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PLOS Medicine Journal: Integrating Florence into Clinical Workflow at Scale

posted 1 Jul 2020, 06:55 by Hollie O'Connell

02 July 2020 

Telemonitoring at scale for hypertension in primary care: An implementation study 

Uncontrolled hypertension is the largest manageable cause of stroke and myocardial infarction.  Despite the effectiveness of anti-hypertensive medication, many patients still have uncontrolled blood pressure (BP).

Having previously demonstrated that Florence encourages medication use and is effective at lowering BP in this cohort, NHS Lothian’s award winning Scale-Up BP Team led by Professor Brian McKinstry expanded their scope to understand if integrating Florence directly into the clinical workflow would increase adoption even further, what impact this would have on clinician workload, and if study participant changes in BP would match those of randomised controlled trials (RCTs).

NHS Lothian subsequently developed an integrated system providing regular summaries of patient home-monitored BP readings via Florence to routine GP data management systems accessed by their general practitioner.  Patient home-readings were delivered alongside routine laboratory results for clinical review.

The number of participating practices grew steadily following the launch, and by July 2019 75 practices had participated and recruitment reached 3,200 patients with established hypertension.  Expected challenges to the adoption of new technology were mitigated well by the project team by engaging frontline clinicians in development of Florence’s use, activating local champions, and strong continuous support from a facilitator team.  The success of practices who recruited large numbers of patients acted as a stimulus for other practices to follow; patients liked Florence and there was a low rate of discontinuation.  Previous studies have been in the context of RCTs with practices contributing relatively small numbers of patients that are relatively easy to manage however within this study some practices were recruiting hundreds of patients.

The evaluation subgroup of 8 practices (905 patients) demonstrated clinical value in that BP fell in the intervention group:
  • a mean systolic BP reduction of 6.55 mm Hg
  • a mean diastolic BP by 4.23 mm Hg
Click image to enlarge

Along with Florence’s uptake, change in BP and participants’ views, a key objective of the study was to understand the impact on changes in clinician appointment use.  Compared with the previous year, the study demonstrated that there was no increase in practice workload, specifically:
  • participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not supported by Florence.
  • total consultation time for participants fell by 15.4 minutes, compared with 5.5 minutes in patients not supported by Florence.
The paper states;

 " There have been no direct trials to our knowledge exploring the impact of telemonitoring on cardiovascular outcomes, but based on previous studies of anti-hypertensive agents, BP reductions of the magnitude achieved in this study, probably through intensification of anti-hypertensive therapy, if sustained, would be expected to lead to a greater than 15% reduction in risk of stroke and a greater than 10% reduction in risk of coronary heart disease 

Learning from Flo: STP TEC programme supporting the adoption of technology-enabled care for patients with respiratory conditions in primary care

posted 26 Jun 2020, 03:24 by Hollie O'Connell   [ updated 26 Jun 2020, 03:36 ]

26 June 2020 

Empowering patients to feel confident and supported in managing their health can be a key role for technology-enabled care (TEC) such as Flo, with robust evidence citing the benefits to both patients and clinicians.

To encourage more wide-spread adoption of TEC, Staffordshire Sustainability and Transformation Partnership’s (STP) Digital Workstream have introduced a TEC programme aligned with the national ambitions for STPs using Flo as an exemplar.  Focuses of the programme include:
  • Strengthening prevention and early intervention
  • Improving productivity
  • Tackling variations in care
  • Developing enablers
  • Upskilling the workforce
  • Redesigning and improving healthcare services in all settings
The programme has now rolled out nationally supporting general practices to become more digitally-enabled whilst supporting respiratory conditions at scale.  Promoting TEC and digital care not only gives patients the reassurance and confidence to manage their health at home, but it can also upskill clinicians, improve patient safety and improve clinical capacity.
Around 300 attendees have taken part in workshops so far across the country, giving them the opportunity to discuss the learning developed during their local TEC implementation.  A number of attendees provided feedback that they would like to improve their digital capabilities, such as:

I would like to persuade the practice nurse team to use Flo Simple Telehealth to engage younger asthmatic patients

Flo telehealth is a good way to monitor patients’ blood pressure and chronic obstructive pulmonary disease (COPD)

To find out more about the programme, take a look at the full article available via RCNi’s Primary Health Care journal, to read examples of how Flo is supporting respiratory patients please see here

Lifestyle Industry Magazine features our partner Bitjam, and Nellie!

posted 17 Jun 2020, 07:58 by Hollie O'Connell

17 June 2020 

Based on 10 years of healthcare quality and safety learning through clinical innovation with Florence, ethical development company, Bitjam Ltd are featured in the new issue of Lifestyle Industry Magazine sharing how they are working with us at Simple Shared Healthcare to deliver telehealth with a human touch worldwide.

