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Innovation 'Elevator Pitch':
Florence is a sophisticated digital platform used to deliver personalised, targeted behavioural psychology-based messaging, interacting with patients as the friendly non-judgemental persona, “Florence” through familiar and accessible SMS texts.
Overview of Innovation:
The NHS owned “Simple Telehealth” methodology on which Florence is based, has challenged clinical thinking about the role and effectiveness of messaging in healthcare, delivering better & faster clinical outcomes by improving patients’ motivation, engagement & adherence to their best practice healthcare regime.

100,000+ patients on from inception, Florence continues to stand out by consistently producing independently evaluated positive results across wide-ranging clinical applications irrespective of patients’ age, ethnicity, socio-economic background or clinical setting.

With an active not-for-profit Community of Practice & extensive independent evidence base including multi-region economic evaluation, Florence has already been applied within mental health cohorts targeting local needs & priorities, some examples here http://www.simple.uk.net/system/app/pages/search?scope=search-site&q=mental+health

The integration of Florence into a psycologyical therapies pathway at King's Mill Hospital, Nottingham has been shortlisted for 2019 HSJ "Innovation in Mental Health" award "Enhancing psychological therapy for cancer and palliative care patients and relapse prevention: a digital health intervention" I am happy to introduce you to the Clinical Psychology Lead, Dr Sam Malins for an independent discussion.

The Simple Telehealth methodology is based on simple, interactive, practical & academic behaviour change principles designed to deliver a low cost approach for the NHS. It is the intelligent mixture of the almost invisible technical platform, subtle methods and psychology that invoke responses from patients akin to engagement with their own clinician that results in such high satisfaction and efficacy. The methodology balances the needs of the clinical community with the everyday needs of patients & their aspiration to carry on life as normally as possible despite having a condition that needs regular and consistent management.

Florence allows clinicians to design specific protocols for large cohorts or an individual patient, where a patient’s health will benefit with improved health literacy or improved adherence to a shared clinical management plan. Once enrolled, interactions can be personalised to suit the complex needs of an individual patient or left to follow templated best practice guidance, such as for diagnosis of hypertension.

Florence creates a genuine partnership between professionals and patients, moving towards shared responsibility for health
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
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Innovation 'Elevator Pitch':
Florence is a sophisticated digital platform used to deliver personalised, targeted behavioural psychology-based messaging, interacting with patients as the friendly non-judgemental persona, “Florence” or "Flo" through familiar & accessible SMS texts
Overview of Innovation:
The NHS owned “Simple Telehealth” methodology on which Flo is based, has challenged clinical thinking about the role & effectiveness of messaging in healthcare, delivering better & faster clinical outcomes by improving patients’ motivation, engagement & adherence to their best practice healthcare regime. 

100,000+ patients on from inception, Flo continues to stand out by consistently producing independently evaluated positive results across wide-ranging clinical applications irrespective of patients’ age, ethnicity, socio-economic background or clinical setting.

With a not-for-profit Community of Practice & extensive independent evidence base, Flo is consistently integrated within treatment pathways across a breadth of diabetic patient cohorts targeting local needs & priorities, some independent outcomes here 

Many of Flo's patients experienced difficulties in managing their diabetes or were at high risk of further complications or exacerbation if their diabetes remained uncontrolled. Patients & clinicians reported experiencing a number of self management challenges that Flo now addresses:
  • Avoidable diabetic diagnosis
  • Adherence to blood glucose monitoring & self management advice
  • Titration of insulin
  • Confidence to administer own insulin as prescribed
  • Understanding diabetes for newly diagnosed patients & how dietary/lifestyle changes can significantly impact on clinical outcomes
  • Motivation to commit to lifestyle changes
  • Compliance with the administration of prescribed medications, including insulin
  • Increased acute admissions due to complications caused by uncontrolled diabetes
  • Management of associated comorbidities eg. diabetic foot care
The Simple Telehealth methodology is based on simple, interactive, practical & academic behaviour change principles designed to deliver a low cost approach for the NHS via an intelligent mixture of the almost invisible technical platform, subtle methods & psychology that invoke responses from patients akin to engagement with their own clinician.

The methodology balances the needs of the clinical community with everyday needs of patients & their aspiration to carry on life as normally as possible despite having a condition that
a) needs regular & consistent management or
b) displays indicators towards a disease diagnosis that may be avoidable with patient sustained behaviour change and/or improved health literacy. 

Flo creates a genuine partnership between professionals & patients, moving towards shared responsibility for health.
 
 
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Mental Health: recovery, crisis and prevention / Long term conditions: a whole system, person-centred approach / Advanced diagnostics, genomics and precision medicine / Wellness and prevention of illness / Education, training and future workforce / Wealth creation / Clinical trials and evidence / Digital health / Innovation and adoption / Patient and medicines safety / Person centred care
Benefit to NHS:
Patients increase their motivation, involvement and therefore engagement in the shared management of their health and consequently improve their clincial outcomes, faster.

