Download Florence Tele Health - North Derbyshire CCG

Derbyshire
Florence Simple Tele Health (STH)
Project Evaluation
November 2015 - DRAFT
Version 1 - Draft
1
Table of Contents
2
Project Overview..........................................................................................................................5
2.1
How is Florence different and who is it for? .........................................................................5
2.2
Project aims and objectives ..................................................................................................6
2.2.1
Promote and support Patient Self-Care and Health Education .....................................6
2.2.2
Integrated care and individualised patient care ............................................................6
2.2.3
Aging population and rising demand on health services ...............................................7
2.3
3
Benefits of Florence STH .......................................................................................................8
2.3.1
Patient Safety .................................................................................................................8
2.3.2
Patient Empowerment/Experience ...............................................................................8
2.3.3
Quality of Patient Care ...................................................................................................8
2.3.4
Empowering Health Professionals .................................................................................9
2.3.5
Efficiency & Effectiveness ..............................................................................................9
CCG/GP Practice and Services Current Usage ...........................................................................10
3.1
North Derbyshire CCG .........................................................................................................10
3.2
Hardwick CCG ......................................................................................................................13
3.3
Erewash CCG .......................................................................................................................17
3.4
Southern Derbyshire CCG....................................................................................................18
3.5
Other services......................................................................................................................21
3.6
Overview .............................................................................................................................22
3.7
Monthly Reporting – October 2015 ....................................................................................23
3.8
Patient Information .............................................................................................................25
3.9
Text Message Tracking – October 2015 ..............................................................................26
3.10
4
Current CCG KPI’s ............................................................................................................27
Detailed evaluation of Florence usage within the DCHS Community Diabetes Team ..............28
4.1
Members of the Team .........................................................................................................28
4.2
General overview and application ......................................................................................28
4.3
Key Benefits .........................................................................................................................28
4.4
Reason for referral ..............................................................................................................29
4.5
General Diabetes Patient Evaluation ..................................................................................30
4.5.1
Levels of patient interaction with Florence STH ..........................................................30
4.5.2
Levels of growth in patient registrations .....................................................................32
4.5.3
Levels of growth in text messaging..............................................................................33
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4.5.4
4.6
Patient A’s Story ...........................................................................................................35
4.6.2
Blood Glucose Reading ................................................................................................36
4.6.3
Cost of Text Messages .................................................................................................37
4.6.4
Cost of Messages (Actual and Projected) ....................................................................38
4.6.5
Cost Comparison ..........................................................................................................39
Specific Patient Evaluation - Patient B ................................................................................40
4.7.1
Patient B’s Story ...........................................................................................................40
4.7.2
Medication Reminder ..................................................................................................40
4.7.3
Cost of text messages ..................................................................................................41
4.7.4
Patient B reduction in HbA1c .......................................................................................42
4.8
HBA1C Analysis ....................................................................................................................43
4.8.1
What is HbA1C .............................................................................................................43
4.8.2
HbA1c in diagnosis .......................................................................................................43
4.8.3
What are the benefits of lowering HbA1c? .................................................................44
4.9
6
Specific Patient Evaluation – Patient A ...............................................................................35
4.6.1
4.7
5
The number of alerts generated ..................................................................................34
Patient information and HbA1c levels and acheivements ..................................................45
4.10
Case Study .......................................................................................................................46
4.11
DCHS Voice Article – Patient Story Chris Pettett .............................................................48
4.12
One Patient Feedback on Flo – NHS Choices...................................................................49
4.13
Patient Letter to DCHS Diabetes Service Manager – Jonathan Sanderson .....................50
4.14
A patient quotation .........................................................................................................52
4.15
NED patient feedback – Future .......................................................................................52
4.16
Case Study – Patient gets long term condition under control - Future ..........................52
4.17
Reduction of face to face appointments for newly diagnosed patients - outline ..........52
4.18
Reduction of face to face appointments in general - outline .........................................52
4.19
Joint Clinics and Integrated Care .....................................................................................53
4.20
Life without Florence .......................................................................................................53
Southern Derbyshire Care Coordination ...................................................................................54
5.1
Micheala Kirkman ................................................................................................................54
5.2
Alison Goodrum ..................................................................................................................54
5.3
Case Study ...........................................................................................................................55
Ashgate Medical Centre – Early findings ..................................................................................57
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Castle Street Medical Centre – draft of 2nd December meeting ...............................................58
8
Areas of potential development ................................................................................................59
9
Appendices.................................................................................................................................61
9.1
Self Care...............................................................................................................................61
9.1.1
Wagner’s Chronic Care Model .....................................................................................61
9.1.2 Factors to strengthen the promotion of Patient Self-care as an integral part of the
healthcare system. .....................................................................................................................62
9.1.3
9.2
Self-Management for Life ............................................................................................62
Integrated care, continuity of care and individualised patient care ...................................63
9.2.1
Fulop’s Typologies of Integrated Care (from Lewis et al 2010) ...................................63
9.2.2
Intensity of integration (Shaw et al 2011, p15; after Leutz 1999) ...............................64
9.3
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More information on the impact of lowering HbA1c .........................................................65
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2
Project Overview
The project has been commissioning and funded by all four Derbyshire Clinical Commissioning
Groups (CCGs). Details of funding arrangements/breakdown can be found in the document:
Florence Funding Breakdown CCG Agreement.
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North Derbyshire CCG
Hardwick CCG
Erewash CCG
Southern Derbyshire CCG
Implement and support the roll out of Florence STH to GP practices and other healthcare
providers such as Community teams involved in direct patient care. To bring together systems,
processes and clinical expertise by embedding Florence STH within clinical pathways
comprehensive approach to providing patient care. Clinical focus will be with the following
patient usage:
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Respiratory – Chronic Obstructive Pulmonary Disease (COPD) and Asthma
Diabetes Management
General medication reminders
Broader application of Florence STH at the request of individual GP Practices and services
as and when required. E.g. Appointment reminders for B12 Injections, Depo Provera
Injections and regular DMARD Testing
2.1 How is Florence different and who is it for?
Traditional Telehealth requires dedicated communication equipment installed at a patient's home.
Florence is different. From a patient's perspective they communicate with Florence through their
standard mobile phone, all they need is text messaging. And because they use their mobile phone
there is no expensive communication equipment involved. It’s cheaper for the NHS to operate and
patients are not tied to their Home. As long as they have their mobile with them they can enjoy
the benefits of Florence from anywhere they choose.
Florence is for the NHS in the UK. Florence is already being used in over 70 health and social care
organisations; the number is increasing all the time. Florence has been designed to enable
patients to increase their involvement in the management of their treatment, condition or
lifestyle. Clinical staff use Florence to collect readings or symptom information remotely from
patients in relation to their healthcare needs. In return Florence sends health advice based on the
readings, as agreed with their clinician. Florence can also alert clinicians if a patient's condition
worsens to allow them to intervene appropriately. Florence can also send reminders and health
tips to support engagement and compliance with health or lifestyle advice.
Source: https://www.getflorence.co.uk/faqs/
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2.2 Project aims and objectives
This section is to identify general, national and specific clinical or GP/CCG aims and objective to
support the application of Florence STH across Derbyshire. This will help to guide this evaluation
and focus further work with assistive technology.
2.2.1 Promote and support Patient Self-Care and Health Education
Florence STH provides clinicians with a tool to promote and support patient self-care/management.
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Remind patients to take their medication as prescribed
Remind patients to complete regular monitoring
Focus’s the patient on monitoring of their condition
Focus’s the patient on agreed parameters
Provides help and advice
Change patient behaviours
Gives patient more confidence
The importance of self-care is illustrated here by the British Medical Journal.
Support for self-care for patients with chronic disease
Self-care is defined as the actions individuals “take to lead a healthy lifestyle; to meet their social,
emotional and psychological needs; to care for their long-term condition; and to prevent further illness or
accidents.” The potential benefits of self-care are substantial. According to the proponents of the chronic
care model (one of the most comprehensive models of care for long term conditions): “All patients with
chronic illness make decisions and engage in behaviours that affect their health (self-management).
Disease control and outcomes depend to a significant degree on the effectiveness of self-management.”
http://www.bmj.com/content/335/7627/968
2.2.2 Integrated care and individualised patient care
Florence STH provides clinicians with a tool to enable them to share care and information across
boundaries and continue to close the gap between health settings.
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Patient information can be easily shared with other health care providers – e.g. Diabetes
Specialist Nurse is able to share patient reading with the patient’s Practice Nurse.
If a patient is discharged from one service or referred to another service the Florence
patient record can transfer to the new carer.
Enables joint decision making between patient and clinical staff e.g. readings are a valuable
resource for discussion a joint service clinics or multi-disciplinary team meetings.
Reduces the risk of conflicting advice and guidance and unnecessary treatments/test etc.
Enables clinicians to complement each other use of Florence STH. Avoiding duplication in
effort for both patients and clinical staff.
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2.2.3 Aging population and rising demand on health services
Florence STH is a flexible yet simple tool to enable users to reach
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The clinicians does not have to check Florence on a regular basis – Florence has an
