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Hypertension and Flo in General Practice; exploring evidence supporting sustainable scale-up of services

posted 28 Aug 2019, 07:50 by Hollie O'Connell




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.

More recently, NHS Grampian published a 90 day study where “the evidence shows that home BP monitoring using Florence improves efficiency for practices, supports improved clinical decision making, and delivers a positive patient experience” which provided patients with multiple benefits including 50% of patients avoiding ambulatory monitoring.

Highlands also evaluated a number of applications in Flo which included their use of hypertension diagnosis, where:
  • 86% of patients found Florence easy to understand, and felt that Florence had helped them manage their own health condition.
  • 76% found Florence encouraging and supportive, and felt that Florence had enhanced their experience of NHS Highland healthcare.
  • 71% found Florence motivating and informative, and felt that Florence had helped increase their independence.
  • 67% felt Florence had reduced the need for them to attend clinic appointments.
On the journey to Scotland’s Scale-up, in 2017 NHS Highland shared their success at the World Congress on Integrated Care’s ‘International Conference on Integrated Care’ in Dublin, with Ian Trayner also presenting the outcomes from NHS Western Isle’s redesigned hypertension pathway, demonstrating that Flo can be used sustainably at scale with great effects.

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:
  • Using Flo helped improve efficiency by reducing the amount of appointments needed and releasing clinical time.
  • Flo helped support clinical decision making and enabled faster clinical decision making.
  • Patients found Flo easy to use to monitor their BP and would use Flo again.

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.”


The widespread adoption across our Community of Practice with hypertension pathways, would not have been possible without the robust governance arrangements.  Florence is NHS IG ToolKit level 2, ISO 9001, ISO 14001 and ISO/IEC 27001 certified and is fully GDPR compliant providing assurance to clinicians around the safety of patient data and it’s transfer via the newly developed API which enables Flo data to be integrated into local clinical records. 


As our Community of Practice continues to grow and share, we are now seeing hypertension pathways being replicated with positive results both inside and outside of the UK.  In this video, Dr Geoff Campbell presents a case study using Nellie (our NextGen system used in Australia) for hypertension diagnosis, highlighting that “this is about self-management for the patient and they’re getting a nudge in the right direction from Nellie”.  Although Flo and Nellie look different, the methodology is the same, improved adherence to best practice results in better and faster clinical outcomes. 

We would like to thank all members of our Community of Practice who contributed their case studies and evaluation.  If you would like to learn more, have any questions or would like to be put in touch with a member of our community, please contact Lisa.Taylor@simple.uk.net



#Hypertension #Blood Pressure #BP #BMJ #Scotland #NICE #AIM #Scale-Up #TotallyUnique

Focus on COPD: Improving quality of life in the Highlands

posted 20 Dec 2018, 01:05 by Hollie O'Connell   [ updated 28 Dec 2018, 07:37 by Hannah Mountford ]


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:
  • Increased personal responsibility
  • Patients will see the link between worsening clinical signs and symptoms and learn to take action at the right time
  • Increased confidence in patients
  • Reduced exacerbations
  • Fewer hospital admissions
  • Fewer clinic appointments
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.

Clinician comments

“Florence has helped patients self-manage their COPD. Patients have said that they understand their condition more now”

“Some of my patient’s spouses really like Florence. They see it as a ‘back-up’ and an ‘extra-nag’, it gives them the confidence to care for their partners”

“I see that a patient has started taking some medication, I ask them if they would have done that without Florence prompting them to do so – they say no, they would have left it another few days. Patients who come to the end of using Florence say they are now in the habit of checking their stats every day. It embeds something into their daily routine. They feel connected, well cared for and not so isolated”

“I’m increasingly confident that Flo supports patients with COPD and their families by reinforcing the messages we give around early recognition of worsening symptoms in exacerbations. Also, Flo reminds them of the techniques which help keep them well, such as pacing their activity and using their breathing control methods in their daily activities”

Patient comments

“I liked the fact that Florence could alert me to a possible level drop in my oxygen and let me know before a negative outcome! I would welcome the idea of having Florence on a long-term basis”

“Florence always texts at the same time and gives me advice on what I should do depending on my SATs. It’s like having a doctor on call when I’m not sure whether to take antibiotics and steroids”

“It has helped me to understand and control my condition a lot more with positive results, as I haven’t had to rescue medication for months”

“Florence made me feel safe – someone was keeping an eye on me”


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:

  • 87% of patients agreed that Flo helped them to understand and manage their own health.
  • 71% of patients would recommend Flo to other people in their circumstances.
  • 100% of patients who responded agreed that the COPD Flo protocol was encouraging and motivating and helped them manage their own health.
  • 83% of patients agreed that Florence helped them remember health information and advice and to comply with health advice.

