she has more energy for activities and also for continuing the care of her sister.” Michelle Denyer, Lead Community Diabetes Nurse (May 2017) Main benefits:
| Case study 7 Previously disengaged patient reduces HbA1c from 13.5% to 6.9% with Flo Main benefits:
Case study 8 Patient controls diabetes and reaches weight loss goal Mick was diagnosed with type 2 diabetes 10 years ago. He first started taking tablets for his diabetes, at which point he began to gain weight. He continued to gain weight which resulted in Mick needing to begin to inject insulin, which in turn caused further weight gain. Mick also had problems with his driving license due to his health, and he was issued a temporary one by the DVLA. His HbA1c was 9.4%. Main benefits:
Case study 9 Improved glycaemic control and weight loss has given patient confidence and more self-esteem While using Flo, the patient also started to use carb counting to help his glycaemic control, and also to try and lose some weight. The patient was able to reduce his weight from 14st 12lb to 13st, and has said “…it’s wonderful I have self-esteem for the first time in years!”. From the patient’s perspective, it is reassuring to know that his blood glucose levels are okay, and if they are not then a clinician will be able to intervene in a timely manner. Flo has given the patient the confidence he needed to self-manage his condition. From a clinician’s perspective, using Flo is great because it means that patients can receive the best ongoing care; if a clinician is on annual leave, it is easy for a colleague to check the patient’s readings and provide continuity of care. Main benefits:
Case study 10 After losing Flo due to funding, patient is now disengaged with her health Flo was used by Naomi to remind her to take her insulin and to help her keep track of her medications. At its highest in 2011, Naomi’s HbA1c was 16.4%. In June 2015 her HbA1c was 13.2%, but after using Flo for four months, Naomi’s HbA1c dropped to 8.6% which was a fantastic result. Using Flo really helped Naomi to self-manage her condition, and gave her the confidence and support she needed. However, since Naomi’s story was shared, there have been some developments. Naomi was told that Flo was likely to be stopped due to funding. Although Naomi was offered to continue with Flo until it was actually stopped she decided to stop immediately, saying that Flo was the only thing that had really helped her. This caused Naomi to become withdrawn and upset. Since then, Naomi has not engaged with the specialist diabetes team, and her HbA1c has risen back up to 13%. Naomi’s story highlights how patients can be put at risk if services they have found useful in managing their health, such as Flo, are withdrawn – especially if the patient is particularly vulnerable. The DSN continues to try to re-engage with Naomi. |
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Significant reduction in diabetes health risks through self-management
South Tyneside
NHS Foundation Trust
Safe Care Lead Diabetes
15 January 2018
Patient self-management is significantly reducing short and long term health risks associated with diabetes
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.
CASE STUDY 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;
| 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. |
For further information please contact Alison.Stewart@stft.nhs.uk
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