integrated alert system that is active given that a set of pre-determined parameters have
been breached
Counteract increases in demand allowing for reminders and monitoring to be sent, and
received, automatically without the need for regular instigation by clinical staff.
Put in place simple but effective system that can lead to a reduction in appointments.
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2.3 Benefits of Florence STH
2.3.1 Patient Safety
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Flo provides a simple and effective tool to enable patients to manage their health better. SelfManagement is an integral part of any care plan for patients. Patient’s active in their own health
care can considerably reduce their risk of medical problems.
Flo is clinically built and tested, and has in-built patient safety features. The patient is made aware
that Flo does not replace usual face to face interaction. Flo does encourage patients to contact
their health professional if pre-set safety parameters are breached.
Flo has a simple but effective alert system, alerting clinical staff should (vital signs or other)
readings, sent to the system by the patient, breach the patients pre-set safety parameters. Clinical
staff can see developing situations and take action as appropriate.
Reminding patients to take their medication as prescribed can reduce the level of medication
noncompliance. Stabilising the taking of medication and establishing effective routines will allow
for effective assessment of the patient condition and their response to the medication and other
treatments.
2.3.2 Patient Empowerment/Experience
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Reduce the number of patient attended appointments for gathering routine monitoring
information (e.g. blood pressure readings)
Less disruption to working lives of patients. Patients are not tied to their home.
Enable patients to have more control over their own care, greater control leads to greater
confidence.
Enable patients/carers dealing with long term conditions such as Diabetes and Chronic Obstructive
Pulmonary Disorder (COPD) to manage their condition effectively with appropriate direction and
support.
Use of existing technology through the patients mobile phone, all they need is text
messaging - which is free of charge. As long as they have their mobile with them they can
enjoy the benefits of Florence from anywhere they choose.
Florence has been designed to enable patients to increase their involvement in the
management of their treatment, condition or lifestyle – supports self-care regularly and
consistently.
Florence can also send reminders and health tips to support engagement and compliance
with health or lifestyle advice.
Florence provides contact and support between face to face visits.
2.3.3 Quality of Patient Care
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Flo is another tool available to clinicians to enhance patient compliance in key clinical areas and
works as a reassurance to patients between face to face visits
Regular monitoring/early warning has the potential to reduce emergency admissions
Employ systems that have the capability to work across care settings prompting integration and
continuity of patient care. To link with strategic groups, secondary care providers and primary care
providers to support the integration of care through the health and social care community.
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2.3.4 Empowering Health Professionals
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Florence STH will provide a regular feed of metrics inputted by the patient, viewable at the
clinician’s discretion at a time suitable to them.
Florence STH has an additional function of sending one off emails to a patient – direct link to the
patient, and is auditable through the system.
A clinical decision support system that promotes self-care enabling clinician and patient/carers to
work together – improving relationships and outcomes.
To lessen the burden on front-line clinical staff to develop and maintain locally defined STH clinical
guidelines by providing clinical support and clinically approved flexible STH solutions to meet the
needs of practices/services and patients.
2.3.5 Efficiency & Effectiveness
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Flo can reduce the number of calls and face to face visits required by patients.
Practice clinical staff should experience fewer calls from difficult patients on their caseload.
Better compliance to medication will ensure more cost effective use of prescription drugs
Allow for regular/cost effective patient monitoring systems e.g. Blood Glucose or Oxygen
saturation levels.
Using existing patients devises means that there is no expensive communication equipment
involved.
Regular monitoring/early warning has the potential to reduce emergency admissions.
Clinical staff use Florence to collect readings or symptom information remotely from patients in
relation to their healthcare needs – saving time and appointments.
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CCG/GP Practice and Services Current Usage
Active Protocols unless specified. Most recently added practices at the top of each table.
3.1
North Derbyshire CCG
Practice/Service
Date
added to
Flo
Clinician Information
Number
With
Without
Patients Patients
1
0
Arden House Medical Centre - (C81634) ND
23/11/15
Protocols
 Arden House Medication reminder
 Arden House Type 2 Diabetes BG Results - Insulin
 Arden House Reminder for Blood Glucose Testing
(Protocols to be rename and numbered)
1
Ashgate Medical Centre (C81045) ND
Protocols
 AP008 DMARD Blood Test 3mth Reminder
17/08/15
2
2
0
Avenue House & Hasland Partnership (C81084) ND
28/07/15
Protocols
 DT003 DCHS Reminder for Blood Glucose Testing
 DT002 DCHS Type 2 Diabetes BG Results – Insulin
5
0
5
Lime Grove Medical Centre (C81101) ND
15/04/15
Protocols
 DT004 DCHS How’s your exercise going Text
 DT005 DCHS How’s your Diet going Text
 DT003 DCHS Reminder for Blood Glucose Testing
 DT007 DCHS Tablet Reminder for adults (Diabetes)
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2) Notts
2
1
1
Dronfield Medical Practice (C81025) ND
20/11/14
Protocols
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2) Notts
 AIM-11. COPD v2
 AIM-09. Medication reminder for adults and teenagers
7
0
7
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10
Hartington Surgery (C81082) ND
Protocols
 MR010 21 Day Contraceptive
 AP004 B12 Reminder every 12 weeks
 AIM-09.Med Rem. A&T – Triggers
1
2
The Springs Health Centre (C81001) ND
22/10/14
1
Protocols
 DEMO: AIM-02. Hypertension poor control or newly diagnosed
 DEMO: AIM-01. Initial high BP reading - hypertension not yet confirmed
 DEMO: Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2) Notts
 DEMO: AIM-11. COPD v2
0
1
Darley Dale Medical Centre (C81030) ND
24/09/14
Protocols
 DEMO: Meds Reminder : Every so many days @18:30 - QAD
 Hypertension 6 Month Reminder
2
0
2
Gosforth Valley Medical Centre (C81627) ND
19/08/14
Protocols
 Demo: Asthma SMP
 AIM-11. COPD v2
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2) (Notts)
 AIM-09. Medication reminder for adults and teenagers
 AIM-09. Medication reminder for adults and teenagers
1
0
1
Imperial Road Surgery - (C81028) ND
30/06/14
Protocols
 AIM-09. Medication reminder for adults and teenagers
 AIM-11. COPD v2
6
1
5
Tideswell Surgery - (C81076) ND
27/06/14
Protocols
 AIM-14. Overweight and obesity v2
 AMI-09 Medication reminder for adults and teenagers
1
0
1
Ashover Medical Practice - (C81611) ND
26/06/14
Protocols
 AIM-09 Medication reminder for adults and teenagers
1
0
1
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17/11/14
3
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11
Baslow Health Centre - (C81013) ND
08/04/14
Protocols
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2) Notts
 AIM-09. Medication reminder for adults and teenagers
4
0
4
Barlborough Medical Practice - (C81662) ND
02/04/14
1
Protocols
 DEMO: AIM-09. Medication reminder for adults and teenagers
0
1
Additional Information
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Total number of GP Practices in CCG – 36
Total number of GP Practices (Flo groups) on Florence – 14
Percentage of GP Practices on Florence – 38.9%
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3.2 Hardwick CCG
Practice/Service
Group
Added
to Flo
06/08/14
No. of
Users
With
Without
Patients Patients
Wellbeck Drive Surgery - (C81658) H
Protocols
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2) (Notts)
 AIM-09. Medication reminder for adults and teenagers
4
1
3
North Wingfield Medical Centre - (C81055) H
29/07/14
Protocols
 AIM-09. Medication reminder for adults and teenagers
2
1
1
Blackwell Medical Centre - (C81661) H
21/07/14
2
Protocols
 AIM-09. Medication reminder for adults and teenagers (No Q)
 AP007 Reminder B12 injection - 12 Wks
 AP006 Prostap Remind patient to book appt 10 Wks (3 mths)
 AIM-09. Medication Reminder - Warfarin No Q
 AIM-09. Medication reminder for adults and teenagers
0
2
Creswell & Langwith Medical Centre - (C81011) H
18/07/14
Protocols
 AIM-09. Medication reminder for adults and teenagers
1
1
0
Castle Street Medical Centre - (C81638) H
17/07/14
Protocols
 MR004 Reminder B12 injection - 12 Wks
 MR007 Reminder Zoladex injection -12 Wks
 MR008 Reminder Prostap injection -12 Wks
 AP003 Zoladex Remind patient to book appt 10 Wks
 AP002 Prostap Remind patient to book appt 10 Wks
 MR003 Reminder B12 injection - 11 Wks
 MR002 Reminder B12 injection -10 Wks
 AIM-09. Medication Reminder - Warfarin No Q
 MR006 Reminder Depo Injection - 11 Wks
 MR005 Reminder Depo Injection - 10 Wks
 WF010 Reminder Warfarin Monitoring - 10 Wks
 WF009 Reminder Warfarin Monitoring - 9 Wks
 WF008 Reminder Warfarin Monitoring - 8 Wks
 WF007 Reminder Warfarin Monitoring - 7 Wks
2
1
1
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WF006 Reminder Warfarin Monitoring - 6 Wks
WF005 Reminder Warfarin Monitoring - 5 Wks
WF004 Reminder Warfarin Monitoring - 4 Wks
WF003 Reminder Warfarin Monitoring - 3 Wks
WF002 Reminder Warfarin Monitoring - 2 Wks
WF001 Reminder Warfarin Monitoring - 1 Wk
AIM-09. Medication reminder - Warfarin
AP001 B12 Remind patient to book appt 10 Wks
AIM-09. Medication reminder for adults and teenagers
Blue Dykes Surgery - (C81008) H
26/06/14
Protocols
 AP005 Depo Reminder every 12 weeks
 AIM-09. Medication reminder for adults and teenagers
9
2
7
Staffa Health - (C81029) H
14/05/14
Protocols
 MR009 Prostap/Zoladex Reminder every 12 weeks
 AP005 Depo Reminder every 12 weeks
10
2
8
Emmett Carr Surgery - (C81095) H
08/05/14
Protocols
 AIM-02. Hypertension poor control or newly diagnosed
 AIM-16L. hypertension 9 month check
 Weight Tracking, M-F, 10:30 ( WT/WEIGHT >2kg in 4 days)
 Hypertension Trend: 12:00 (BLOOD, BP 140-105 / 90-60)
 Meds Reminder : Every so many days @18:30
 AIM-11. COPD
3
1
2
The Village Surgery - (C81050) H
29/04/14
Protocols
 Hypertension BP Readings
 AIM-09. Medication reminder - Warfarin
 AIM-14. Overweight and obesity v2
 AIM-02. Hypertension poor control or newly diagnosed
 Aim-04 Inhaler reminder for adults and teenagers
 AIM-11. COPD
3
1
2
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Shires Health Care - (C81033) H
29/04/14
Protocols
 DT006 DCHS Injection Reminder adults (Insulin&Injectables)
 DT001 DCHS Type 1 Diabetes BG Results
 DT005 DCHS Hows your Diet going? Text
 DT003 DCHS Reminder for Blood Glucose Testing
 DT004 DCHS Hows your exercise going? Text
 DT007 DCHS Tablet Reminder for adults (Diabetes)
 DT002 DCHS Type 2 Diabetes BG Results - Insulin
 DT012 LD Blood Glucose Reading
 DT012 LD Blood Glucose Reading
 DT009 LD Take your diabetes tablet now
 DT010 LD Take your insulin now
 DT011 LD Take your blood sugar now
 DT014 Blood Glucose Reading no advice or messages
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2)
 AIM-04. Inhaler reminder for adults and teenagers
 AIM-11. COPD
 Meds Reminder : Every so many days @18:30
8
2
6
Friendly Family Surgery - (C81655) H
24/04/14
Protocols
 MR009 Prostap/Zoladex Reminder every 12 weeks
 AP004 B12 Reminder every 12 weeks
 AIM-14. Overweight and obesity v2
 Notts-Rainworth: Depo injection Reminder every 11 weeks
 AIM-09. Medication reminder for adults and teenagers
 Blood Glucose 12:00 (BG 4 - 8.2) Notts
1
1
0
St Lawrence Rd - (C81647) H
16/04/14
Protocols
 AIM-14. Overweight and obesity v2
 Peak Flow 11:00 (PEAK, PF 100 - 400)
 AIM-04. Inhaler reminder for adults and teenagers
 Smoking cessation just quit, 3-12 months
 AIM-11. COPD
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2)
 Meds Reminder : Every so many days @18:30
7
1
6
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15
Crags Healthcare - (C81096) H
15/04/14
Protocols
 AIM-09. Medication reminder for adults and teenagers
5
0
5
Clay Cross Medical Centre - (C81056) H
15/04/14
Protocols
 B12 Reminder every 12 weeks
 AIM-09. Medication Reminder - Warfarin
 AIM-09. Medication reminder for adults and teenagers
4
2
2
Limes Medical Centre - (C81099) H
03/04/14
Protocols
 (Notts N&S COPD) SATS
 smoking cessation first 3 months
 Smoking cessation just quit, 3-12 months
 Smoking cessation (contemplating quitting)
 Medication reminder for adults and teenagers
 DEMO: Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2)
 COPD
 hypertension 9 month check
 Obesity and quit smoking v2
8
1
7
Additional Information
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Total Number of GP Practices in CCG – 15
Total Number of GP Practices (Flo groups) on Florence – 15
Percentage of GP Practices on Florence – 100%
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3.3 Erewash CCG
Practice/Service
Group
Added
to Flo
21/07/15
No. of
Users
With
Without
Patients Patients
Gladstone House (C81115) E
3
Protocols
 Daily depression monitoring
 AIM-09. Medication reminder for adults and teenagers - NO Q
0
3
The Golden Brook Practice (C81083) E
02/02/15
Protocols
 HY001 Hypertension-6mths BP, 12mths review
1
5
6
Additional Information
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Total Number of GP Practices in CCG - 12
Total Number of GP Practices (Flo groups) on Florence - 2
Percentage of GP Practices on Florence – 16.7%
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3.4 Southern Derbyshire CCG
Practice/Service
Chapel Street Medical Centre (C81068) SD
Protocols
 Home Blood Pressure Reading for 2 Wks
Group
Added
to Flo
23/09/15
No. of
Users
With
Without
Patients Patients
3
0
3
1
0
1
Gresleydale Healthcare Centre (C81114) SD
27/05/15
4
Protocols
 AP008 DMARD Blood Test 3mth Reminder
 MR005 Reminder Depo Injection - 10 Wks
 AIM-09. Medication reminder for adults and teenagers - NO Q
0
4
The Meadowfields Practice (C81665) SD
26/01/15
Protocols
 PQ002 Flu Vaccination Decision Option 2
 AP008 DMARD Blood Test 3mth Reminder
 PQ001 Flu Vaccination Decision Option 1
 AIM-09. Medication reminder for adults and teenagers
 AIM-09. Medication Reminder - Warfarin
 AP004 B12 Reminder every 12 weeks
4
0
4
Somercotes Medical Centre - (C81027) SD
28/07/14
Protocols
 AIM-09. Medication reminder for adults and teenagers
1
0
1
Whitemoor Medical Centre (C81038) SD
04/06/15
Protocols
 AIM-09. Medication Reminder - Warfarin No Q
 AP008 DMARD Blood Test 3mth Reminder
Additional Information - relates only to the GP practice table above.