Cutting edge telehealth technology is extremely powerful, as it allows the NHS to care for more people in their own homes, thereby reducing GP visits and hospital admissions and saving money.  Many people are finding the system useful because it is ‘telehealth with a human touch’. "

East London Foundation Trust: Maintaining Connectedness post COVID-19 Discharge with Flo

posted 12 Jun 2020, 00:59 by Hollie O'Connell

12 June 2020 

Community of practice members from East London NHS Foundation Trust (ELFT) were some of the first to recognise Flo’s role in their local COVID-19 response and begin developing pathways to support patients during the COVID-19 pandemic.

The ELFT Telehealth Team is aware that people may be overwhelmed with the amount of official information and updates, and confused by misinformation spread via word of mouth and social media.  However, it was of the utmost importance that members of the public adhere to and follow up-to-date official advice in order to reduce the likelihood of further transmission of the COVID-19 virus.  As a result a pathway was developed to provide reassurance to patients with a confirmed diagnosis of COVID-19 who were well enough to be discharged home, and patients that were at the extremely high risk group in the community.

On a daily basis, patients are self-monitoring their symptoms including patients post-Covid discharge through integrated discharge hubs from the acute setting, with Flo providing approved guidance or support around how to continue to monitor their recovery at home.  If a patient meets a designated clinical threshold, Flo directs the patient to contact 111 as per official guidance.

In addition, the Telehealth Team at ELFT have integrated daily symptom checker questions into pathways for patients already being supported by Flo.  These patients are likely to already have pre-existing health conditions; the consequences of contracting the virus could therefore be more severe, thus increasing the importance of following current guidance.
Recognising the increased levels of anxiety around both their physical and psychological wellbeing during COVID-19 within these patient cohorts, Flo’s regular friendly prompts are reassuring patients, keeping them safe and helping them to feel cared for, connected during this difficult time and getting a holistic intervention in the community at the right time and thereby avoiding hospital admissions where appropriate.

One patient was particularly grateful for Flo’s help and provided some feedback explaining how Flo has helped them during this difficult time:

 The team are looking after me very well. But at this time when I feel more anxious with COVID-19, they have added some new questions to my Florence app. I can answer the questions and send my answers over very quickly, and they respond to me if I’m having any problems. This has made me feel a bit more at ease and not call my GP at this busy time.
Thank you to the Telehealth Team 

Raguraman Padmanabhan, Telehealth Clinical and Service Lead, commented on his experience implementing Flo during the COVID-19 outbreak:

Flo for COVID-19 has been a significant addition to the existing protocols and has helped reshape care pathways to facilitate care from hospital to home. Our service users informed us that it has been very reassuring and felt well connected with the team if they had any queries. We are looking into extending it to other specialist services in the community.

British Journal of Psychology; Preventing relapse with personalized smart‐messaging after cognitive behavioural therapy: A proof‐of‐concept evaluation

posted 11 Jun 2020, 04:42 by Hollie O'Connell

11 June 2020 

We are delighted to share a recent British Journal of Psychology publication “Preventing relapse with personalized smart‐messaging after cognitive behavioural therapy: A proof‐of‐concept evaluation”.  The study independently evaluates the application of Florence’s smart-messaging techniques to reduce relapse from Cognitive behavioural therapy (CBT) and compliments the recent publication from the Clinical Psychology Cancer Service Team at Sherwood Forest Hospital Foundation Trust, around their proof of concept evaluation of using Flo to support cancer patients undertaking mindfulness-based CBT in the open-access Psycho-Oncology journal.