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: 

  • Reduced the number of hospital admissions
  • Reduced the total number of bed days
  • Reduced GP appointments 
  • Reduced clinic appointments


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
Joanna Gilliatt at joanna.gilliatt@nhs.net 

Providing a "convenient" and "relaxed environment" to help patients stabilise blood pressure

posted 30 May 2018, 03:18 by Hollie O'Connell   [ updated 15 Aug 2019, 01:45 ]

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 One

A 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 "

"

#Blood Pressure #Chronic Disease Management #TotallyUnique

Removal of gastrostomy tube, independence and education are some of the goals achieved by Adult Cystic Fibrosis patient with Flo's tips and support

posted 20 Mar 2018, 04:47 by Hollie O'Connell   [ updated 1 Jun 2018, 01:39 ]


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.

As a specialist dietitian, Alison regularly reviews patients and offers advice and support around all aspects of nutritional care, such as weight control, supplementary feeding and helping her patients to manage their gastrointestinal symptoms.  In addition to this, Alison is keen to tailor the care that she provides based on her individual patient; Alison also offers cookery or shopping sessions, which can be based in the patient’s own home if appropriate.


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.

Alison, “ The ideal place for Adam health wise was to have a BMI (Body Mass Index) of 23, but a cystic fibrosis patient won’t always find it easy to eat as much as they need to, so the gastrostomy tube can make a big difference in terms of their nutrition .” 

However, Adam was still at school and naturally wanted to be able to take part in different activities, such as swimming, which would be more difficult for him with a feeding tube in-situ.  Adam wanted to do the same as everyone else his own age, but still knew the importance of maintaining his weight.  Adam was very conscientious about his health and as time went on, even with a full-time job he would make sure he was home early enough in the evening to allow the gastrostomy tube to do its work.

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.

Adam now happily says; “I have managed to achieve a significant weight increase which led to the removal of my gastrostomy in my stomach which I was wanting desperately.”  Adam is now extremely busy completing an internship with a national utilities company, while Alison is still able to send Adam a message via Flo now and then to make sure he is still on track, helping to maintain their relationship whilst Adam maximises his independence.

Flo still maintains her ‘Bossie Flossie’ image however as Adam says “Sometimes the texts could get a bit annoying and if you didn’t send in your weight she would send it a couple of times.”  However, this didn’t put Adam off at all as he says “Other than that, Flo was a great help!”, Flo has made a huge difference to Adam, and with Flo’s help he has reached his personal goals, and has a very exciting future ahead.


Click image to enlarge



#Adult Cystic Fibrosis #CF #NHS Tayside #Scotland #TotallyUnique

Diabetes; Flo improves efficacy of best practice care - a collection of ten patient stories

posted 9 Feb 2018, 02:53 by Hollie O'Connell   [ updated 20 Mar 2018, 06:59 by Hannah Mountford ]


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: 
  • Reduction in contact time resulting in increased capacity for clinician. 
  • Timely intervention by clinicians helping to avoid admissions and ambulance call outs. 
  • Patient and care home staff felt reassured. 
  • Improved blood glucose control. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.


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 patient was put onto a basal bolus regime and set up on Florence to help them to monitor their blood glucose.  They would receive advice and feedback from Florence depending on their readings, and the diabetes specialist nurse would receive alerts if the patient’s readings were of concern.

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.

The patient’s blood glucose levels are not as stable since surgery, this is to be expected and so they are continuing to use Florence for added support and guidance for the time being.

Main benefits: 
  • Blood Glucose controlled to allow surgery to continue as planned. 
  • Reduced appointments for patients. 
  • Reduction in contact time resulting in increased capacity for clinician. 
  • Patient felt reassured.


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:
  • Care staff reassured and found advice from Flo helpful. 
  • Improved blood glucose control. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this. 
  • Reduction of ambulance call outs due to episodes of hypoglycaemia.




 

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: 
  • Improved medication compliance. 
  • Improved blood glucose control. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this. 
  • Cost saving associated with patient not needing to begin taking insulin or GLP-1. 
  • Patient feels reassured.


Case study 5
Timely and appropriate intervention reduces A&E admissions and consultations

The patient was a 60 year old with type 1 diabetes who was living in supported care due to profound learning disabilities.  The patient was having difficulty in controlling their blood glucose levels, leading to episodes of hypoglycaemia which required medical intervention.  In the 12 months prior to the patient starting to use Florence, they had a total of 10 consultations and 2 A&E visits.  At this time, the patient’s HbA1c was 10.1%.