Total Number of GP Practices in CCG - 56
Total Number of GP Practices (Flo groups) on Florence - 5
Percentage of GP Practices on Florence -
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18
Practice/Service
Group
Added
to Flo
12/08/15
No. of
Users
Care Co-ordinator - Sarah Hanel SD
(Swadlincote Surgery)
Protocols
 AIM-09. Medication reminder for adults and teenagers
1
0
1
Care Co-ordinator - A Goodrum SD
(Jessop Medical Practice and Crich Medical Practice)
Protocols
 MR001 Blister Pack Medication Reminder
19/02/15
1
1
0
Care Co-ordinator - L Battle SD
27/01/15
(Meadowfields Medical Centre)
Protocols
 AIM-09. Medication reminder for adults and teenagers
 AP004 B12 Reminder every 12 weeks
1
0
1
Care Co-ordinator - H Riley SD
29/09/14
1
(Riversdale Surgery)
Protocols
 DEMO: AIM-09. Medication reminder for adults and teenagers
 DEMO: AIM-11. COPD v2
0
1
Care Co-ordinator - M Kirkman SD
25/09/14
1
1
(Ripley Medical Centre and Ivy Grove Surgery)
Protocols
 HY002 BP Reading 11:00 3 Days
 DT016 Blood Glucose 11:00 3 Days
 DT008 Blood Glucose 11:00 3 Days
 AIM-09. Medication reminder for adults and teenagers - 8 reminders total
 AIM-09. Medication reminder for adults and teenagers - 7 reminders total
 AIM-09. Medication reminder for adults and teenagers - 6 reminders total
 AIM-09. Medication reminder for adults and teenagers - 5 reminders total
 AIM-09. Medication reminder for adults and teenagers - 4 reminders total
 AIM-09. Medication reminder for adults and teenagers - 3 reminders total
 AIM-09. Medication reminder for adults and teenagers - 2 reminders total
 AIM-09. Medication reminder for adults and teenagers
0
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With
Without
Patients Patients
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19
Additional Information - relates to GP practices and associated Care Coordinators.