The publication reports outcomes from two focussed studies
  • STUDY 1: Clinical Outcomes of Smart-Messaging Users Versus Non-Users Following Remotely Delivered CBT for Health Anxiety
  • STUDY 2: Feasibility of Smart-Messaging Users in Routine Care (see here)

CBT can improve symptoms of anxiety and depression, but importantly also reduces the risk of future relapse after therapy completion.  However, current CBT relapse prevention methods are resource‐intensive and can be limited in clinical practice.  Studies suggest that acquiring CBT‐related coping skills is an important component of any relapse prevention.  However, 30–50% of patients attending CBT for anxiety and depressive disorders still relapse within the first year after treatment, with greater relapse rates found in clinical practice than controlled research conditions (Delgadillo et al., 2018; Hollon et al., 2005).  Existing CBT interventions to specifically prevent relapse are time and resource intensive with mitigation typically involving additional therapy sessions focused on developing relapse prevention plans, identifying potential triggers for relapse, and learning coping strategies to manage such eventualities (Bockting et al., 2005).
Digital health interventions have previously been harnessed to increase the reach and accessibility of relapse prevention interventions in several recent trials, however meta‐analyses of digital relapse prevention interventions suggest that the benefits are moderated by the degree of personalisation included (Hennemann et al., 2018).  In addition, minimal, but personalised, relapse prevention methods that include an individual plan are preferred if regular contact with a mental health professional is not an option (Muntingh et al., 2019). 
From this evidence, the team identified that Florence's unique persona-based, pragmatic and innovative mix of messaging technology and psychology was an opportunity to extend the impact of therapy sessions across both cohorts.  The team also recognised that it was critical for Florence’s interactions to be personalised, and subsequently worked with participants within their final two therapy sessions to co-design Florence’s interactions around the advice that they would want to receive once face-to-face therapy had ended if in future they were either doing well, experiencing early warning signs of relapse, or experiencing full relapse including patterns of thought, behaviour, and characteristic emotional responses. 
For 25 weeks post-therapy, participants were supported by weekly interactions with Florence, being able to rate their well‐being and dependent upon their response, receiving the tailored advice they had written, appropriate to the well‐being level reported after recovery from health anxiety. 

Outcomes collected by independent researchers demonstrated that:
  • Across a 12‐month follow‐up, participants receiving smart‐messaging showed greater health improvements than those who did not.  Well‐being scores showed stability between CBT completion and 6‐month follow‐up among routine care patients.
  • The findings suggest that a low‐intensity, personalised relapse prevention method can have a clinical benefit following CBT for common mental health problems.
  • In clinical practice, post‐treatment smart‐messaging can be well used by patients and may help maintain stable well‐being in the 6 months after CBT ends.
  • The evidence supports the clinical utility of a brief tailored digital intervention, which can be integrated within routine clinical practice with minimal therapist input.
  • Overall, longer‐term post‐CBT outcomes may be improved by integrating a smart‐messaging intervention at the end of therapy.
  • The study offers initial evidence that post‐treatment smart‐messaging may support greater outcome improvement over a 12‐month follow‐up period and is worthy of formal evaluation in a randomised controlled trial, due to its potential as a cost-effective and accessible means of enhancing CBT outcomes.
The full journal article is open-access and available here, or if you would like to learn more about the pathway and the team’s journey, please don't hesitate to get in touch via our contact us form.

Journal of the American Medical Informatics Association: “Veterans’ Response to an Automated Text Messaging Protocol During the COVID-19 Pandemic” (29 May 2020)

posted 10 Jun 2020, 07:23 by Hollie O'Connell

10 June 2020 

We are delighted to share the new Journal of the American Medical Informatics Association publication “Veterans’ Response to an Automated Text Messaging Protocol During the COVID-19 Pandemic” (Saleem, Read, Loehr et. al) from our community of practice members from the US Department of Veterans Affairs (VA) who have employed ‘Annie’ as part of their coronavirus disease 2019 (COVID-19) response, adding several protocols, including a Coronavirus Precautions Protocol (CPP).  Annie, as with Nellie, both use the same methodology as Flo and although these locations are very different, Annie has continued to demonstrate the same positive and sustainable outcomes as her UK cousin.

After the first known cases of COVID-19 were diagnosed in the U.S. in February 2020, many health care organisations, including VA facilities, were overwhelmed with calls seeking guidance and support.  Recognising Annie’s proven techniques in delivering a rapid public health response, the VA identified the role that Annie could play in reaching their Veterans remotely and enabling clinicians to continue to provide high quality, safe healthcare as part of their COVID-19 response.  A specific protocol for coronavirus precautions was developed, helping the Veteran to be able to monitor their symptoms safely and advising them when it was necessary to contact their VA care team
 or a nurse triage line.

