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© NATT C/O Mansfield and Ashfield CCG

NOTTINGHAMSHIRE ASSISTIVE TECHNOLOGY TEAM (NATT) ANNUAL REPORT 2015/16

2/29/2016 Strategy and Service Offering 2016/17

This annual report outlines the progress of the service and achievements to date.

The report also outlines future capabilities to support the needs of the Health and

Social care services supporting patients across Nottinghamshire.

Version Control Version 1.1 Public Final February 2016

Nottinghamshire Assistive Technology Team (NATT) Annual Report 2015/16

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Table of Contents

Table of Contents

SERVICE VISION ....................................................................................................................................... 2

National Approach ............................................................................................................................................................. 5

ANNUAL ACHIEVEMENTS ........................................................................................................................ 6

Funding .............................................................................................................................................................................. 9

Governance and Standards ................................................................................................................................................ 9

EVIDENCE AND PUBLICATIONS………………………………………………………………………….9

Feedback – Primary Care……………………………………………………………………………………………………13

Feedback – Community Services……………………………………………………………………………………………15

Feedback – mental Health…………………………………………………………………………………………………..21

PATIENT REPORTED OUTCOMES 15/16…………………………………………………………………23

ACTION LEARNING EVENTS 15/16…………………………………………………………………...…25

BUDGET 16/17……………………………………………………………………………………………28

2016/17 REQUESTED DELIVERY REQUIREMENTS……………………………………………………….29

FUTURE SUGGESTIONS…………………………………………………………………………………..31

APPENDICES………………………………………………………………………………………………32


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Nottinghamshire Assistive Technology Team (NATT) Annual Report 2015/16 Strategy and Service Offering 2016/17

Service Vision The Nottinghamshire Assistive Technology Team has been an operational service since April 2015. Continuing on

the growth and success due to the number of patients/pathways utilising Flo or Florence Simple Telehealth since

the Assistive Technology Workstream inception back in 2012.

The service has been created/expanded to:

- Support the deployment of technology enabled care services (TECs)

- Improve the quality of self-care through the use of technology aids

- Increase capacity in teams and services

- Improve engagement and adherence and increase relevant monitoring information and access for

clinicians

- With an ever changing technological market keep abreast of new developments, assess, evaluate and

research effectiveness and ROI

- Patient direct training and support as required or outsourced

- Support Regional adoption through Academic Health Science Network (AHSN)

- Support Nottinghamshire and Regional Community of Interest through sharing of best practice and

website access

- Support CCGs and providers to meet and evidence Digital Maturity Assessments aligning TECs to NIB

strategy requirements

- Our focus is on TECs for whole pathway transactions

- Push forward with integration of TECs such as Flo with clinical system providers i.e. TPP and EMIS


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Sian Clark Assistive Technology Innovation and Operational Manager - Sian

has over 12 years’ experience in the NHS as an accomplished Change

/Project Manager and has worked on large scale change through

implementations of Clinical Systems such as TPP, Mobile Working and the

Summary Care Record. More recently she has developed and influenced the

use of Assistive Technology and Flo or Florence Simple Telehealth creating

a mainstreamed operational service across Health and Social Care. Her

protocol creation/pathway redesign skills have also influenced the

American Veterans Health Administration deployment of their version of

Flo “Annie”. Sian also sits on the implementation group for the NHS

England TECs board and has numerous publications. She has presented her

work and spoken at conferences nationally and internationally with regular

appearances on BBC Radio Nottingham on John Holmes show. As well as a

Master level qualification and a PGCE, Sian also has a PGCert in Health

Informatics.

Natalia Remizovsky Assistive Technology Support Officer – Natalia worked

in the private sector providing training before joining the NHS in 2005.

Natalia is a qualified trainer and has excellent presentation and

communication skills. Working in Nottinghamshire Health Informatics

Service(NHIS) Natalia delivered training and service redesign on systems

such as TPP SystmOne. Natalia is pivotal in the organisation of our Action

Learning Events and Communications.

Carol Turner AHSN Flo Simple Telehealth Project Manager – Carol is an

ODP with over 30 years of clinical experience in theatres and Pre Op.

Carol has a passion for use of technology and Flo after successfully

leading its deployment in Pre Op for Hypertension. Carol was chosen as

an NHS England Clinical Advocate and presented her work in

Washington USA in 2014. The East Midlands AHSN have funded Carols

role to support the deployment of Flo within the Acute sector until July

2016.

Meet the Team


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Dr Nigel Marshall Clinical Lead for AT– Nigel trained at St Georges

Medical School in London. Graduation took him to Yorkshire to undertake

a number of junior posts before returning to Nottinghamshire. Nigel

became a partner at a large and busy market-town practice in Newark-

on-Trent where he spent 10 happy years. Whilst retaining a foundation

in General Practice a portfolio career started with Practice Based

Commissioning (PBC), which enabled a move to a more specific and

senior role as Clinical Advisor for the local CCG. Nigel was a Telehealth

sceptic and perfect challenger to be part of our team, he is now our

Clinical lead and a champion.


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NATIONAL APPROACH

The Five Year Forward View made a commitment that by 2020, there would be “fully interoperable electronic

health records so that patient’s records are paperless”. The National Information Boards vision focuses on local

design and delivery and best use of existing assets. Through this there is a drive for remote and assistive care

and the use of technologies such as Flo and the interoperability of this patient reported data into healthcare

records. The NATT service is best placed to support these plans and has gained recognition for the approach

from the national team.

“I am delighted to have the opportunity to support the work of the Nottinghamshire Assistive Technology Team

(NATT).

