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.

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.

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

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.