Workforce Impact in Practice (WIP) – Capture Template
Title of Workforce Project or
Initiative
Tele-Health: Implementing the FLORENCE text messaging
service for patients who have Mild Cognitive Impairment
and early stage dementia.
Name of Lead organisation
(and any partners)
North Staffordshire Combined Healthcare Trust, Simple
Tele-Health, Stoke CCG
What was the workforce
issue you were trying to
address?
One of the interventions offered by the Stoke early
intervention in dementia team is to assess and assist
patients in the self-management of their vascular risks.
Uncontrolled vascular disease is now known to increase
your chances of developing dementia (Bowler and Jorm
2002) and for patients already diagnosed with early
dementia uncontrolled vascular risks may accelerate the
progression of the disease (Mielke 2007). Mental ill health
or stress is also identified as an important risk factor for
vascular disease (Chen 1999). Every patient who is seen
by the team is offered a personalised vascular risk
management which is a patient held record called the
“Take Heart” booklet. The service also provides
psychological therapy to help with coexisting mood
disorders with the inclusion of five ways to wellbeing
guidelines as part of the interventions offered.
As with the nature of mild cognitive impairment (MCI) and
early dementia, cognition and short term memory are often
compromised and patients were reporting that they had
forgotten important information discussed in their clinical
sessions. The team were looking for solutions in order to
help support and provide reminders and prompts for
patients to improve engagement of patients in their
treatment plans.
FLORENCE (Flo) provided by Simple Tele- Health and
operated by Stoke CCG has been actively used within
Stoke On Trent in primary care and has been found to be
cost saving, effective and most importantly patient
feedback has been positive . It has been designed to
enable patients to dual manage their own conditions
treatment or lifestyle. Flo text messaging service also
collects, monitors and trigger alerts and collates patient
responses about their experiences with targeted
messages.
It was postulated that this type of Tele-Health text
messaging service could provide a useful platform to act as
a gentle reminder, scaffold and prompt for patients who
may struggle with memory difficulties and thus improve
outcomes.
How did you address this
issue?

The team held a number of meetings with the
Simple Tele-Health lead to ascertain if the team
objectives could be achieved using the Flo system.

The team clinicians wrote and completed two
protocols which included an interactive anxiety
mood measurement tool and a vascular risk and
wellbeing management plan.
Focus group



The team took the two protocols to a patient focus
group. The proposed protocols were shared and
feedback obtained. It was suggested that
participants may be unhappy to receive all the
health promotional messages written into the “Take
Heart” protocol and would prefer them to be tailored
to their particular needs as identified in their
individualised management plan. From the groups
perspective this would herald the best chance of
engagement.
They also suggested that due to poor memory and
concentration difficulties reminders would be
extremely useful and may prompt patients to use
their management plans more frequently.
Following the focus group a protocol review was
held with the Simple Tele-Health team to ascertain
if a more tailored protocol could be achieved and it
was suggested by them to split the risk factors into
different protocol sections 1,2,3,4,5 (see chart
below).
Diagram 1

Each patient would be allocated to the protocols
that were pertinent to their individual vascular risks
on registration. For example a patient who was
struggling with smoking and sedentary lifestyle
would be assigned to the smoking (1) and exercise
(5) protocols only. All patients were allocated to the
wellbeing messages (1).

Following the re-draft and peer review by the
Simple Tele-Health team the protocols were
uploaded to the Flo system.
Prerequisite for using Flo
 A random sample of ten patients were invited to
participate in Flo. Eight patients verbally
consented.
 All patients had a diagnosis of MCI or early
symptoms of dementia and also had a co-existing
anxiety disorder.
 The patients all received a number of clinical 1:1
sessions including a full assessment, agreed to a
joint management plan and had a completed copy
of this in their “Take Heart” booklet personal hand
held record and management plan.
 Patients completed a written consent form and were
reminded they will be receiving an interactive
automated text messaging system and not
interacting directly with a clinician.
 A leaflet was designed and provided for patients
explaining what Flo is and how to respond to any
text messages sent to them and what to do if they
wished to withdraw consent and stop the message
service.
Protocols
 The patients were allocated to the protocols which
reflected their individual clinical needs.
 Messages would be sent daily for a six week period.
However patients could be reallocated to the
protocols if this was requested by them and there
was a clinical need.