Whether this be in becoming more engaged and adherent with pre-diabetic medication, commiting to and sustaining lifestyle changes recommended through face to face clinical contact or post diagnosis management of their diabetes and/or comorbidities. By following clinical guidance more thoroughly and developing what typically become sustained behaviour changes, both the patient and NHS benefit.

Since meeting Flo, patients demonstrate that her relevant, real time advice, aligned to their health is motivating them to become more engaged and regain a feeling of control over their likelihood of becoming diabetic/ their diabetes and consequently lives again. Flo will target the key risk factors for the patient as identified by their clinician, personalising care and prioritising the focus towards that which will deliver the greatest impact.
- Reduction in the likelihood of avoidable diabetes diagnosis as a result of non compliance to healthcare advice
- Reinforcement of management strategies to help patients take control of their lifestyle
- Improved sense of control of patient's own health and avoidance of interia due to feeling overwhelmed
- Improved feeling of support to implement lifestyle changes and accountability to their clinician when going about day to day life
- Can provide clinicians with additional insight into patients’ subjective measurement of their lifestyle changes to inform clinical sessions
- When targetted, improved risk reduction for modifiable diabetic risk factors
- Reduction in costs to the NHS associated with additional clinical sessions required as a result of a prolonged pathway to behaviour change and/or subsequent treatment post diabetic diagnosis.
- Reduction in DNA rate for clinical appointments where poor health engagement increases likelihood of non attendance
 
Initial Review Rating
4.60 (2 ratings)
Benefit to WM population:
Flo provides a low cost and scalable opportunity for population health coverage targetted at solving local challenges where improved engagament and adherence would impact on both the patient and service. Flo requires the patient to have only a basic mobile phone so is accessible and familiar and has high levels of patient and clinician acceptance. Flo is free for patients to use in the UK.

Flo provides an opportunity for a consistent digital tool to become familiar to patients regardless of their condition as can be applied across many patient cohorts. This also broadens the scope of Flo's use as additional protocols targetted at  subsequent patient and/or service need can be introduced as required.

Pre-diabetic and diabetic patient cohorts where supported by Flo feedback signifcant quality of life improvements as a result not only of becoming more compliant with preventative or treatment regimes but also of not feeling alone, feeling supported and connected to their clinician when the go about their day to day lives.
The reduction in the likelihood of a diabetic diagnosis has wide ranging savings for the NHS. The trajectory toward further complications when diabetes is diagnoses or remains poorly controlled is inevitable . Poorly controlled diabetes increases the risk of amongst others cataracts, glaucoma, various foot complications, cardiac and kidney complications are also more likely. All of these complications can be avoided or have the date of onset delayed by maintaining stable blood glucose levels. The reduction in cost implications and clinical impacts are significant.

 
Current and planned activity: 
Flo is currently commissioned by NHS organisations to support their patients and services according to local challenges. Once commissioned, support is included to develop pathways integrating Flo targetted at local priorities or to access the learning from existing applications withi the Simple Telehealth Community of Practice. Critically, being part of the Community of Practice means uses need to be evidence based so the design of uses, evidence and sharing studies and evaluation is key to the whole community. The culture is that it is as important to share what doesn't work as what does work and how that has been achieved. Our primary objective is to invest in organisations for the long term to continually increase their capabilities to ensure patients and the organisation benefit from evidence based implementations for the lowest possible cost. Our commitment to do the right thing for the right reasons for the benefit of patients.
 