At local, regional and national (NHS England & Dept of Health) levels NATT’s approach, methodology and success

continues to be cited as the definitive exemplar of ‘how to do TECs’. Established at a difficult time and operating is

a new innovative environment, NATT has established the most successful, wide ranging and cost effective TECs team

in England.

Whilst other localities struggle to achieve the level of multi-organisation cooperation and collaboration seen

in Nottinghamshire regarding TECs, NATT continue to build on this, pushing forwards the boundaries of what is

possible to pragmatically and cost-effectively improve health outcomes

The national Simple Telehealth team use the NATT model as the aspirational goal for all Simple Telehealth licence

holders.”

Phil O’Connell NHS Simple

There is a growing wealth of knowledge across Nottinghamshire around assistive technology and this will be

further utilised and required as Remote and Assistive care will be embedded into the 16/17 Operating

Framework and will be mandated through the GP contract.

Since the inception of the our workstream over 3000 patients have utilised Flo across Nottinghamshire,

Nationally it’s over 30000. Compared to 2014/15 this year(15/16) the average number of patients active

each month has increased by 45%.

Our KPIs have been met with monthly performance reports sent to the identified leads in each organisation.


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Key Annual achievements Year 13/14 First evaluation report produced and recognized

nationally as leading the way for Technology

Enabled Care (TECS). First deployments.

Year 14/15 HSJ Value in Telehealth Finalist

Publications in various Journals and Further

Evaluation data

ASHN Secondment funded post focusing on Acute

sector

Year 15/16 Operational Service began April 2015

Service Catalogue of protocols

IHI scholarship awarded with poster presentation

and chairing of session on LTC and use of

technology with Sir John Oldham in Florida, USA.1

East Midlands AHSN Innovation Award for

Roundwood surgery

Flo cited in CQC outstanding report for Roundwood

Surgery

Film Launch – The Health Foundation view here

http://www.health.org.uk/flo

Number of Live Practices and Services

Use of Flo per organisation in 2015/16 (at 9 months based on Patient numbers and text usage)

Organisation Usage %

Mansfield and Ashfield CCG 35.73%

Newark and Sherwood CCG 20.83%

Nottingham North and East

CCG

9.15%

Nottingham West CCG 13.94%

Rushcliffe CCG 9.20%

Nottingham City CCG 4.92%

BHP 6.23%

1 http://www.ihi.org/education/Conferences/Forum2015/Documents/Storyboard%20Handout%20Forum%202015_ALL.pdf

http://www.health.org.uk/flo


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Organisation Service/Practices Areas used

M&A CCG 14/28 Hypertension

Weight

COPD

Asthma

Medication Compliance

Heart Failure

Diabetes

N&S CCG 10/15 Hypertension

Respiratory Heart condition

DMARD/Injection reminders

Blood test reminders

Weight

Diabetes

Medication Compliance

NNE CCG 4/21 Hypertension

Diabetes

Weight in LD patient

NWCCG 1/12 Medication Compliance

Hypertension

Rushcliffe CCG 1/12 Hypertension

Nottingham City CCG 3/64 Hypertension

Asthma

Medication Compliance in LD

patient

SFHFT Heart Failure

Pre Op

Stroke ESD Team

Orthopaedics

Observation monitoring

Hypertension identification

Diary compliance

Follow up appointment


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NUH Hepatology

Epilepsy

Parkinsons

Pre Op

Clinical Genetics

Ascites management

Medication prompting and diary

Hypertension identification

Scan/Blood Test reminders

Mansfield Community Hospital Parkinsons

Physio

Medication compliance

Newark Hospital Fernwood Unit

Pre op

Medication compliance

Circle Treatment Centre Pre Op Hypertension

Nottinghamshire County Council Aspergers Service

Everyone Health

CRI

Activities of daily living

Weight mindfulness texts

Alcohol withdrawal

Nottinghamshire Healthcare

Foundation Trust which covers

Mental Health services

The Recovery Service

LTC Substance Misuse services

Learning Disability Service

County Health Partnerships –

Heart Failure

Bassetlaw Health Partnerships

Recovery College

Cancer Mindfullness Dr Sam

Malins

Speech and Language Therapy

Substance misuse motivational

messaging/group sessions

Ascites management

Medication compliance in LD

patients

Co-morbidities observations

Pulmonary Rehab

Cancer mindfulness CBT support

Home Talk tasks and support

messages

Continence service

PICs Heart Failure team

Care Co-ordination team

Observation monitoring

Medication prompting

CityCare Diabetes

Heart Failure

Glucose monitoring

Observations


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Framework Last Orders Alcohol withdrawal

CNCS/Out of hours TBC TBC

Funding The service is funded jointly by all 6 Nottinghamshire CCGs ensuring economies of scale and ability to share

best practice. This also enables all providers commissioned to have access to our service provision. The costs of

the service are divided up on a per usage basis and calculated annually.

Governance and standards Annually the Standard Operating procedure is reviewed and continual improvements made with the service

using the knowledge built from Clinical champions utilising Flo. The Privacy Impact Assessment and associated

risk/patient safety documentation again are reviewed if there are any changes in the system or procedures.

Evidence and publications

Publications include: - Further publications can be found at www.simple.uk.net

Tackling Telehealth: How CCGs can commission successful telehealth services (2014) includes Nottinghamshire as

a case study2, describing the approach taken locally to identify clinical, patient and commissioning

requirements in relation to the benefits of telehealth.

How CCGs can use 'speed-dating' to successfully commission new services (2014)3 describing our innovative

approach to consultation has engaged clinicians and patients in Nottinghamshire to deliver a highly effective

telehealth service and significant cost savings.