Veterans can self-enrol, or be added by a member of their care team to the specific CPP protocol which lasts for 2 months with Annie interacting with each Veteran to deliver approved education around coronavirus precautions, guides the monitoring of temperature and other clinical symptoms, and advising them to call their care team or a nurse triage line when they meet certain clinical thresholds.  Check-ins were sent daily for the first two weeks with wellness and educational interactions also following. 

Evaluation included over 1000 Veterans on their use of Annie in this cohort with demonstrable outcomes delivering substantial resource savings for the VA, as well as non-VA community healthcare.  In addition, the majority of Veterans reported at least one positive sentiment e.g. that they felt more connected to the VA, more confident, or more educated and/or felt less anxious by receiving Annie’s interactions. 
In addition to interactions with Annie bringing a sense of connectedness and reduction in anxiety, a decrease in avoidable contacts with the VA was evident with Annie as an extra member of the team, allowing clinical resources to focus on those Veteran’s most in need.  Of the 1,134 Veterans who answered the question ‘Would you have taken any of the following actions if you were not receiving Annie’s Coronavirus Precautions messages?’, 532 (47%) reported they would have otherwise reached out to the VA in at least one way (either secure message, phone call, visit or some combination of those).  In addition, 159 (14%) Veterans report they would have interacted with community (non-VA) care (called or sought care).

Patient quotes:

Just knowing there is a link and the brief message asking ok or not helps being, even momentarily, in the moment and requires some action .... a crutch for corona!

They gave me a sense that despite all the chaos there was someone that cared just about me.

To know that Annie alerts keep me positive and happy to know that someone cares about my well being! Keeps me mindful of what I need to do if I have to go out

The publication explains that the findings from this study have implications for other healthcare systems to help manage a patient population during the coronavirus pandemic.

The full journal article is open access and available here, or if you would like to learn more about the pathway please contact Lisa Taylor via our contact us form.

Protecting Workforce Mental Health Through COVID-19

posted 29 May 2020, 03:28 by Hollie O'Connell

29 May 2020 

We are delighted to announce that from an unprecedented number of applications nationally, Simple Shared Healthcare Ltd. has been selected by the UK’s innovation agency, Innovate UK to refocus their internationally recognised work with healthcare psychology to support the mental health of staff in the workplace, to improve well-being and protect productivity and thereby make a significant contribution to UK’s business recovery during and following the current COVID-19 outbreak.

Based in Stoke-on-Trent, Simple Shared Healthcare has a mature legacy in partnering with healthcare organisations to provide education, coaching and support for patients to achieve better and faster clinical outcomes than can be achieved under normal care.  Simple Shared Healthcare works with intellectual property owned by NHS Stoke-on-Trent and develops innovative services deployed as friendly personas including 'Florence' (UK & Ireland), 'Annie' (USA) and 'Nellie' (Australia) to engage directly with patients.

Phil O’Connell, Founder of Simple Shared Healthcare Ltd. and former NHS Innovator of the Year commented,
“We are immensely grateful for the foresight of Innovate UK to recognise the opportunity to leverage Simple Shared Healthcare’s mature, independent evidence base that has consistently delivered internationally-recognised economic and behavioural change in healthcare to assist businesses to cost-effectively manage and mitigate the impact of COVID-19 on staff whilst reducing the associated economic costs of lost productivity for years to come. This opportunity allows the development of a unique product that will provide a substantial catalyst to any business’s post COVID-19 recovery; and most importantly the quality of life and wellbeing of staff through and beyond this challenging time. ”

For over 10 years and founded upon business psychology, "Florence" is a digital platform used by NHS Hospitals, General Practice, Mental Health and Community teams that has been formally evaluated across hundreds of clinical conditions harnessing targeted behavioural psychology-based Smart Messaging to engage patients, change their behaviour and help them attain better and faster clinical outcomes in hundreds of clinical conditions.

Building on the capabilities of Florence, an international collaboration including ethical development company Bitjam Ltd inspired the development of our Next-Generation smart messaging system "Clara"(UK/USA) / "Nellie"(Australia).  The technologies have proven to be massively scalable and flexible and incorporates both workflow and messaging improvements learned from 10 years with Florence.