Total number of GP Practices in CCG - 56
Total number of GP Practices (Flo groups) on Florence - 9
Percentage of GP Practices on Florence – 16.1%
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3.5 Other services
Practice/Service
Palliative CNS
Protocols
 CNS Medication reminder
Group
Added
to Flo
20/10/15
No. of
Users
With
Without
Patients Patients
1
0
1
Derby City ESSD
28/09/15
1
Protocols
 DEMO: AIM-09. Medication reminder for adults and teenagers
0
1
Amber Valley & Erewash ESSD
28/09/15
4
Protocols
 AIM-01. Initial high BP reading - hypertension not yet confirmed
 DEMO: AIM-09. Medication reminder for adults and teenagers
0
4
Acute Hospital Discharge Team
Protocols
 Evening Meal
09/07/15
1
0
1
DCHS Community Respiratory Team
Protocols
 AIM-11. COPD v2
15/04/15
1
0
1
DCHS Derbyshire Heart Failure Service
Protocols
 HF001 Derbyshire Heart Failure Q & BP,P,WT
10/09/14
6
0
6
Chesterfield Royal Diabetes Team
07/04/14
Protocols
 AIM-14. Overweight and obesity v2
 AIM-08. Smoking cessation (contemplating quitting)
 AIM-09. Medication reminder for adults and teenagers
 AIM-10. Hypertension poor control, CKD or diabetes
 Blood Glucose 12:00 (GLUCOSE, BG 4 - 8.2)
2
0
2
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DCHS Community Diabetes Nurse
24/03/14
Protocols
 DT013 Drinks reminder
 DT003 DCHS Type 2 Diabetes BG Results
 DT014 Blood Glucose Reading no advice or messages
 DT011 LD Take your blood sugar now
 DT010 LD Take your insulin now
 DT009 LD Take your diabetes tablet now
 DT012 LD Blood Glucose Reading
 DT002 DCHS Type 2 Diabetes BG Results Insulin
 DCHS 007 Medication Reminder
 DT004 DCHS How’s your exercise going? Text
 DT003 DCHS Reminder for Blood Glucose Testing
 DT005 DCHS How’s your Diet going? Text
 DT001 DCHS Type 1 Diabetes BG Results
 DT006 DCHS Injection Reminder adults (Insulin&Injectables)
4
3
1
3.6 Overview
As of October 2015 there were:



Total number of users - 159
Total number of users without patients – 97
(of which the vast majority have never registered a patient)
Percentage of users without patients – 61%



Total number of GP Practices – 119
Total number of GP Practices registered on Florence - 40
Percentage of GP Practices registered on Florence – 34%

Total number of other Health Services registered on Florence – 8
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3.7 Monthly Reporting – October 2015
The chart below shows the number of active patients per CCG.
The chart below shows the percentage of GP Practices on Florence per CCG.
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The chart below shows of the practices added the percentage with active patients per CCG.
The chart below shows the number of Florence Users per CCG.
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The chart below shows of the users added the percentage with active patients CCG.
3.8 Patient Information
As of October 2015 there were:

Total number of enrolled patients – 295
(Includes active, inactive and test patients – test patients estimated at a minimum of one
per user)
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3.9 Text Message Tracking – October 2015
The chart below shows the number of text messages sent and received per CCG.
The chart below shows the number of text messages remaining.
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3.10 Current CCG KPI’s
H ND CCG Florence Plan 2015-06-07 Draft
Key Performance
Indicators (KPI's)
80% of patients who enter
onto Flo show an
improvement to managing
their health - post patient
questionnaire
75% of practices are signed
up and actively using Flo
Patients with active uptake
- 80/90% of Patients
registered on Florence actively using it
Percentage split
Push messages % split
activity
Reading interactive % split
activity
100% practices signed up
to Florence - monitoring of
practice activity and
community services
activity - Equality and
Diversity 100% practice
should be offering the
same services.
Notes/Originator
CCG
Action
ND KPI Qtly
Reporting Submission to
Rebecca Manning
Tracie Booth and Judy
Derricott
ND
ND KPI Qtly
Reporting Submission to
Rebecca Manning
Tracie Booth and Judy
Derricott
ND
Direct evaluation
of AT Funding - to
be carried out by
Florence Clinical
Lead
Overall Florence
utilisation –
available from
monthly reporting
TBC
Debbie Bennett
H
Open action – to
be put in place
following review of
monthly reporting
TBC
Debbie Bennett Actively recruitment of
patient either by the
practice or the
community services. If
community services, GP
practices need to be in
support of the
enrolment.
H
Open action – to
be put in place
following review of
monthly reporting
There is still some work to be complete in this section. The project team intend to review the
monthly reporting and complete the review of aims and objectives (and benefits) with all CCGs.
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4
Detailed evaluation of Florence usage within the DCHS Community Diabetes
Team
4.1 Members of the Team




Michelle Denyer – Lead Community Diabetes Specialist Nurse
User from 7th April 2014
93 Patients registered on Florence – October 2015
Beth Cooper – Community Diabetes Specialist Nurse
User from 7th April 2014
19 Patients registered on Florence – October 2015
Joanne Hulme – Community Diabetes Specialist Nurse
User from 29th June 2015 – newly trained, assessing suitable patients
No patients as yet, registered on Florence – October 2015
Clare Reynolds – Community Diabetes Specialist Nurse
User from 28th October 2015 – newly trained, assessing suitable patients
1 Patient registered on Florence – October 2015
4.2 General overview and application
At the end of October 2015 the Community Diabetes Team had approximately 450 patients on its
case load. At the end of the same period there were a total of 113 patients registered on Florence
STH. This represents 25% of the services case load. This number continues to rise for both the
total number of patients and the patient utilising Florence.
Florence has become an invaluable tool for the management of patient with Diabetes. Patients
referred to the diabetes service are offered Florence STH and can take advantage of a number of
different protocols it provides:




Medication Reminders – Daily Prompts
Blood Glucose Testing reminders – Daily Prompts
Blood Glucose monitoring – Type 1 and Type 2 Diabetes
Several patient specific and learning disability support/reminder messages
4.3 Key Benefits








Patients committed to monitoring their own blood glucose levels, sharing this information
with their Special Diabetes Nurse will benefit from swifter intervention
Enriched patient information
Improve/Informed clinical decision making
Quicker/earlier clinical intervention
Support patient safety
Enhanced relationships with patients
Patient conditions and outcomes improved
Works quickly to focus the patient attention on their Blood Glucose levels which often
leads to changes in behaviour and life style.
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