How a patient champion can help spread telehealth innovation (2014)4

Holmes, M and Clark, S (Dec 2014) Gastrointestinal Nursing Journal Technology enabled care service: novel method of managing liver disease5

Implementing a technology enabled care service (2016)6 includes Nottinghamshire as an example service.

Our evidence on Flo use was also provided to Public Health England and incorporated into the recent report Tackling high blood pressure From evidence into action 7. The NATT team are also supporting the East Midlands Hypertension Project Group.

2 Birch-Jones, J (2014) Inside Commissioning (2014) Tackling Telehealth: How CCGs can commission successful telehealth services. Case Study: How Nottinghamshire CCG’s are tackling telehealth.pg 10. 3 Birch-Jones J (2014) http://www.insidecommissioning.co.uk/article/1297822/ccgs-use-speed-dating-successfully-commission-new-services 4 Birch-Jones J (2014) http://www.insidecommissioning.co.uk/article/1298274/patient-champion-help-spread-telehealth-innovation 5 http://www.magonlinelibrary.com/doi/full/10.12968/gasn.2014.12.Sup10.S22 6 http://www.magonlinelibrary.com/doi/abs/10.12968/bjhc.2016.22.1.23 7https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/404881/Tackling_high_blood_pressure_-_FINAL.pdf

http://www.simple.uk.net/

http://www.magonlinelibrary.com/doi/full/10.12968/gasn.2014.12.Sup10.S22


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The evaluation of our 2013/14 outcome data was academically reviewed by the University of Strathclyde and

was circulated to Chief Officer’s and Clinical Chairs in early September 2014. The evaluation data was very

positive in terms of cost, quality and clinical benefits.

An overview of outcomes include:

Heart failure nurse team – home visits halved and telephone calls from patients more clinically appropriate, patients feel more supported between visits. One home visit costs £67. Flo including all equipment = £92.46p.a.

COPD – patients have more understanding of their condition; when to take rescue medication or contact their nurse as their condition requires possible change in treatment. Admissions to hospital are avoided. One hospital admission = circa £2,000. Flo including all equipment = £74.96p.a.

ADHD clinic appointment reminders have reduced DNAs from 55% to 0% in patients using Flo. Averted appointment wasted income for the Trust = £155. Cost of using Flo = £0.72p

A cohort of long-term anorexic Asperger’s patients using Flo for meal reminders put on weight after a few weeks, preventing inpatient admission and reducing support worker visits. One support worker visit costs £9.10. Cost of using Flo = £9.60 a month

Use of Flo to monitor diabetic blood glucose readings helped one patient with previous average inpatient admission every 9 days, having only 3 admissions in 8 months post Flo. His compliance to treatment, overall motivation and wellbeing has improved significantly. Cost of using Flo = £350.40 p.a. One hospital admission = £2,000 (based on previous years pattern of admissions - £82,000 cost avoidance)

Pre-operative patients found to be hypertensive used Flo to send in twice daily BP readings for a week. Cost of Flo for week = £3.15. 73% (8) of patients found to be hypertensive. A cancelled surgical procedure = £232, therefore a £1,856 cost avoidance for the 8 patients.

The Evaluation for 2014/15 focused on primary care impact of Flo with further positive evidence and recommentations:

• Not enough data to assess changes in hospital and A&E admissions but the data does suggest that the

Flo service is having a beneficial impact at the primary care level.

• Findings 12 months before and 12 months after the adoption of Flo, there is a significant reduction in the number of GP consultations for both hypertension and COPD respondents.

• Similar reductions might have been observed for the other patient groups though data was unavailable to examine.

• For every patient group, at least 80% of respondents reported less frequent usage of GP services following the initiation of Flo, which corroborates the clinical system data and suggests that the significant drop in consultations observed for hypertension and COPD does indeed extend across patient groups.

• Overall Flo appears well received by patients, improves self-management skills and general health and particularly in primary care, it helps them to reduce their uptake of other healthcare services.

• Further study impact with more data focusing on patient outcomes, looking at trends in A&E and Admissions data. Obtain longer term data for initial patients set up back in 2012.


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So what has 2015/16 continued use and new pathways, evidenced? As the first year as a mainstreamed operational service 2015/16 the evaluation below further shows positive outcomes and growing support and usage from primary care and secondary care. Community specialist services have also increased usage but there is continued variation across Nottinghamshire. There was also a delay in some areas at the start of 2015 financial year while the cost model was agreed with providers nervous to continue use without clear CCG backing, this certainly impacted patient numbers in services such as PICs. In 2015 Mansfield and Ashfield CCG also conducted a Best Practice deep dive exercise to analyze improvement in practice activity. The report showed that in the areas where Flo was utilised this could be attributed to considerable progress made in reducing secondary care activity and was a top performing FCG. The other possible contribution was from the virtual ward provision through Skype. Therefore as a service we do not have local Randomised Control Trial Level (RCT) evidence but the impact in areas can at least be attributed to some degree to the inclusion of Flo as a tool for patients and further analysis would be required if funding was available to conduct such a study as suggested in the 2014/15 report by the University of Nottingham, Institute of Mental Health Dr Louise Thomson and Laurie Hare Duke. Further work is also underway in the table below.

Service Name Evaluation to be conducted Date to be published Acute – NUH Hepatology 12 month evidence of reduced re-

admissions/improved patient compliance

July 2016

Acute - NUH Parkinsons Reduction in caseload size as patient compliant/reduction in admissions

July 2016

Acute- SFHFT Orhtopaedics Reducing the number of follow ups/ Improving the New: Follow up ratio/ Increasing capacity for new appointments OR to see review patients and impacting positively on the 18 week RTT/ Providing an option of converting a clinic to an operating list/ Improving the peaks and troughs of Radiology department attendance

July 2016

Acute – SFHFT Early supported discharge team (Stroke)

Increase capacity/quicker discharge/improved compliance

July 2016

Acute – Circle Pre-Operative Reduction in cancelled operations/appropriate signposting/cost savings

July 2016

Best Practice Lessons Learned GP viewpoint N&S CCG

Feb/March 2016 best practice learning from successful practices and expansion of Flo use. Identification of protocols to use and audit outcomes then present at PLT.

