NHS Stoke on Trent
Flo telehealth: a key element of
registeredintegrated
patients, care
54 GP practices
• 270,000
Professor Ruth Chambers OBE, GP
• 2 new GP practices
and
GP
led
Health
Centre
& Clinical Telehealth Lead, Stoke-on-Trent
CCG
planned for 2009
and
• Some of the most deprived
Phil O’Connell,
wards in England,
NHS Innovator of the Year
• 5 PBC clusters closely
aligned
with
Staffordshire
and Lancs
CSUthe Local
Authority neighbourhood areas
I see it hasn’t taken you long to get up to speed with the new mobile
telehealth service
It’s about the basics
improving delivery of best practice care
Best clinical
practice &
shared
management
Improved
QUALITY
of clinical
care
Tech
3
Simple Telehealth
developing the eco-system
Apps &
digital
Telehealth
Partners
Clinical
systems
Devices
Simple
Telehealth
& Florence
IP Licensing
Professional
services
Clinical
Community
= NHS enabler
4
simple & instinctive, helping patients to help themselves
£ free to txt
all my
teams
Readings &
answers
Opt-in/out,
prompts,
questions,
feedback,
advice,
education
Alerts if needed
5
6
Working with industry
Designed for collaboration
Enabling an industry &
academia ecostructure, building on
the core
7
Behaviour change techniques via Flo across patient pathways
• individual feedback on personal health measures
• social support – ‘Flo’
• information on consequences of behaviour
• information on tailoring behaviour
• tailoring – selected messages to patient, timing, frequency
• goal setting (behaviour, outcomes)
• relapse prevention
• follow up prompts
• clinician overview – giving assurance, titrating treatment
• prompted self monitoring of behaviour
(Free C, Phillips G, Galli L et al. The effectiveness of mobile-health technology based health behaviour…..
PLOS Medicine 2013; 10 (1) )
Asthma/COPD inhaler reminder protocols x 2 (key elements):
• Inhaler reminder (adult- asthma or COPD) x 2 reminders per day
• Inhaler reminder (child/parent) x 2 reminders per day
(Phase 2 when NHS team confident – poor control asthma (adult); poor control
(child/parent); COPD (support and trigger standby rescue medication if early warning
of deterioration): all interactive for 3 months + health promotion information
messaging
That’s Flo reminding me to give you your inhaler. Now, if only
she could sort out your gym kit and packed lunch, too...
Risk profiling your COPD patients
Level 3: High
Complexity
Case
Management
Level 2: High risk
Disease/Care
Management
Low cost, large-scale: ‘simple
telehealth’
Level 1:
70-80% of LTC population
Self care support/management
Flo says my oxygen level’s normal today, so I think I’ll have a fag...just
kidding!
How Flo Simple Telehealth can support the whole patient pathway
Supporting
people at
home
Enhanced
support at
home
Specialist
acute
input
Manage Crisis
Effectively
Manage step
down from acute
effectively
Enhanced
support at
home
Supporting
People at
Home
Home
Home
Support*
Long term
hypertension
Smoking
Cessation
Long term vital
signs monitoring
Care Homes
Pain Mment
Medicines
Management
“Worried Well”
INR
Weight loss
motivational
messages
Health self
assessment
Sexual health
Crisis
Unstable
Hypertension
EMAS unstable vital
signs monitoring
Newly diagnosed
hypertension
Oncology
Medication
Reminders for: Hypertension /
Ashma inhaler /
pain management
Paediatric ashma
COPD
Diabetes (type1& 2)
Neurology
Speech therapy
Acute
Pregnancy induced
hypertension
Virtual Wards
Gestational diabetes
Intermediate
care
COPD
CHD
Alcohol support
Learning disabilities
Mental health behaviour
Mental Health appt &
medication reminders/
supportive messages
Diabetes
physiotherapy
Monitoring of pre op
patients to reduce
cancelled operations
Daily living/ medication
reminders for people
Palliative care carer with Aspergers/autism
support/wellbeing
Out patient acute
specialist follow up
Falls prevention
Support early discharge
Heart Failure
Trf of care
DNA management
Step down
facilities
Unstable vital
signs monitoring
Medication
management
Support
Long term
hypertension
As *
Smoking
Cessation
Long term vital
signs monitoring
Care Homes
Pain Mment
Medicines
Management
“Worried Well”
INR
Weight loss
motivational
messages
Health self
assessment
Sexual health
Palliative Care
HF Nurse
HF Nurse Support
ECHO
Primary Care Core
GP Service
Practice Nurse
District Nurse
Urine
Analysis
Full Blood
Community
Matron
GP
Patient
Self Care
Weight Management
Fluid Restriction
Symptom Monitoring
Lifestyle Changes
17
Any risks from increased focus on
remote monitoring of clinical
conditions?
Enriching self care as agreed shared
management
The Flo effect: helping people to help
themselves – as agreed with their
clinicians – throughout all
tiers of care
Integrated care: right
treatment, right delivery, right
time, right team, right intensity
Personal responsibility & self care
What can AHSN investment achieve by March 31st 2014
(midnight!) via Flo Telehealth exemplar?
• Model, trial & disseminate Flo across patient pathways for asthma – self care,
schools, general practice, acute care, community care settings, includes:
* inhaler reminder
* step up Rx
* step down Rx
• Model, trial & disseminate Flo across patient pathways for COPD – self care, care
homes, general practice, acute care, community care settings, includes:
*inhaler reminder
*trigger standby rescue medication
*lifestyle advice
• Model, trial & disseminate Flo across patient pathways for hypertension – self care,
care homes, general practice, acute care, community care settings, includes:
* opportunistic findings of raised blood pressure
* enhanced control of hypertension eg pre-operation, after myocardial
infarction