The patient was signed up to Florence via their carers, who would take blood glucose readings at mealtimes and send the results back to Florence.  The diabetes specialist nurse would then receive alerts when readings were of concern.  This allowed the DSN to intervene in a timely and appropriate manner to avoid episodes of hypoglycaemia.  Alerts are also received by the DSN via email, so intervention with insulin doses can be recommended if needed.

Since the patient began to use Florence, they have had no further admissions to A&E, demonstrating an efficient use of resources and an obvious cost benefit, and reducing stress for the patient.  The patient’s HbA1c has reduced 9%.

Main benefits: 
  • Improved blood glucose control. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this. 
  • Timely intervention by clinicians helping to avoid admissions and ambulance call outs. 
  • Reduction in contact time resulting in increased capacity for clinician.


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

Diane is a 62 year old with type 2 diabetes.  She is the main carer for her sister who she takes to hospital for renal dialysis 3 times each week.  Due to her commitments as a carer, Diane had no time for appointments to help her manage her diabetes.

Diane’s blood glucose levels were not well controlled, with HbA1c 8.7% and due to her insulin regime she had experienced some weight gain.  The diabetes specialist nurse discussed changing Diane’s type of insulin, as well as exercise, and suggest that she try using Florence to help her to self-manage her condition.

Diane felt hugely reassured by using Florence, and was confident that someone was looking out for her.  In January 2017 Diane reduced her insulin dosage, and in February 2017 she was able to stop it completely as her glycaemic control had improved with an HbA1c of 7.9%.

Diane was able to communicate with her DSN via free Flo texts, and felt this didn’t impact on her role as a carer.  This was great for Diane as she found it difficult to see her DSN face-to-face due to her time commitments caring for her sister.  Instead, it meant that she could take care of her own health at times that fit around her schedule.

Diane felt that the improvement in her health gave her more energy, and can do things for herself , that she had previously been unable to do.  With help from her DSN and Florence, Diane has lost a fantastic 22kg!

Diane: "I am 54 years old and was diagnosed with Type 2 Diabetes when I was 40.  I started on tablets but was soon put on insulin.  I thought that was it for the rest of my life and so stupidly I plodded on, not eating brilliantly and gradually increasing my insulin until I got up to 56 every morning and 56 every evening!  Then I met Louise, the Diabetic Nurse from my Surgery, and Michelle, Lead Diabetes Specialist Nurse.  I was overweight and felt very lethargic and so knew I should start to do something about it.  Louise and Michelle were absolutely brilliant - they advised me on what to eat and how to exercise - and so it began!  I cannot pretend it has been easy but with Louise and Michelle’s support, it has been achievable.  In approximately the last 6 months I have lost over 2 stone and have come off insulin.  I feel so much better - I now eat very healthily and exercise every day.  I would recommend anyone on insulin to do this as the results are amazing.  I would like to say a very big thank you”Diane’s practice nurse: “The confidence and self belief that Diane has now got has been very evident; she had something to work towards with a plan of care; including the goal of reducing her weight and being able to stop her insulin.”

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: 
  • Improved blood glucose control. 
  • Patient able to stop taking insulin; associated cost savings with this. 
  • Convenient for patient whose time was limited due to being a carer. 
  • Patient feels reassured and more confident. 
  • Patient has also lost weight which has associated health benefits.
Case study 7

Previously disengaged patient reduces HbA1c from 13.5% to 6.9% with Flo

The patient was a 68 year old man with type 2 diabetes.  He was disengaged with his health; he didn’t really want to attend appointments, or discuss his diabetes in general.  The patient was also not taking his medicine, so initially he was set up on Florence to receive medication reminders to try and improve his adherence.  However, after a short time he began to use Florence to help him monitor his blood glucose levels.  Due to complications with his diabetes, the patient also developed a foot ulcer which required treatment.

Since beginning to use Florence, the patient’s HbA1c has dropped from between 13.5% – 12.9% to 6.9%.  Additionally, during the 2 years that the patient has been using Florence, they have only had 2 face-to-face appointments, with potential cost and time savings.  The patient has expressed his gratitude for the help received from his DSN and Florence towards improving his health.  The longer term savings with improved control are also significant. This man still continues to use Flo.

Main benefits: 
  • Improved blood glucose control, resulting in a HbA1c reduction by around 50%. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this. 
  • Reduction in contact time resulting in increased capacity for clinician.