September 2016

Interim data for the above will be presented by the clinical teams at our next Action Learning Event April 26

th 2016 and it is anticipated will create further expansion and interest in Flo.


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CASE Study 1 - My patient is a lady aged 44, known hypertension, poorly controlled, using FLO has helped

her to see that her blood pressure is raised, which has encouraged her to comply with her medication and

understand the need for it to be increased. She has been able to see the effect complying with her medication

has had on her bp.

Her blood pressure is now under control and she is going to commence Flo for weight management.

CASE Study 2 - My patient is a 56 year old man not diagnosed with hypertension but who had persistently

high clinic readings, he works full time out of town and was finding it frustrating and increasingly difficult to come

in for appointments. FLO has enabled him to have his hypertension diagnosed and treated with minimal disruption

to his life. Although not yet well controlled he has engaged with the team and with FLO. I feel that without FLO

this patient may have stopped coming to appointments and therefore not been treated.

Feedback - Primary Care

GP /Nurse responses The following questions were asked to gain feedback from active service/practice users and a call for Case studies was made.

Q1 - Has the use of Flo shown a reduction in clinical appointments/Visits required compared to your process before Flo? Q2 - Are contacts with patients more appropriate? Q3 - Are more patients able to self-manage because of using Flo?

They were also asked whether they would be willing to be clinical champions, whether the service should continue

and many have booked in visits to look at expanding their use with the team in 2016.

Practice 1 –

The number of appointments for each patient after introducing the use of Flo for hypertension management has

removed the need for at least 3 appointments per patient. Contacts are more appropriate and the practice feel

patients are more able to self-manage.

Nurse quote - really pleased with the support we have received, due to time constraints on our part have not used

to full effect yet but we hope to make better use of FLO in the future


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Practice 2

The responses were similar to the above practice in that prior to the introduction of Flo patients would have had 4

appointments for managing hypertension and this has reduced to 1 per patient. Contacts again were reported as

more appropriate and the nurse felt patients were able to self-manage more effectively with the use of Flo.

Practice 3 Q1 response for this practice was for Flo use to titrate patients medication with hypertension. Has the use of Flo shown a reduction in clinical appointments/Visits required compared to your process before Flo? It is likely that the number of face-to-face appointments has reduced, though numbers of telephone consultations will have increased instead. Previously, if a pt had uncontrolled BP, they would see a GP and then either see the GP again and/or a health care assistant for repeat blood pressure monitoring and medication titration until stable. With Flo, after the initial GP appt they then see a HCA and then have telephone consultations with the GP until stable. Q2 Are contacts with patients more appropriate? Yes, more appropriate. NICE says that hypertension should be diagnosed using home / ambulatory monitoring so it does not seem appropriate to rely on clinic BPs for titrating. Practice 4 Q1 response for this practice was again for hypertension management. Has the use of Flo shown a reduction in clinical appointments/Visits required compared to your process before Flo? * Yes - reduction in booked appointments as patients do not need to attend surgery for regular BP check. Pt only needs to attend 1 appt with nurse to set Flo up and then has telephone review with doctor. This is also a time saving for the patient not having to attend surgery as often. * Improved care and treatment for patients. * Reduced waiting list for 24 hour BP slightly. Pts able to be booked in and undertake BP readings sooner with Flo. * We also previously loaned out BP monitors for pts to use at home but did not always receive them back. We have seen a reduction in missing BP monitors with Flo. For medication – the practice reported. “We have used Flo for medication prompts for a patient who was set up

by another organisation (Fernwood unit) and their care transferred to us on discharge”

Again contacts were reported as more appropriate and evidence of improved self-management was shown. We would like to expand our use of Flo to other areas such as INR monitoring, and yes we would support the Flo service to continue. It has been very useful to the surgery and to our patients.


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Practice 5 Feedback was received from the lead nurse. “I have used FLO on 8 patients now to determine white coat and all but 1 came back ok, I am now tasked with getting just normal hypertensives”. Practice 6 Roundwood Surgery in Mansfield has the highest number of Flo users and took a unique ‘big bang’

approach to introducing Flo to their patients. Flo is used to support patients with COPD, Heart Failure, Asthma,

Hypertension, Weight Management and Diabetes. In the waiting area there is lots of information available for

patients about Flo including an enquiry box so if they are interested in how Flo can help them manage their

condition or just prompt for medication they fill in a slip and pop it in the box. The Practice reviews and then

discusses with the patient whether Flo would be suitable for them to use using administrative staff support.

The practice are now using Skype in conjunction with Flo to further exploit remote care monitoring and increase

patient access to General Practice which we hope to expand.

One patient with COPD reported that he felt really supported by Flo in between practice visits, as it really

reassured him as he had never been sure when to take his rescue medication before, but now Flo will tell him

when it is needed. Flo was also cited in the recent Outstanding CQC report for the practice. 8

Feedback Community service case studies

Nottinghamshire Healthcare Trust LTC substance misuse team The team have been using Flo for over a year now and their responses were: Q1. Has the use of Flo shown a reduction in clinical appointments/Visits required compared to your process before Flo? We have cut down appointments by 25% however the increased monitoring also means the patient feels more control over their own health. Would like to expand to relapse prevention and hypertension in 2016. The following case study was provided by the team and the work undertaken in this area was presented at the Institute for Healthcare Improvement December 2015 and through the East Midlands AHSN Mental Health Innovation Exchange October 2015 as a poster presentation.