Partnering with workplace mental health and wellbeing charity Mates in Mind, this project will re-purpose Clara for use by businesses, assisting them to effectively manage the many challenges to staff wellbeing, mental health during self-isolation and sickness/absence, generated by the first and subsequent waves of the COVID-19 pandemic.

This will be achieved through evidence based smart interactive messaging to motivate staff, reduce anxiety, change thinking and associated behaviour toward forming confident healthy and productive personal and workplace habits and reduce the feelings of loneliness and isolation.  Furthermore, the service aims to create a sense of appreciation and wellbeing, whilst reducing the workload of HR departments.

Executive Chair, Innovate UK, Dr Ian Campbell, said: 
“Businesses from all over the UK have answered our call rapidly to meet the challenges we face today and in the future through the power of innovation. The ideas we have seen can truly make a significant impact on society, improve the lives of individuals, especially those in vulnerable groups and enable businesses to prosper in challenging circumstances.”

Inaugural COVID-19 rapid innovation forum

posted 22 May 2020, 01:56 by Hollie O'Connell   [ updated 22 May 2020, 04:25 ]

22 May 2020 

During the current outbreak of COVID-19, many of our community members are continuing to adapt and innovate with Flo to enable sustainable provision of high quality care to their patients under difficult circumstances.  To support our Members, we recently held our first in a series of Forum Calls.  The calls are being facilitated to provide technology-enabled care leads from the Community of Practice with the opportunity to share how Flo is being utilised during the COVID-19 outbreak within their organisations.  

Read on to find out more about the ideas shared & discussed on the first of these calls.

Symptom Based COVID-19 Monitoring Protocol

Based on new learning around the recovery period for COVID-19, NHS Scotland are taking a lead to develop a multi-symptom monitoring pathway with Flo to support those with a diagnosis of COVID-19.  The aim of implementing more specific monitoring of a wider set of symptoms is to enable early detection of any deterioration of the patient’s condition, thus ensuring timely and appropriate medical intervention when required.

In support of government guidance, the pathway monitors patient’s symptoms for a period of two weeks, and Flo will ask daily questions around a wider set of symptoms, including breathlessness while talking and during activity plus the presence of a cough and muscle aches/pain. Patients also have the option to take their temperature, O2 & pulse readings if clinically significant.  Flo interacts by providing clear advice and reassurance, where a patient’s symptoms or readings are of concern, Flo will flag an alert on the patient’s record, and advise them to contact 111 for further medical advice.

Staff Emotional Wellbeing

Providing additional help to those working under even greater pressure at this time is vital in ensuring that the health of frontline staff is not overlooked.  As a result, a number of community members have expressed an interest in developing pathways that support staff emotional wellbeing during what is a both psychologically, and physically tiring time.

Suggestions as to how this support will be delivered include requesting wellbeing scores, providing wellbeing support messages, and signposting to services open to staff, such as occupational therapy.   Flo’s unique ability to interact remotely with staff members also creates an opportunity to understand when, and which staff may need further support and either direct staff to step-up interventions or notify their Line Manager to facilitate personal intervention.

Increased Interest in, and Uptake of Remote Monitoring with Flo

A number of TEC leads commented on seeing a general increase in queries received around implementing Flo in various areas of clinical practice.  Due to social distancing measures, reducing clinical contact is imperative, with only the most essential face-to-face appointments going ahead.

As a result, many teams who may have been previously aware of Flo, but not actively implementing her, are now looking to develop new pathways to enable patients to monitor safely at home and receive additional advice and motivation as needed.  Examples of increased interest in implementation include pregnancy induced hypertension, sexual health, respiratory and mental health.

Royal College of Obstetricians & Gynaecologists - Flo stars in new guidance for safe home monitoring

posted 16 Apr 2020, 02:50 by Hollie O'Connell

17 April 2020 

Supporting ladies to monitor their BP safely at home for pregnancy induced hypertension is one of Flo’s most mature & evidenced uses, with numerous sites adapting existing community protocols to suit their local needs. 

This innovation continues, most recently in Nottinghamshire, where the Local Maternity Systems are engaging in a rapid role-out of BP monitoring for postnatal and antenatal ladies.  The driver to implement the pathway originates from a desire to help reduce the number of clinic appointments ladies would need to attend during the current COVID-19 outbreak, which has the added benefits of convenience for patients, but also released capacity for clinicians.

