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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.
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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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#Adult Cystic Fibrosis #CF #NHS Tayside #Scotland #TotallyUnique
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. |
#Diabetes Specialist Nurse #DSN #Derbyshire Community Health Services #TotallyUnique
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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
#Diabetes #South Tyneside #TotallyUnique
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Single Point of Access reduces need for home visits
Sheffield Teaching Hospitals
NHS Foundation Trust
Jayne Stocks
Clinical Lead Assistive Technology
Jeanette Deslandes
Telehealth Nurse
Joanne Sellers
Health Care Assistant
15 August 2017
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.
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.
CASE STUDY ONE
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.
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 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.
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.
CASE STUDY TWO
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.
CASE STUDY THREE
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.
CASE STUDY FOUR
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.
# Sheffield Teaching Hospitals # Single Point Access #SPA # Diabetes #TotallyUnique
Asthma - "Very positive results"
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:
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?
- 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
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.
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.
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:
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
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
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
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.
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.
CASE STUDY ONE 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. | CASE STUDY TWO 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
Sharon Poll
Liverpool CCG - GPN Lead
30 May 2017
Hypertension case studies
CASE STUDY 1
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;
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. "
CASE STUDY 2 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
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. | CASE STUDY 3 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. 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
Pennine Care
NHS Foundation Trust
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.
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.
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.
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“Even if Flo is helping just a quarter of the patients we have on our caseload, that’s massive, it's really is massive.”
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E029_ Oldham Podiatry Diabetic Foot messagesE029_ Oldham Podiatry Diabetic Foot chart
#Diabetes #Podiatry #Pennine Care #TotallyUnique
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