Significant life improvements – happier, more confident patients controlling their
condition rather than the condition control them
Reduction in levels of HbA1C leading to significant reduction risk of major complications
4.4 Reason for referral
Patients are referred to the Community Diabetes Team because their Diabetes is more complex
and there is a need for specialist care and attention. The Diabetes Specialist Nurses are adept at
managing these complexities and working with patients to improve their health and wellbeing.
Their intervention can often be significant and life changing for the patient. Florence STH has
given the team means to support patients as they learn to manage their conditions better.
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4.5 General Diabetes Patient Evaluation
4.5.1 Levels of patient interaction with Florence STH
The chart below shows how many readings patients have sent to Florence during the month of
October 2015.
This is a breakdown of the information shown above:





Only patients that were registered on the system before October 2015.
The patient will receive one message per day from Florence but have been invited to send
in their Blood Glucose readings as and when they test throughout the day.
Some patients respond directly to the text message request and only send one message
per day to Florence. Theses patient continues to monitor their blood glucose levels during
the day and the general feeling is that monitoring habits have improved and are
supporting better control.
There are two protocols at work – one directed at patients with Type 1 Diabetes and one
directed at patients with Type 2 Diabetes – both protocols work in the same way only the
advice messages vary.
In the course of one month the patients reactions to medication, implementation of
changes to their life styles can be reflected in the information sent to the clinician for
review. Decisions about care and treatment can be produced quickly increasing patient
safety and the quality of the care provided.
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







The alerts system guards against patients that are having difficulties managing their Blood
Glucose levels – Alerts are sent to clinical staff enable earlier intervention if required.
Highest number of readings per patient – 124.
Lowest number of readings per patient – 3.
Average number of readings – 46 (Blue Line on Chart).
Total number of readings received – 3343.
Total cost of readings received - £267.44
Total number of all text messages sent and received October 2015 – 13,293
Total cost of all text messages sent and received October 2015 - £1063.44
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4.5.2 Levels of growth in patient registrations
The chart below shows the growth in the number of patients added to the Florence STH from the
outset with the exception of February and March 2014 – no system data was available to that
time.
Rising Number of Diabetes Patients added to
Florence STH
140
120
100
80
60
40
DCHS decision to postpone adding patients
to Florence STH until a Quality Assessment
had been completed
20
0
Number of Patients
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4.5.3 Levels of growth in text messaging
The chart below shows the growth in the number of text messages sent and received from the
outset of the project with the exception of February and March 2014 – no system data was
available to that time.
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4.5.4 The number of alerts generated
The chart below shows the growth in the number of alerts generated and emails sent to the
clinical staff. Prior to January 2015 Florence STH was used for medication reminders only.
Number of Alerts Generated
Prior to January 2015 Florence STH was used for
Medication Reminders
700
600
500
400
300
200
100
0
Jan
2015
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Alerts
Alert observations




Highlights a patient changing or worsening condition
Evidenced based decision making – leading to changes in care plans and treatment regimes
Clinical staff have the opportunity to intervene quicker/earlier
The potential to avoid out of hours and hospital interventions
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4.6 Specific Patient Evaluation – Patient A
Patient A was register on Florence STH and started to receive and send regular text messages from
the 26th June 2015.
4.6.1 Patient A’s Story
A north Derbyshire patient was having difficulty controlling her Type 2 Diabetes. For months the
situation continued and resulted in frequent clinic appointments to try and bring her condition
under control. Following all the initial advice and guidance and as a result of the condition still
being out of control the clinical team was forced to consider medication as an intervention. The
patient was also referred to the Community Diabetes Team where she met with one of the
Specialist Diabetes Nurses, and agreed to use Flo.
After a short period of time the Specialist Diabetes Nurse was really encouraged by the readings
that the patient was sending to her. Over the coming months the patient continued to make
progress, monitoring her own blood glucose and finding that with small changes to her life style
she was taking control of her diabetes.
The patient returned to her Doctor for a review of her condition. The Doctor was able to see
significant progress had been made and decided to postpone the use of medication indefinitely.
The patient is happy to have avoided the need to take medication for what could have been a
prolonged period.
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4.6.2 Blood Glucose Reading
The chart below shows the patients’ blood glucose reading from the start of their time on
Florence to the end of the evaluation period.
This is a breakdown of the information shown above:






Desirable Range (Low) – 4.10
Desirable Range (High) – 11.00
Number of readings received – 130
Number of readings above 11.00 – 9
Number of readings below 4.10 – 1
At no point did the patient have more than three high or low (or a combination of both
high and low) blood glucose readings. The clinician received no alert emails.
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4.6.3 Cost of Text Messages
The chart below shows the cost of the text messages sent to and received from the patient during
the 19 weeks they have been using Florence.
This is a breakdown of the information shown above:


Highest weekly cost – Week 3 – £3.44
Lowest weekly cost – Week 13 & 14 – £1.12 (week 1 was an incomplete week)





Date range – 26/06/15 – 31/10/15 (19 weeks)
Total number of text messages received – 130
Total number of text messages sent – 301
Total number of text messages sent and received – 431
Total cost of text messages sent and received – £34.48






Average number of text messages received per week – 6.8
Average cost of text messages received per week – £0.55
Average number of text messages sent per week – 15.8
Average cost of text messages sent per week – £1.27
Average number of text messages sent and received per week – 22.7
Average total cost of text messages (sent and received) per week – £1.81
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4.6.4 Cost of Messages (Actual and Projected)
The chart below shows the cost of the text messages over 52 weeks, an arrow at week 19
indicates a change from actual data to projected data; these predictions are hypothetical and
assume the patient’s condition remains unchanged. The anticipated outcome of a recent HBa1C
blood test will determine any changes that are required to the management of this patient’s
condition. The projected data is based on the average cost of text messages (£1.81 per week).
Accumulated
This is a breakdown of the information shown above:


Cost of text messages for 19 weeks – £34.48
Cost of text messages for 52 weeks – £94.54
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4.6.5 Cost Comparison
The chart below shows the comparison of the weekly cost of text messages to the weekly cost of
medication (GLP1) proposed for this patient.
This is a breakdown of the information shown above:
GLP1 Treatment Costs
Compared to Text
Message Cost
Version 1
Period
Week (Avg)
Month (Avg)
Week 1-19
26 Weeks
39 Weeks
1 Year
GLP 1
18.00
78.00
342.00
468.00
702.00
936.00
Costs (£)
Texts
Variation
1.82
7.88
34.48
47.22
70.88
94.54
16.18
70.12
307.52
420.78
631.12
841.46
% Avoided
89.9
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4.7 Specific Patient Evaluation - Patient B
Patient B was register on Florence STH and started to receive text messages from the 16th April
2014. Patient B was one of the original 10 patients that joined Florence before DCHS put a
temporary hold on the use of the system. On the 12th August 2014 Patient B opted out of the
system re-joining on the 18th February 2015. One or two issues resulted in Patient B opting out of
the system again on the 19th February 2015 only to opt back in on the 25th February 2015. The
patient remains opted into the system receiving messages.
4.7.1 Patient B’s Story
Patient B has had Type 1 Diabetes for over 10 years – half of her life. Now still only 20 years old
she now has greater control over her diabetes and attributes much of her success to Florence STH.
Managing a serious long term condition has been overwhelming. Anxious about her condition and
struggled to take her medication regularly meant that she was particularly unwell and suffered a
great deal stress on a day to day basis. Still not without life’s challenger she is able to celebrate
her recent achievements and provide the project with some feedback.
Feedback has been document and needs writing up into a case study.
More information to follow
4.7.2 Medication Reminder
To help Patient B to become more compliant with their medication, Michelle Denyer set up a
number of medication reminders using Florence STH. Michelle has used a number of protocols in
search of the perfect application for this patient. Michelle and Patient B finally settle upon the
following combination of reminders.
Patient B has a 08:00 reminder to remind her to not to forget her Lantus Insulin today. This
reminder was actioned in February 2015. In August 2015 an additional reminder was added
reminding Patient B not to forget to take her Novo Insulin today. This reminder has two messages
one delivered at 12:15 and the other delivered at 17:45.
More information to follow
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4.7.3 Cost of text messages
The chart below shows the cost of the text messages sent to the patient from 25th February 2015
to the 31October 2015.
Patient B - Cost of Text Message
25/02/15 - 31/10/15
8
7
6
5
4
3
2
1
0
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Cost of Texts
This is a breakdown of the information shown above:




Total number of text messages: 543
Total cost of text messages: £43.44
Average number of text messages: 60.3
Average cost of text messages: £4.83
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4.7.4 Patient B reduction in HbA1c
In 2012 Patient’s HbA1c was 16.4% with hospital admission
In July 2015 it had fallen to 13.2%.
Last test, complete week commencing the 16th November 2015 HbA1c has come down to 8.6%
Patient B’s Specialist Diabetes Nurse wrote,
Comment to be approved
Patient B says,
Comment to be approved
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4.8 HBA1C Analysis
4.8.1 What is HbA1C
The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within
red blood cells that carries oxygen throughout your body, joins with glucose in the blood,
becoming 'glycated'.
By measuring glycated haemoglobin (HbA1c), clinicians are able to get an overall picture of what
our average blood sugar levels have been over a period of weeks/months. For people with
diabetes this is important as the higher the HbA1c, the greater the risk of developing diabetesrelated complications.
4.8.2 HbA1c in diagnosis
HbA1c can indicate people with prediabetes or diabetes as follows:
HbA1c
mmol/mol
%
Normal
Below 42 mmol/mol
Below 6.0%
Prediabetes
42 to 47 mmol/mol
6.0% to 6.4%
48 mmol/mol or over
6.5% or over
Diabetes
Source: http://www.diabetes.co.uk/what-is-hba1c.html
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4.8.3 What are the benefits of lowering HbA1c?
Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes Control and
Complications Trial (DCCT) - demonstrated that improving HbA1c by 1% (or 11 mmol/mol) for
people with type 1 diabetes or type 2 diabetes cuts the risk of microvascular complications by
25%.
Microvascular complications include:



Retinopathy
Neuropathy
Diabetic nephropathy (kidney disease)
Research has also shown that people with type 2 diabetes who reduce their HbA1c level by 1%
are:



19% less likely to suffer cataracts
16% less likely to suffer heart failure
43% less likely to suffer amputation or death due to peripheral vascular disease
Source: http://www.diabetes.co.uk/what-is-hba1c.html
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



Diabetes Retinopathy – Diabetic retinopathy is a common complication of diabetes. It
occurs when high blood sugar levels damage the cells at the back of the eye (known as the
retina). If it isn't treated, it can cause blindness.
Nephropathy – Kidney disease (or nephropathy to give it its proper name) is when the
kidneys start to fail.
Neuropathy – Depending on the cause of the peripheral neuropathy, symptoms may
develop slowly or quickly. The specific symptoms of peripheral neuropathy vary according
to the type of peripheral neuropathy you have. There are three main types:
o sensory neuropathy – affects the nerves that carry messages of touch,
temperature, pain and other sensations to the brain
o motor neuropathy – affects the nerves that control movement
o autonomic neuropathy – affects the nerves that control involuntary bodily
processes, such as digestion and your heartbeat
Microalbuminuria – a term to describe a moderate increase in the level of urine albumin.
It occurs when the kidney leaks small amounts of albumin into the urine, in other words,
when there is an abnormally high permeability for albumin in the glomerulus of the kidney.
4.9 Patient information and HbA1c levels and acheivements
The project has been provided with some detailed information regarding patients HbA1c. We are
also waiting for several patients to have blood test to see if their HbA1c levels have fallen.




Patient – A
August 2014 Hba1C was 11.1%
At the start of Florence it was 13%
Blood Test results are expected - Practice Nurse has been emailed.




Patient – B
2012 Patient’s HbA1c was 16.4% with hospital admission
July 2015 it had fallen to 13.2%.
Last test, complete week commencing the 16th November 2015 HbA1c has come down to
8.6%