8 http://www.cqc.org.uk/location/1-559475799/reports


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CASE Study - Sandra is a 45-year-old woman with a long history of alcohol dependence. Sandra had been

diagnosed with alcohol related liver cirrhosis and over the past 5 years and as a consequence had been experiencing

intermittent periods of decompensation of her liver.

Following another relapse into drinking alcohol Sandra was admitted again to hospital due to both ascites and

jaundice. Whilst on the ward Sandra underwent detoxification from alcohol having ascites drained and placed on a

diuretic spironolactone for her ascites. It was expected that based on Sandra’s past history she was highly likely to

drink again.

When Sandra was discharged home from hospital, follow up was arranged with her local alcohol related long-term

condition team (ARLCT) and also with support from her husband. The ARLCT had been introduced to ‘Flo’ and

identified that this simple intervention could offer support to Sandra in managing her condition once she was back

at home. The ARLCT therefore recommended that Sandra accessed Flo’s ascites pathway to enable quicker

identification of an exacerbation in her ascites by monitoring Sandra’s weight twice weekly.

This simple approach led to Sandra’s baseline weight being submitted upon introduction to Flo with the ARLCT

agreeing that an alert to the team should be triggered if Sandra’s weight varied more than1kg plus or minus her

baseline weight. Sandra was then prompted by Flo twice weekly to weigh herself on the scales provided by the

nurses at home. Initially Sandra’s weight was stable however 3 weeks later Flo alerted the ALRCT that Sandra had

not weighed herself as prompted.

Subsequently, the ALRCT contacted Sandra’s husband who felt that Sandra had once again relapsed into heavy

drinking due to observed symptoms of stumbling confusion and tiredness. Sandra’s husband managed to weigh her

which revealed Sandra’s weight had dropped by 3kg initiating a review by the nursing team. Upon review, the

nurses identified that upon being breathalysed, Sandra was found to be negative from alcohol.

The subsequent physical examination revealed Sandra’s weight loss to be caused by dehydration. This prompted an

adjustment of Sandra’s diuretic medication in the community thus avoiding the need for a hospital admission when

Sandra’s condition inevitably deteriorated without such timely intervention.

It transpires that after Sandra was discharged from hospital, she had indeed maintained her abstinence and that her

liver had begun to regain its function faster than had been expected. Flo had alerted the ALRCT to this problem and

allowed the team to intervene quickly.

Sandra continues to use Flo and finds that the “Big Brother” element is a positive rather than negative one. Sandra’s

husband also finds reassurance in Flo’s monitoring.


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SLT Stammering and home talk The community speech and language therapy team based across the county were keen to see how Flo could support Home Talk and stammering work. The Home Talk service saw mixed results with some families feeling supported by the tasks via text. The texts were to motivate and remind families about techniques/information and are continuing with expansion a across wider area in order to evaluate. The stammering group was a summer intensive programme for parents of children that stammer. A message was

sent once a week - asking parents to let Flo know how many days in a week that they have had opportunity to

practice their child’s speech aims with them and additional support/advice texts. The result s from the feedback

are below:

Analysis I feel confident that Florence protects mine and my child’s personal information/data. 100% Strongly agree/Agree Florence is easy to use 100% strongly agree/Agree I feel comfortable using a mobile phone with Florence 100% strongly agree/Agree As a result of using Florence, I remember to use strategies that help my child’s talking more regularly. 87.5% Strongly Agree/Agree 12.5% Strongly Disagree/Disagree As a result of using Florence my child’s speech, language and communication skills are improving. 1 no answer 50% Strongly Agree/Agree 12.5% were indifferent (agreed and disagreed) 25% Strongly Disagree/Disagree 12.5% No answer given The lack of human contact when I use Florence does not bother me 87.5% Strongly Agree/Agree 12.5% were indifferent (agreed and disagreed) I find Florence very convenient 62.5% Strongly Agree/Agree 37.5% Strongly Disagree/Disagree Florence has not made a difference to the amount I use the strategies that help my child’s talking to develop. 25% Strongly Agree/Agree 75% Strongly Disagree/Disagree


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I feel very reassured that Florence is keeping me in touch with the strategies discussed with my Speech and Language Therapist. 62.5% Strongly Agree/Agree 25% were indifferent (agreed and disagreed) 12.5% Strongly Disagree/Disagree I feel that Florence supports the Speech and Language programme and other children’s centre language activities. 62.5% Strongly Agree/Disagree 25% were indifferent (agreed and disagreed) 12.5% Strongly Disagreed/Disagree I believe that Florence should be part of the confident communication group programme for all families in the future. 62.5% Strongly Agree/Agree 25% were indifferent (agreed and disagreed) 12.5% Strongly Disagree/Disagreed I would recommend Florence to a friend or family member. 50% Strongly Agree/Agree 12.5% Strongly Disagree/Disagree 25% were indifferent (agreed and disagreed) 12.5% non-applicable I felt that the number of messages from Florence was just right. 50% Strongly Agreed/Agreed 50% Strongly Disagree/Disagree I felt that the number of messages from Florence was too many 62.5% Strongly Agree/Agree 37.5% Strongly Disagree/Disagree I felt that the number of messages from Florence was too few 100% Strongly Disagree/Disagree Evaluation by HealthCare Professional at the end of the Questionnaire

All families used Flo from August 2015-November 2015

The evaluation suggests that Flo has helped families to better support their child’s speech and language skills (except for the familie/s which stopped use (1/8)

Flo use did not make a difference to the number of contacts with each family. The number of contacts with the family was appropriate with Flo not impacting on this.