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%.

Following complications after treatment for cancer, Mick gained the motivation to begin to tackle his increasing weight.  To do this, Mick spoke to his dietician and started to eat healthily and count his carbs.  He also signed up to Flo for additional motivation and support on his weight loss journey.

Mick’s hard work has paid off – he managed to lose a total of 27.8Kg (4st 7lb) over a period of 9 months.  In addition to this, he has also been able to stop taking insulin, and now only has to take tablets for his diabetes.  The support that Mick received from clinicians, along with Flo, was really important in ensuring that he reached his weight loss goal.  Mick even commented “I couldn’t have done it without Flo” – and he has been able to have his permanent driving license reissued by the DVLA!

In addition to this, Mick’s weight loss means that he has reduced his other risks related to being overweight, and as his diabetes is now better controlled with an HbA1c of 5.9% he has lowered the chance of other condition related complications going forward.  Mick now has a healthier future ahead of him, which will hopefully mean that he is able to seek less medical intervention than he would have if he continued to gain weight and struggle to control his diabetes.  This demonstrates potential long term cost and resource savings due to the patient’s improved prognosis.

Mick was taken off the telehealth system [Flo] and his HbA1c has risen to 7.8%, the current plan is to offer the telehealth service again to see if this improves control.

Main benefits: 
  • Patient lost weight which has associated health benefits and potential cost saving benefits. 
  • Improved blood glucose control. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this. 
  • Patient able to stop taking insulin; associated cost savings with this. 
  • Patient has improved confidence.


Case study 9

Improved glycaemic control and weight loss has given patient confidence and more self-esteem

The patient was a 46 year old man with type 1 diabetes, he used Flo to help monitor his blood glucose levels.  When the patient began to use Flo he was taking 120 units of insulin, but this was decreased to 60 as his glycaemic control improved, and his HbA1c went down from 10.1% to 9.3%.

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: 
  • Improved blood glucose control. 
  • Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this. 
  • Patient able to significantly decrease insulin dosage; associated cost savings with this. 
  • Patient lost weight which has associated health benefits and potential cost saving benefits. 
  • Patient has improved confidence and self-esteem.


Case study 10 

After losing Flo due to funding, patient is now disengaged with her health

Naomi’s story has previously been shared, but to summarise:  Naomi was a patient with poorly controlled type 1 diabetes.  She was diagnosed at the age of 10 years and then struggled to control her condition throughout her teenage years; Naomi was also concerned about how taking insulin could affect her weight.

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.



For a previous focus on the team click here.



#Diabetes Specialist Nurse #DSN #Derbyshire Community Health Services #TotallyUnique


Significant reduction in diabetes health risks through self-management

posted 18 Dec 2017, 00:15 by Hollie O'Connell   [ updated 2 Mar 2018, 04:45 by Hannah Mountford ]


South Tyneside 
NHS Foundation Trust 
 
Alison Stewart 
 Safe Care Lead Diabetes 

15 January 2018 

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



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


What do South Tyneside Diabetes Specialist Nurses do?  

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

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;

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

What did the patient think?  

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

What are the benefits? 

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


Single Point of Access reduces need for home visits

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


Sheffield Teaching Hospitals 
NHS Foundation Trust 


Jayne Stocks 
Clinical Lead Assistive Technology 

Jeanette Deslandes 
Telehealth Nurse 

Joanne Sellers 
Health Care Assistant 

15 August 2017 



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

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

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

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

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

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

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

 

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. 

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

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

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

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

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

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



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"

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

Corinne Clark 
Respiratory Specialist Nurse 

07 September 2017 


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

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


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

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

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


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

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

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

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

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

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


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


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

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



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

Mental health; Flo reinforces coping techniques

posted 23 Jun 2017, 01:50 by Hollie O'Connell   [ updated 22 Aug 2019, 02:26 by Hannah Mountford ]



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.




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.


For more information please contact kathryn.sumner@stft.nhs.uk

Protocol reference; NHS STFT Talking Therapies Protocols
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#South Tyneside #Gateshead Talking Therapies #TotallyUnique

Liverpool Health Trainers and home blood pressure monitoring

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



Sharon Poll 
Liverpool CCG - GPN Lead 

30 May 2017  


Hypertension case studies 



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


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;

" 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 
  • Week 1 - average BP 163/122 
  • Week 8 - average BP 142/98 

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

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



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.

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

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

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


For more information please contact Sharon.poll@livgp.nhs.uk



#Liverpool Health Trainers #Person Shaped Support #PSS #Hypertension #TotallyUnique

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