Patient received informational and / or interactive
daily messages. They may receive more than once
message a day depending on the number of
protocols allocated.
.
 The patient responds to the interactive text
messages and the evaluation questions.
Workforce / clinicians role
 Obtains patient’s signed agreement to respond to
Flo.
•
Enrols patient on to Flo by using the patient’s
current mobile phone number and NHS number.
 Evaluates the effectiveness of the Flo messaging
system by monitoring patient feedback.
 A number of evaluation questions were asked via
the Flo text messaging service including the friends
and family test.
 The Warwick and Edinburgh Wellbeing Scale
(WEMWBS) was also administered pre: enrolment
to the protocols and post completion
Optional question-Did you
use any products or
services to help you?
What did you achieve?


Development of two text messaging protocols:



What was the project’s
impact?
What was the WIPS impact?
“Simple Tele-Health” which uses the FLORENCE
web based text messaging service.
The NHS change model
Interactive mood measures for anxiety patient are
able to send in their daily anxiety ratings and
receive a text message response with tailored
advice dependant on their rating. This is now being
used with patients receiving psychological therapies
(CBT / ICP) within the service.
A “Take Heart” Vascular risk and mental wellbeing
management plan protocol providing health
promotional and motivational information
messages tailored to the individuals specific needs
A full evaluation from CESU of the effectiveness of
Flo including quantitative and qualitative data.
Costs
Set up costs £3,700 – factoring in staff time /
administration. However once the protocols were complete
and uploaded costs were minimal (based on 8p per text
message sent)
Workforce
 Clinical time (activity) was reduced as staff were
spending less time in sessions on reminders,
prompting, repeating information and revisiting
areas within treatment and management plans as
patients recall was improved due to the text
messages. This was possibly increasing



productivity by reducing the amount of activity spent
on this particular interventions.
Flo collated patient readings in “real time” and
alerted staff when readings were high. Readings
were shared with patients at the next clinical
session.
Increase in team cohesiveness and motivation as
clinicians found Flo very easy to navigate and use
and once protocols were loaded took surprisingly
very limited clinical time.
This project has provided an introduction to the use
of Flo within the Trust which has raised other team’s
interests in using this tool in their particular areas.
Patients empowerment
 Increased understanding and knowledge about their
current management plan
 Improved self- management of physical and
psychological health
 Greater understand how to self- measure, rate and
use interventions to manage and reduce their
anxiety levels and vascular risks.
 Improved mental wellbeing WEMWBS scores
increased in all but one of the participants ( see
diagram 2)
Diagram 2

Positive feedback was received from patients
through structured interviews and the consensus
was that they enjoyed receiving the messages with
statement such as “it feels like someone cares
about me even though I know it’s a computer.”
 All agreed that they would recommend the Flo
protocols to a friend or family member.
 Two patients requested to be reallocated to the
protocols following its completion.
Service delivery
 Flo Tele-Health has become an enhancement to
assessment and treatment as part of the current
service pathway
Quality
 Provides patients with additional treatment choices.
 Allows patients the opportunity to continue to
engage with their management plan and treatments
outside of clinical sessions.
 Introduces remote monitoring

Hints and tips for others


What will you use the prize
for?
Name and Contact details of
person completing template
Facilitate a focus group! This was immensely
beneficial and potentially time and cost saving.
Providing a fair critique of the protocols and
providing valuable feedback prior to the completion
and upload of the protocols. It also puts the patients
at the heart of any service improvement.
Use the NHS change model. It’s really useful for
thinking about small scale changes too.
Don’t be afraid to explore the use of Tele-Health in
mental health services.
Following this project the team in partnership with Simple
Tele-Health were inspired to look towards using the Flo text
messaging service in combination with another well
researched telehealth technology that supports
autobiographical memory recall in patients with MCI / early
stages of dementia. As part of this patients would need to
review information electronically on a frequent basis (at
least 3-4 times weekly) It is proposed that the Android
Tablets would be used with patients and the staff involved
in this project for that purpose and as a communication tool
possible accessing tele: conferencing.
Name: Lisa Sharrock
LisaA.sharrock@northstaffs.nhs.uk
Title:
CBT Therapist /RMN /Team Manager
Organisation:
North Staffordshire Combined Healthcare Trust
Harpfields Road
Stoke On Trent
Staffordshire
ST4 6RR
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