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Mental Health – Nottinghamshire Healthcare Foundation Trust Community Learning Disability (LD) nursing team A nurse in the LD team identified a patient who may benefit from support through Flo texts. At the patient visit it was agreed what would work for them. It was important the patient was involved in the design of the messages and responses she would want. The clinical outcomes for this patient have been reviewed and are on-going, the patient is still complying.

Patient A was referred due to noncompliance with her oral medication. The patient has type 2 diabetes and had not taken her medication for approximately 8 months. Her Hb1Ac was running at a level that the next step would have been to commence her on insulin.

The impact of her non-compliance was significant on a number of her activities of daily living, her physical wellbeing and her emotional and mental health.

The introduction of Flo has made a massive impact, patient A is now taking her medication as prescribed. There has been significant improvements in her HbA1c levels reducing from a recording of 104 to a level of 64 just above the local diabetic guidelines. Plus other significant improvements in other blood tests.

Patient A has now been removed from the avoiding admissions register due the significant health improvement.

This has also had a massive impact on her physical and mental wellbeing, she is now engaging with her local community.

Without a doubt Flo has been instrumental in supporting patient A to manage and get control of her long term health condition. Patient A feels very involved in her care and is delighted with how things are going.

Evidence has shown that

Improving HbA1c by 1% cuts the risk of microvascular complications by 25%. This include: Diabetic

Retinopathy, Nephropathy, Neuropathy and Microalbuminuria (kidney disease).

Example of potential savings per procedure when risk of complications is reduced:

Cataract operation - £763 to £1,164

Heart valve surgery - £7,294 to £9,788

Amputation - £60,000, with an addition £17,000 - £24,000 in ongoing social costs9

9 http://www.diabetes.co.uk/what-is-hba1c.html

http://www.diabetes.co.uk/what-is-hba1c.html


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Mental Health – Cancer focus

Dr Sam Malins and Dr Jo Levene – Nottinghamshire Healthcare Foundation Trust Technology-assisted Mindfulness-Based Cognitive Therapy (MBCT) for cancer.

Main findings:

Table 1 and Figure 1 present the mean scores of depression (PHQ-9) and anxiety (GAD-7) for the seven cancer

patients who took part in a pilot of technology-assisted Mindfulness-Based Cognitive Therapy (MBCT) adapted

to cancer patients. Higher scores represent higher levels of depression or anxiety. The results show that

following the eight-week program, the average scores for both the depression and anxiety scores have moved

from the clinical range for anxiety and depression to the sub-clinical/normal range. This type of change denotes

clinical recovery.

Table 1. Mean scores of PHQ-9 and GAD-7 for participants who took part in a technology-assisted MBCT

Figure 1. Mean scores of PHQ-9 and GAD-7 for participants who took part in a technology-assisted MBCT

Baseline session 1 session 2 session 3 session 4 session 5 session 6 session 7 session 8

PHQ-9 11.27 14.67 11.22 6.75 10.17 9.33 7.83 8.86 6.86

GAD-7 12.55 14.67 12.11 7 10.33 8.56 7.5 8 7.43


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Yes, patients reported being able to maintain mindfulness practices that support improvements in their

wellbeing. It will be much easier to tease out the specific contribution of Flo to health with the relapse

prevention stuff, but I think their comments show that it was a valuable part of the group effectiveness.

Dr Sam Malins was asked the question are more patients able to self-manage because of using Flo?

Data extracts from semi-structured interviews about the experiences of receiving text messages as part of

the therapy:

I didn’t think I’d like them cos I’m not very good with my mobile, but I did actually like them (…) It was a good

reminder of the main themes and homework. I think I would quite like to respond to them. I wonder how it would

have been like if I could have replied.

(Middle-aged woman recently treated for colorectal cancer)

They were good. Very helpful. Good reminders. I think knowing now that we can use these (…) so that you can be

asked a question and then you can respond, I think that’s gonna be really, really useful.

(Middle-aged man who has metastic cancer receiving palliative care)

They were a good reminder. If you found yourself getting lost (…) they were a good reminder to put you back on

track.

(Middle-aged woman with metastatic cancer)

I actually liked them (…) in a silly way you felt like somebody was motivating you (…) it was just positive

encouragement. The only negative thing was the three-hour period to reply to get them. I did miss it a couple of

times.

(Middle-aged woman recently treated for colorectal cancer)

They were good. When you got it, you just thought ‘someone is thinking about me’, even though it was just a text

message

(Young woman recently treated for breast cancer)

Next Steps – Flo will be trialed with another group in May 2016 and further analysis undertaken. A protocol

called Spiral support is also in development and potential to apply for research funding.


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CASE Study - Shirley is a 40 year old woman who had a breast removed as part of treatment for cancer.

She has prophylactic surgery planned to remove her other breast due to genetic risks identified. She had a

history of chronic pain prior to the cancer diagnosis and has experienced recurrent depression. Shirley was

offered 20 sessions of one to one psychological therapy for depression with a chronic physical health problem (in

line with NICE guidance). There was some improvement but this did not continue.

She was subsequently offered a place on a pilot of Flo-supported Mindfulness-Based Cognitive Therapy (MBCT)

group adapted to cancer. She reported a significant improvement in functioning and a greater sense of

belonging as a result. She specifically identified the Flo texts as a contributing factor. She was among a few

members of the group who requested ongoing Flo texts to prevent relapse after the group, which is being

arranged.