Patient – C
10.10 reduced
More information to follow
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4.10 Case Study
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4.11 DCHS Voice Article – Patient Story Chris Pettett
High Peak resident Chris Pettett is enjoying the
peace of mind of having his own virtual diabetes
nurse to keep a daily check on him.
Chris, a retired chartered accountant, has been living
with diabetes for 16 years and last month became
one of the first to join our new FLO telemedicine
scheme.
FLO provides the benefit of knowing somebody is
keeping a regular expert eye on his blood sugar
readings and can head off any problems before they
start.
It involves taking a finger prick blood test once a day
and then texting the reading to FLO’s automated
system. FLO then flags up any readings which fall
outside Chris’ normal range to the diabetes nurse.
And if Chris forgets, he gets a reminder text from
FLO.
“It’s a lot easier than keeping a diary and it means
my results are reviewed regularly by the diabetes
team. It really is a 30 second job for me,” said Chris,
who lives in Combs, near Chapel en le Frith.
Once his daily blood test reading has been reviewed he will receive a response. “I usually get a
text back to say it’s fine, but if it’s too high or too low I get instructions on what to do next.
Before I started on FLO it could be weeks between my readings being reviewed at the GP.”
Chris, a grandfather to seven, ranging in age from 17 years to 18 months, would recommend FLO
as beneficial in helping to manage his diabetes. “It means I’m being monitored on a regular basis
instead of going to the doctor for a check up on a less frequent basis.”
And because it is so quick and easy, it means he can manage his diabetes around his enjoyment of
normal life. Not least of which is being involved with all his grandchildren and running a local quiz.
For a man who spent his working life with numbers it seems numbers are still playing a key role in
his retirement – at least the few digits he texts to FLO each day.
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4.12 One Patient Feedback on Flo – NHS Choices
A joint review of services provided by Imperial Road Surgery Matlock and the DCHS Specialist
Diabetes Nurse Team based at New Holme Hospital.
Staff: Louise Giblin and Michelle Denyer
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4.13 Patient Letter to DCHS Diabetes Service Manager – Jonathan Sanderson
Date: 01/06/15
Dear Mr Jonathan Sanderson,
I am writing to inform you of my experience with the new NHS Florence self-care service. I have
been an Insulin Injecting Type One Diabetic for nearly 38 years since the age of eleven.
Thirty Eight years of dealing with Diabetes has seen improvements of all kinds. No more heavy
metal needles which became blunt before use! A change from heavy metal syringes stored in
Industrial Sprit and boiled in a pan of hot water twice a week to sterilise, to a useful light weight
syringe which looks like a pen!!! No more urine testing with a test tube and tablets to give you a
reading from negative (clear through to Orange) positive, to an easy test strip which records
details.
It is amazing what time and money can do. One day there will be a cure.
All of the improvements are only as good as the Diabetic person understanding them and also
wanting to ensure that they live a pretty healthy and fulfilled life.
I can honestly say I have never really accepted the fact that I am a Diabetic. When it decided to
‘grab’ hold of me it was just another piece of the jigsaw which was not going to fit.
After years of issues in 2010 I had given up. Fortunately, I was referred to the Mental Health team
at Matlock and with their help and the Psychiatric team at the Newholme Hospital I began the
climb out of the ‘hole’
I can now talk about the child hood experiences, which lead me to having no self-worth in myself.
Then the onset of Diabetes which then made other issues more of a problem, so then leading to
Bulimic Nervosa. This will never leave me but I can now like myself more and live through the
rough patches without causing myself too much harm
Unfortunately, with Mental Health Issues and Bulimia the thing which was going to suffer was my
Diabetes Control, which then in return had bad effects on the Mental Health and Bulimia. Quite a
difficult circle to be in!!!!
Then along came my brilliant Lead Community Diabetes Specialist Nurse Michelle Denyer. Apart
from just being a really nice person she understands Diabetes so well and puts things into basic
terms which makes all the ‘ technology stuff’ easier to get your head around.
Florence the NHS self-care service nurse also came along, which for me and I am sure once more
people become aware of it will find it a useful and vital piece of Diabetic Help.
Not just because of my mental health/ eating issues but I had become very ‘I don’t care/ not
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interested/ oh I will be alright’. I would miss injections and then go all day without eating. Then I
would binge, then drink alcohol, then sometimes pass out and go to sleep or hypo and this would
then carry on for days into weeks.
I believe I have been very fortunate to have another go at life!!
Florence is not the complete answer and I believe she still needs some ‘Tweaks’ BUT it gives you
the little support/reminders which make you not take your Diabetes for granted.
The txt messages to remind you to take an INJECTION, ( I would sometimes, well quite a lot of the
time miss my lunch time injection because I was too busy working, my sugar level had been low in
the morning so I did not need Insulin at Lunch time !!!)
Txt reminders to say your Blood Glucose reading needs to be done, so much easier to do when
you are encouraged.
The txt readings which you then receive after you have sent your blood glucose reading in are a
good reminder that if you are out of your control guide lines that you may need to look for some
medical advice. This is not phoning 999 or rushing of to A&E, but perhaps getting into with your
nearest Diabetes Community Assistance.
This side perhaps need s more support but hopefully this will come with funding you may secure?
Florence is a brilliant piece of equipment. She has helped me get back on with understanding my
Diabetes. I have a long way to go and it will be a difficult road but I know I won’t keep beating
myself up about being a Diabetic, even at 49!!!
I hope my experience will help gain more funding which I know is always needed.
Please don’t hesitate to contact me if you need me to talk about my experiences or keep you up
dated on any thing.
Kind Regards
Yours Faithfully
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4.14 A patient quotation
“Even though I know it’s only a computer, I feel very
supported by my texts from Flo”
Passed to the project by Beth Cooper.
4.15 NED patient feedback – Future
Michelle Denyer has indicated that there is a patient on Florence that is happy with the service
and may provide the project with some feedback soon.
4.16 Case Study – Patient gets long term condition under control - Future
There is an opportunity to convert the patient letter, section 4.13, into a case study. Further
confirmation with the patient and staff involved is need.
4.17 Reduction of face to face appointments for newly diagnosed patients - outline
Michelle Denyer has advised the project that the number of appointments required for newly
diagnosed patients has reduced. Prior to Florence STH the patient would be invited for a series of
face to face appointments to enable the patient to be monitored closely during the first few
weeks of their referral. Patients are now set-up on Florence for remote blood glucose monitoring,
additional face to face appointments are now by exception, as Michelle can monitor the
information sent in by the patient, respond to system alerts and contact the patient by phone to
review their readings and condition. Neither the patient nor clinician needs to factor in an
appointment unless it becomes necessary.
Reduction in appointment may have led to an increase in the number of patients that they service
can deal with.
It works quickly to focus the patient attention on their Blood Glucose levels which often leads to
changes in behaviour and life style.
This area requires more investigation and review by the service.
4.18 Reduction of face to face appointments in general - outline
Similar to the initial findings of a reduction of appointments for newly diagnosed patients,
Michelle Denyer has advised the project that appointment in general may have reduced with the
introduction with Florence STH. Patient that have period of difficultly and require closer
monitoring and support and be dealt with in a similar way. Changes in treatment, life style and
medication can be monitored remotely with the same text or telephone call interventions from
the team. Where remote monitoring exists patients have less face to face appointment in general.
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This area requires more investigation and review by the service.
4.19 Joint Clinics and Integrated Care
Sharing information with GP Practice. Easy to transfer the patient to the practice from the service
and vis versa to continue care and use of Florence.
Martin practice Manager and Louise Giblin at Imperial Road
Meeting booked 30th 4pm November.
More information to come
4.20 Life without Florence
No mobile phone no information - gutted.
More information to come
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5
Southern Derbyshire Care Coordination
5.1 Micheala Kirkman
User(s): Southern Derbyshire Care Coordinator
Application: Blood Glucose Reading
Patient Story: Patient with Learning Disabilities Improved control of condition.
More information to come
5.2 Alison Goodrum
User(s): Southern Derbyshire Care Coordinator
Application: Medication Reminder
Patient Story: Reduced calls to the GP practice.
More information to come
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5.3 Case Study
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6
Ashgate Medical Centre – Early findings
Under the instruction of Sharon Dinham, Nurse Practitioner and North Derbyshire CCG Nurse
Lead, the practice has started to use Florence STH to remind patients, taking DMARD Medication,
every three months that they are due a blood test. Just over 70 patients were invited, by letter, to
have a 3 month blood test reminder from Florence. Patients were asked to contact the practice if
they wished to decline the reminders or simply ignore the welcome text sent by Florence. 29
patients out of the 70 invited consented to the text message reminders – 41.4% A further 6
patients, new to DMARD, have been added by Pharmacist Rachel Smith.
Rachel has been overseeing the patients that are registered on Florence and reports that it is too
earlier in the process to give any real feedback about its effectiveness and to hear if patients have
benefited because of the reminders. Rachel does say that the setting up of patients and the
application of the protocol is easy and takes minutes. Rachel has a link to Florence from within her
clinical system making accessing Florence as simple as possible. Rachel has recently requested an
additional protocol for patients new to DMARD so that they can have a reminder for a blood test
every month until they adjust to the medication and can change to the 3 month reminder.
Not too much to report at this stage however:
Would you recommend Flo to your Friends and Family?
Rachel received a call from a patient regarding the DMARD reminder. The patient mentioned that
their son had been offered the reminders from Florence, and had commented how useful it was.
He recommended that his Father should sign up. Now father and son, who both have conditions
that requires DMARD medication and blood test are set up to receive regular text message
reminders.
More information to come
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7
Castle Street Medical Centre – draft of 2nd December meeting
Jude Deeham has been using a serious of medication and appointment reminders.
Appointment reminders
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Reminder B12 injection – 10, 11, 12 Wks. – actual day of appointment
B12 Remind patient to book appt 10 Wks. – if appointment book unavailable
Reminder Depo Injection – 10, 11 Wks. – actual day of appointment
Warfarin Monitoring – 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Wks.
Reminder Zoladex injection -12 Wks. – actual day of appointment
Reminder Prostap injection -12 Wks. – actual day of appointment
Zoladex Remind patient to book appt 10 Wks. - if appointment book unavailable
Prostap Remind patient to book appt 10 Wks. - if appointment book unavailable
Medication reminders
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Medication Reminder – Warfarin with Questions and without
Medication reminder for adults and teenagers
Meeting with Jude Deehan 02/12/15
More information to come
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8
Areas of potential development

Ashgate Medical Centre
Asthma – stable patients pilot
Contact: Sharon Dinham and Rachel Smith
Meeting(s):
17/11/15 – Sharon Dinham
Protocol created and tested locally.
Instruction/Direction/Link: Sharon Dinham

Chesterfield Royal Hospital
Diabetes – young people pilot (recommendation from Bernie decision lies with Sarah).
Contact: Sarah Allcard Nurse Lead Diabetes CRH
Meeting(s):
18/11/15 – Sarah Allcard
25/11/15 – Jo Lacy – Head of IG CRH
Instruction/Direction/Link: Bernie O’Donnell

Young Cares/Health Watch
General Messaging
Contact: Tanya Nolan
Meeting(s):
13/11/15 – Tanya Nolan
Magazine – Carers News – Article – Kye 01773 743355
Every GP and Carer in Derbyshire – ideas: Patient Stories
4 times per year: next December 2015 closing date is 15/11/15
Carers Association in Derbyshire
Instruction/Direction/Link: Contact in PPG in Bakewell Group was at the same meeting.