Reducing contacts is particularly important during the outbreak of COVID-19, as further outlined in a recent publication by The Royal College of Obstetricians and Gynaecologists. RCOG has published new guidance for clinicians caring for women with pregnancy induced hypertension (PIH), urging maternity services to implement safe home-monitoring for women to reduce the need for face-to-face appointments, thus reducing the risk of further spreading the virus.

In support of this new guidance, NHS England has also offered to supply blood pressure monitors free of charge to Trusts who wish to take forward plans for self-management of blood pressure in pregnancy (see guidance for details on how to apply).

The RCOG publication includes extensive guidelines for inclusion criteria (table 1) and implementation of home monitoring and includes details of support for safe home monitoring, of which we are extremely proud to share that Flo is one. 

Click image to enlarge

Click image to enlarge

Dr Kim Hinshaw at City Hospitals Sunderland was involved in a peer review of the guidance prior to publication.  Kim and his team in Sunderland have worked with Flo for anumber of years to support women with PIH, and their learning and experience has contributed greatly to the Community of Practice since the implementation of their pathway.  You can find out more by taking a look at this short video.

As part of the guidance, safe BP ranges & corresponding advice is given (depending on if women are prescribed BP medication or not).  Simple Shared Healthcare has made available a protocol that adheres to these ranges and the advice given, with the aim of maintaining high levels of patient safety during this difficult time.  

If you would like to find out more about the pathway, & how Flo can support pregnant women during COVID-19, please contact Hannah.Mountford@simple.uk.net 

COVID-19; Digital Health response for the UK and Australia

posted 25 Mar 2020, 09:56 by Hollie O'Connell   [ updated 25 Mar 2020, 10:05 ]

25 March 2020 

During the current outbreak of COVID-19, adherence to official national guidance1 is a primary determinant of the effectiveness of any precautionary steps that members of the public take.  There is currently a wealth of advice shared from various sources, including the NHS and Government around self-isolation, social distancing and other preventative measures. 

However, people may be overwhelmed with the deluge of official information and updates, and confused by misinformation spread via word of mouth and social media.  This is a particular problem for vulnerable groups and serves to exacerbate anxiety.

While concerns about COVID-19 are raised globally, for at risk groups (e.g. the elderly and those with pre-existing conditions such as respiratory or heart diseases), the outbreak is even more concerning as the consequences of contracting the virus are more severe. 

At the time of writing, Simple Shared Healthcare are collaborating with NHS organisations on pathways to help patients self-isolating and social-distancing at home.  The collaboration has created a bank of advice messages and structured protocols based on official NHS and Government guidance that can be integrated into pathways with Flo, covering all manner of topics from symptom tracking, hygiene, loneliness and isolation, to advice for parents.

Flo’s gentle prompts are also designed to encourage subtle behaviour-change over time.  This is particularly crucial for those self-isolating or social-distancing to ensure guidelines are followed to reduce the likelihood of contracting or further spreading COVID-19.

Building on Flo’s considerable capability, her ‘Next- Gen’ cousins Clara and Nellie, who’ve been working for over 2 years in Australia, USA and UK, offer a service specifically designed for a rapid public health response.  The foresight of NHS Stoke-on-Trent inspired us to add a layer of functionality to Clara we called self- subscribe.

This enables healthcare workers to ‘prescribe’ Clara for a patient.  The healthcare worker simply advises the patient to text a keyword to a specific mobile number and that’s it!

In the case of COVID-19, this may be as simple as a general self/household isolation protocol which provides a trusted source of information and advice; thus reducing anxiety, increasing adherence and directing patients on the appropriate use of NHS resources at any particular time during self-isolation or just helping vulnerable patients to manage pre-existing conditions.  Clara engages patients with a rich dialogue and updates to guidance provided to patients can be done on the fly, hot off the press.

Most importantly for patients using either Flo or Clara, they feel that they have a ‘human’ connection to their healthcare provider, making them feel that they are not facing this alone, helping to mitigate the mental health issues that self-isolation may cause in many patients.

If you would like to discuss how Flo could potentially support patients during this testing time or are interested in self-subscribe with Clara, please contact us via our website and a member of the team will get back to you.

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