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Patient reported outcomes 15/16

All patients enrolled onto Flo in 2015/16 were asked to complete a patient feedback form after a set period dependent on protocol pathway enrolled. Questionnaires are returned to the patient’s responsible clinician who answers additional questions. Data is collected on the following:

Patient satisfaction

Length of time on Flo

Ability to manage health and wellbeing

Appropriateness of contacts

Hospital Avoidance Nonparametric analysis was used due to a small sample size with a return rate of 20%, with the average age 53.

Fig.1 Patient reported outcomes: hypertension


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Clinicians reported fewer contacts and more appropriate contacts with their patients Fig.2 Patient reported outcomes: heart failure

Clinicians reported fewer contacts and more appropriate contacts with their patients

A survey monkey response questionnaire has now been created to encourage feedback levels to increase and

we will look further into effective evaluation in 2016/17. For some pathways feedback is obtained through

review meetings and audits.


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Action learning Events

2015/16 saw our 6th and 7th Action learning events take place and the following table highlights the key

areas shared with case studies below. The event invites are sent out to all users and non-users of Flo across

Nottinghamshire. It is an opportunity for clinicians and patients to share their experience of using the Flo simple

Telehealth solution. Once a year Flo awards are also handed out for the categories-Most Innovative Use of

Flo/Most Consistent use/Flo Clinical Champion/Flo Business as Usual Award. Newsletters are available with

details from each event.

Presentation Outcomes shared

Fernwood Unit project

Barriers identified at the previous Action Learning

event concerning the transfer of patients between

teams were lifted when Kalu Nwaka (Information &

Performance Analyst, Newark & Sherwood CCG)

spoke about how an integrated approach to

patient care and the engagement of local GPs and

providers contributed to the success of Flo at the

Fernwood Unit, a specialist unit based at Newark

Hospital supporting elderly patients to return home

following hospital treatment. Patients start using Flo

for medication reminders whilst at the unit. On

discharge the patient’s Flo record is transferred to

the GP or community team. Patients have been

signed up and this process has worked but currently

there is a need for more standardised way of

patient identification.

The Reach Learning Disability charity support over 150

adults with learning disabilities across Nottinghamshire.

Tracy Radford from Reach explained how they initially

implemented Flo to help Reach participants with their

weight but they soon realized that Flo could help with

supportive messages around substance misuse and

healthy eating. Tracy highlighted that “the support Flo

provides outside of a persons’ sessions is a massive deal

for someone with learning disabilities” - it is vital to help

people to continue the learning they do in group sessions.

“Flo supports them to maintain good changes in

behaviours that are going on”.

We were lucky enough to have a participant from

the group attend and share their story.


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Heart Failure and weight Management

Patient A was newly diagnosed with heart failure and is clinically obese. The heart failure nurse suggested that the patient uses Flo for monitoring BP and also to encourage weight loss. CHP agreed for the Flo team to source bariatric scales and a bariatric BP monitor for the patient. Flo would text the patient asking for BP readings twice a week. Flo looks for an increase in weight over a number of days which could indicate an exacerbation and will advise the patient to contact the nurse for further advice. Flo also asks for weekly weight readings and sends daily motivational messages around healthy eating and exercise. Since using Flo after 3 months Patient A has already lost two stone and is still losing weight. Patient A has also found Flo really supportive and motivational and gave an inspirational talk, sharing very personal experiences and is a real Flo patient champion.

Continence Service The continence service across Nottinghamshire

County have been actively recruiting patients

onto Flo for mainly Pelvic Floor compliance

messaging. The outcomes have been:

Increased compliance with treatment programmes

Improved outcomes for patients

Faster progress towards self-care and discharge

Clinic patient turnover increased.

Patients strongly agreed that Flo was a

supportive tool and should continue one patients

feedback was:

“Flo is an excellent reminder to the patient to

"do" their exercises regularly. Albeit a sort of

"Pavlov's Dog" syndrome as I find that I

immediately tighten my pelvic floor”. Continence

Patient Age 71


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CHP N&S Care Homes Pressure Ulcer and Falls

prevention

The Clinical Commissioning Group implemented a CQUIN in 2014 to ultimately reduce the incidence of pressure ulcers acquired in care homes. Research was undertaken to identify the needs of the chosen home and how improvements could be made. Solutions were found including utilisation of Flo in 2015 to support care home staff in targeted messaging. The set up of FLO within the care home, saw 2 residents identified from each floor. One, with restricted mobility, the other, independently mobile. This was to show to carers that those who are seen as ‘mobile’ do not necessarily change position frequently. The results were promising with:

No pressure damage reported post Flo.

Both senior carers and carers have been responding to Flo and there has been an improvement in the adherence to individual care plans.

Unplanned nurse visits have reduced. An example is that over the weekend there have been no callouts at all where before Flo there would usually be a request.

Overall, because of the improvement in adherence to care plans and raised staff awareness of reducing pressure the patient care has improved.

Further work in 2016/17 will be undertaken as we have now expanded use to support Falls programmes in N&S and Nottingham West through CHP.

Attendance is a key area for 16/17 that we need to encourage. Regional meetings have now

been set up by the National Simple Telehealth team to support collaboration across the East

Midlands Region.


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Proposed budget requirements 16/17

The cost of delivering the service in 2014/15 was £303,615.

In 2015/16 the proposed budget was £187,290 this significant cost reduction going forward was due to the

reduction in programme management and biometric device costs incurred within the project phase.

The costs are available for the on-going annual service for 16/17 and aims to use Flo with approximately

2000 patients active. The previous proposed budget had £12,000 for consultancy and £10,000 for an

Apprentice these were not utilised. The Acute project manager role is also funded by the EMAHSN.

The service will also explore potential funding awards available.