Ashgate Hospice – Palliative CNS
Medication Reminders – newly diagnosed patients with cancer
Contact: Marie Leadbeater
Meeting(s):
??/??/?? – Jo has set Marie up on the system and she is testing.
Needs follow up soon.
Instruction/Direction/Link: Michelle Denyer

Community Respiratory Matrons
COPD and Asthma
Contact:
Sara Hopkinson - PA/Medical Secretary for Matrons
Meeting(s):
26/10/15 – Jo contact with team – want to start using it
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10/11/15 – Helen Farr to be moved to W/C 7th December as Jo is away.
30/11/15 – Set up staff and protocols and test. Live with patients to be confirmed.
23/11/15 – Meeting with Helen Wren (link to north Derbyshire CCG) to discuss respiratory
protocols and what her plan is to help the project. Linked to Scott Webster through CCG
join meeting.
Instruction/Direction/Link: Bernie O’Donnell and associated with Anil Ramineni DCHS
Respiratory Physio St Mary’s Court

DCHS Tissue Viability
Reminder Messages
Contact:
Trish Mahon Head of Service
Meeting(s):
01/10/15 – Meeting with Jo. Loves Flo and want to start with pressure ulcers reminding
patient to move regularly and management of grade one and two wounds
12/11/15 – Meeting with Pennine Trust to gather intel on Flo. Trish is sending someone
from her team to go with Jo or whoever will attend.
??/12/15 Review meeting with Trish.
Instruction/Direction/Link: Initiative

MacMillan Community and CRH
Contact:
TBC – do detail lady has gone away with Jo’s.
Meeting(s):
Instruction/Direction/Link: Jo at the Young Cares Event Chesterfield

Nurse Forum – North Derbyshire – in Jo’s remitted
COPD and Asthma or Diabetes
Contact:
Sharon Dinham
Meeting(s):
02/12/15 – Nurse Forum Jo to present and network following email and phone call to
nurses at practice
Instruction/Direction/Link: CCG Instruction

General Communications
o Marie-Louise Allred
Project Training/Resource Guide.
o Karen Moore
Florence Regional Event
o Dr John Grenville
Head of the Derbyshire GP association
Article in LMC GP Bulletin – Target GP’s specifically.
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9
Appendices
9.1 Self Care
9.1.1 Wagner’s Chronic Care Model
http://commonwealth.communitycarenc.org/toolkit/8/
The Chronic Care
Model was developed
by the MacColl
Institute, a registered
trademark of ACPASIM Journals and
Books.
Wagner’s Chronic Care Model identifies essential delivery system components that foster high-quality
chronic disease care: the community; the health system; self-management support; delivery system design;
decision support; and clinical information systems. Evidence-based change concepts under each
component encourage productive interactions between informed patients who take an active part in their
care and providers who have the appropriate resources and expertise to serve these patients.
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Self-Management – Patients have a central role in determining their care, fostering a sense of
responsibility for personal health.
Decision Support – Health care organizations integrate into the day-to-day practice of the primary
care providers explicit, proven guidelines for care. These are provided in an accessible manner.
Delivery System Design – The ideal care delivery system empowers providers to determine the care
patients need and clarifies provider roles and tasks to ensure that patients receive that care. The
system must also guarantee that all patient-facing clinicians have centralized, current information
about a patient’s status. Follow-up must be part of clinicians’ standard procedures.
Clinical Information System – A registry or similar information system capable of tracking individual
patients and patient populations is necessary to chronic illness management and preventive care.
Organization of Health Care – Health care systems can create environments in which chronic care
improvement efforts take hold and flourish.
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
Community – To improve the health of the population, health care organizations must reach out to
form alliances and partnerships with state programs, local agencies, schools, faith organizations,
businesses and clubs.
9.1.2 Factors to strengthen the promotion of Patient Self-care as an integral part of the
healthcare system.
Why is it important?
 Around 15 million people in England have one or more long-term conditions. The number of
people with multiple long-term conditions is predicted to rise by a third over the next ten years
(Department of Health 2011c).
 People with long-term conditions are the most frequent users of health care services, accounting
for 50 per cent of all GP appointments and 70 per cent of all inpatient bed days.
 Treatment and care of those with long-term conditions accounts for 70 per cent of the primary and
acute care budget in England (Department of Health 2011c).
 At the heart of the chronic disease management model (Wagner et al 1996) is the informed,
empowered patient with access to continuous self-management support.
 Around 70-80 per cent of people with long-term conditions can be supported to manage their own
condition (Department of Health 2005).
Source: http://www.kingsfund.org.uk/projects/gp-commissioning/ten-priorities-forcommissioners/self-management
9.1.3 Self-Management for Life
It promotes:
 sustainable ongoing support for self-management
 person-centred approach
 patient engagement
 partnership between healthcare professionals and patients.
Patients gain:
 skills to self-manage for life
 tools & techniques
 peer support
 increased confidence in their ability to self-manage and make decisions
 better knowledge of their condition and how the healthcare team can help them
 better quality of life
Health professionals and clinicians gain:
 useful skills for managing consultations and preparing personalised care plans with
patients
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


practical approaches to help safely share responsibility with patients for managing their
condition
self-management enabling tools including goal-setting, action-planning, follow-up,
problem-solving, agenda-setting
increased understanding of the patient perspective and opportunity to explore a more
collaborative approach
Source: http://selfmanagementuk.org/services/self-management-life
9.2 Integrated care, continuity of care and individualised patient care
9.2.1 Fulop’s Typologies of Integrated Care (from Lewis et al 2010)
http://www.nuffieldtrust.org.uk/sites/files/nuffield/evidence-base-for-integrated-care251011.pdf
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9.2.2 Intensity of integration (Shaw et al 2011, p15; after Leutz 1999)
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9.3 More information on the impact of lowering HbA1c
Lower HbA1c linked with dramatically reduced risk of
diabetes complications
Mon, 24 Jun 2013
It is 20 years since the results of the Diabetes Control and Complications Trial (DCCT) were
first published and the results show emphatically that good diabetes control lessens the
likelihood of developing long term complications.
The DCCT trial was a 10 year trial started in 1982 to investigate'' whether achieving good
blood glucose control would reduce the likelihood of developing long term complications
in type 1 diabetes.
During the DCCT trial, patients were given intensive diabetes therapy which included
testing blood glucose levels and taking insulin multiple times per day.
Patients from the original trial have continued to be monitored and in 2013, over 30 years
after patients were enrolled onto the trial, the numbers of complications have been
reviewed again.
The findings show that patients which have maintained lower HbA1c readings of 53
mmol/mol (7%) or below had significantly lower risks of kidney damage, retinopathy and
cardiovascular problems.
The follow up in 2013 showed that patients on intensive therapy showed the following
results compared with patients not on intensive therapy:
� A 57% reduction in heart disease, stroke and cardiovascular death;
� 39% lower incidence of early signs of kidney damage (microalbuminuria);
� 61% lower incidence of higher levels of protein in the urine (macroalbuminuria);
� 46% lower risk of retinopathy.
The trial results offers hope and shows that by achieving good blood glucose control, the
risks of developing complications can be greatly reduced.
Source: http://www.diabetes.co.uk/news/2013/Jun/lower-hba1c-linked-with-dramaticallyreduced-risk-of-diabetes-complications-97539739.html
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1 percentage drop in HbA1c lowers risk of kidney failure by a quarter
Wed, 11 Jun 2014
Researchers from Joslin Diabetes Center have shown that improving HbA1c has a
substantial effect on reducing the risk of kidney failure in type 1 diabetes.
The study reviewed patients at higher risk of end stage renal disease (ESRD) for up to 15
years. 349 participants with type 1 diabetes and chronic kidney disease (CKD) at stages 1 to
3 were reviewed over the course of the study. At the start of the study, all participants had
relatively poor blood glucose control, with an average HbA1c of 9.3% (78 mmol/mol).
Kidney disease (nephropathy) is one of the main complications of diabetes and there are 5
stages of chronic kidney disease. Stage 1 of kidney disease is where the kidneys are
operating normally with the exception of higher than normal levels of protein in the urine.
At stage 3, functioning of the kidneys will be moderately reduced. Stage 5 marks end stage
renal disease ESRD where the kidneys require either dialysis or a kidney transplant to keep
living.
The researchers monitored levels of HbA1c and progression of CKD in the participants. The
researchers noted that whilst a review of kidney health after 5 years showed no clear
difference between those with improved diabetes control and those with unimproved or
worsening control, at the 10 year and 15 year stages, risks of suffering kidney failure were
significantly reduced in participants with better control.
When statistical analysis was applied, the researchers showed that each 1% (11 mmol/mol)
drop in HbA1c levels, the risk of developing end stage renal disease was reduced by 24%.
The results emphasise the importance of maintaining as good control of type 1 diabetes as
possible.
Even if your control is significantly above the recommended target of 48 mmol/mol (6.5%),
don't be disheartened as achieving and maintaining a modest reduction of HbA1c by 10 or
20 mmol/mol can make a big difference in lowering your long term risk of kidney failure.
Whilst type 1 diabetes can be a difficult condition to manage, even small changes to
improve control can give you better results and more confidence to make further changes
to further improve your control.
Source: http://www.diabetes.co.uk/news/2014/Jun/1-percentage-drop-in-HbA1c-lowersrisk-of-kidney-failure-by-a-quarter-97951114.html
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