An analysis of how each organisation want to use Flo in 2016/17 is currently being undertaken in line with the

financial planning round. Internal business cases will be developed and submitted for the associated equipment.

Organisations will be asked to purchase additional text bundles in year if they want to use Flo above what is

planned (n = £3,000 for 37,500 texts).

Funding for Flo has been included in the Better Together self-care budget to provide a year on year uplift of

20% in terms of Flo usage across Mid Nottinghamshire.


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2016/17 requested delivery requirements/project and

pathways planned

Organisation 16/17 Requirements

M&A CCG Better Together Programme pathways –

ophthalmology/midwifery10/Newark strategy

Mid Notts Self-care strategy

4 practices booked

Audit data at Roundwood Surgery

community services = Losartan pathway and

continued use in PRISM

N&S CCG Better Together Programme pathways –

ophthalmology/midwifery/Newark strategy

Mid Notts Self-care strategy

All practices undertaking best practice approach

and audit looking at Asthma pathways at Clipstone

Community services Care Homes deployments and

Pulmonary Rehab/Diabetes and further use in

PRISM teams

Rushcliffe CCG Further expansion at East Bridgford Practice and

audit results

Community services Oxygen Therapy

NNE CCG 2 practices ready to start April/May

Community services such as Oxygen Therapy

Hypertension/and High BP in Diabetics/COPD in

primary care

NW CCG No practices confirmed

Community services Care Homes and community

nursing teams

Heart Failure expansion and PICs Care Co-

ordination team

10 http://www.simple.uk.net/home/casestudies/casestudiescontent/acutetrustmanagementofmildpregnancyinducedhypertensionca10


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Nottingham City CCG 2 practices interested

Community services in citycare– Heart Failure and

Diabetes

Project Medicine Optimisation through Assistive

Technology (MOAT) using Community Pharmacy to

support medication compliance through Flo. 11Evidence of effectiveness for this approach is

growing

Requests to start are being collated in order to assess workload and possibilities. Most recently SFHFT

Paediatric diabetes and epilepsy consultant and nurses have requested to start. Work undertaken by Carol

Turner in the acute has started to see results shared and interest increased as clinicians share results and

knowledge of Flo. An example is below at Circle where the Pre-op deployments have now resulted in

further interest. There were 10 suggestions in total which are being prioritised.

IBD patients

Infusion patients – weight monitoring

Endoscopy pre-assessments (one-off)

Gastro patients

Pain Management – post injection follow-up

Respiratory – Hypertension, Sleep Apnoea

Venesection

Hyperthyroid telephone clinic

Rheumatology – yearly follow-ups

Hepatitis pathway

Expansion across Nottinghamshire 16/17 onwards will also see the following key deliverables:

Project - 2 years Skype – Virtual consultations AHSN funding bid successful across 21 care homes

Project Cancer pathways and use of Telehealth CBT

Project integration Flo Integration with Clinical systems through HSCIC approved

Project Landline IVR improvement and Flo apps August 2016

Project web GP eConsultations practice

Project Videos pilot going live April 2016 in partnership with http://www.healthandcarevideos.com/

Project – training support at the Recovery College

11 http://archinte.jamanetwork.com/article.aspx?articleid=2484905&utm_source=twitter&utm_medium=social_jn&utm_term=353491893&utm_content=press_release%7carticle_engagement&utm_campaign=press_release&linkid=20852423

http://www.healthandcarevideos.com/


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The team are also working with CHP and looking at how Flo and the above video pilot will work with RECAP

website developed by Nottinghamshire healthcare foundation trust. The team will also support the digital

roadmaps across Nottinghamshire.

Future suggestions

Increase attendance at Action Learning Events – sharing best practice

Creation of Clinical Digital alliance or group (already being undertaken by County Health Partnerships)

The NATT team will work with EMAHSN to support evaluation

The NATT team to include the use of Patient Activation Measures to support outcomes evaluation

Clinical leads identified in areas with slow uptake

After small pilot of AliveCor ECG further evidence and review of any potential use

© NATT C/O Mansfield and Ashfield CCG

Appendices

A return on investment work in 16/16 will focus on where does Flo add value? The below Logic diagram highlights our service.

Inputs

Outputs

Outcomes

Activities Outputs Short Medium Impact

A dedicated resource

the Nottinghamshire

Assistive Technology

Team (NATT) deploy

and create technology

enabled care across

Nottinghamshire. NATT

has established the

most successful,

wide ranging and cost

effective Technology

Enabled Care (TEC)

team in England.

TECs protocols

design

Pathway redesign &

Development

Management of

License costs, texts

and associated kit

TECs deployments

for Care homes e.g.

Skype

National input into

developments of

NHS Simple

Telehealth

Research new AT

and evaluation in

collaboration with

EMAHSN and

provide expertise

NHS England TECs

Implementation

board

representation

Service Protocol

catalogue

Evaluation and

evidence of TECs

pathways

Improve quality of

self-care through the

use of technology

aids

Increase clinical and

patient engagement

Action learning

events and

community of interest

AHSN Acute focused

research project

evaluation

Clinical champions

Increased use and

awareness of TECS

across whole health

economy

Impact on reduction

in admissions

Reduction in

unnecessary contacts

Increased

compliance with

treatment

Relapse prevention

Faster

intervention/treatme

nt

Expansion and

spread of best

practice use of TECs

Assessment of other

AT developments

Clinical system

integration with TECs

Development of

NHS Simple

Telehealh solution

offering e.g

Apps/IVR

Better patient

experience

Increase in patients

able to self-manage

Sustainable primary

care

Increased capacity

in teams/services

Quicker discharge

Lower costs/higher

productivity across

organisational

boundaries

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