 
What is the intellectual property status of your innovation?:
The NHS Stoke-on-Trent owned Simple Telehealth methodology including patent GB2483829, encompasses the design and methods to implement and exploit a sophisticated digital platform to deliver personalised, targeted behavioural psychology-based messaging, interacting with patients as a friendly, non-judgemental persona
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
2 years
Ease of scalability: 
4
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Overview summary:
Technology Enabled Care Services (TECS) can transform the way people engage in and control their own healthcare. One method is Florence Simple Telehealth (Flo), a mobile phone text service. WMAHSN has supported Flo as an exemplar of technology in healthcare, providing resources and training for participating organisations.
Challenge identified and actions taken :
The UK’s diversity means that traditional methods of communication between clinician and patient are changing. Technology Enabled Care Services (TECS), such as telehealth and self-care apps, have the potential to transform the way people engage in and control their own healthcare, allowing citizens to monitor their health and activity levels by themselves, so the need to take up valuable clinician time is no longer necessary. One TECS method is Florence Simple Telehealth (Flo), a mobile text service to communicate with patients. A free mobile texting service, it is easy to use and was designed by NHS professionals to provide support and advice for patients to manage their own health conditions. Flo give prompts and advice and helps to monitor vital signs. Flo is being promoted to the whole population of West Midlands via all 22 CCGs and some acute and community trusts, alongside other forms of TECS:
  • CCG intelligence packs
  • Staying Independent online checklist
  • apps (COPD, asthma and diabetes type 2)
  • Skype and social media online toolkits (with some direct expert support)
  • general awareness of Flo with some support and resources for COPD and asthma.
Impacts / outcomes: 
  • Integrated care development continues across participating organisations and now with other interested organisations e.g. interest from community pharmacies in Flo protocols to support the delivery of their New Medicines Service and Medication Use Reviews to support patients, better medicines optimisation and improved patient experience, and avoided healthcare usage
  • A vision of how TECS underpins integrated care has been published (Tackling Telehealth 2) which describes different definitions of integrated care and how Flo and other TECS fit in. The draft paper received broad acknowledgment from clinicians around the country and key TECS leads at NHS England. This paper covers the transformative role that TECS can play in creating integrated health and social care systems based around the patient
  • Since organisations (CCGs/trusts) took out WMAHSN-related project licences - between April 2014 and March 2015 - 2,489 patients had signed up to Flo, with some CCGs and trusts initially piloting Flo on Stoke-on-Trent CCG’s overall Flo licence prior to their own project licence being funded
  • The service hosted events across the West Midlands region - Stafford, West Bromwich, Coventry, Shrewsbury and Worcester - to raise awareness of the range of technology that can support common long term conditions, including COPD, asthma and diabetes, and redress adverse lifestyle habits, using social media, apps, Skype and telehealth. The events were aimed at general practice teams (practice managers, practice nurses and GPs), CCGs and acute and community trust staff. The events covered creating TECS in the NHS and digital delivery in workplace. The events were attended by more than 200 delegates from a wide range of health professionals, GPs, practice nurses, CCG managers and trust representatives. The project team was also pleased to have received the support from the Managing Director of the WMAHSN, who attended the Shrewsbury event
  • Heart failure (HF), diabetes and community pharmacy Flo protocols are ready for use. The HF protocols are related to an integrated care project between acute and primary care to upskill GPs in the titration of HF medication. Flo protocols have also been developed with a mental health trust and are now being deployed for pre-vascular dementia, mood management and depression. Pilot protocols being evolved or used are pre-bariatric surgery weight loss, multiple sclerosis, community and secondary care pharmacies– new medicine and medication review services, wound fluid discharge, enuresis and informal carers’ stress.
  • There is a wealth of additional interest and further innovations:
  • primary care interest in proactive/preventative monitoring of acute HF patients through monitoring of patient submitted data, blood pressure, weight etc.
  • wound fluid discharge monitoring in a community setting, alleviating time for clinician to attend patient home purely for this purpose
  • acute pharmacy interest in stratifying patients through A&E attendance due to medication issues and using Flo to support the patients with their medicines regime for a period of time post discharge
  • anxiety/stress management for carers to support their wellbeing, therefore reducing the chance of failure of care
  • Matched funds from Stoke-on-Trent CCG has supported the evolution of the TECS Staying Independent Checklist, a resource to allow health and social care and other professionals, during assessment of an individual’s support needs, identify what TECS are available and suitable for them
  • Organisations are keen to learn about broader work around TECS and the programme provides a good opportunity to share, promote and relate learning including Skype, child and adult asthma avatar apps, the TECS referral pathway and other WMAHSN projects including STarT Back, the Manage Your Health app and COPD primary care training, so the Flo programme has developed a wider TECS scope
  • The extensive networking undertaken created further interest, links and opportunities in the Flo exemplar project and related TECS
  • The capture of patient outcomes has been included in the evaluation with standard feedback captured at point of patient sign up to Flo and at termination and determined points in the Flo protocols.
  • The team is also working with each participating organisation to capture and evaluate their patient case studies to build a body of qualitative evidence to share and use to promote further the benefits of Flo
  • The Flo data will be used to review patient adherence to protocol/pathway and, dependent upon the LTC, determine any sustained patient outcomes e.g. blood pressure, improved inhaler use
  • There is a focused evaluation underway.
Which local or national clinical or policy priorities does this innovation address:
From the NHS Five Year Forward View: • Incentivising and supporting healthier behaviour • Targeted prevention • NHS support to help people get and stay in employment • Empowering patients • Out-of-hospital care needs to become a much larger part of what the NHS does • Services need to be integrated around the patient • We should learn much faster from the best examples, not just from within the UK but internationally • As we introduce them, we need to evaluate new care models to establish which produce the best experience for patients and the best value for money.
Supporting quote for the innovation from key stakeholders:
Jeff, Flo service user: “FLO resembles a friendly, good natured and trusted member of the family. I feel more able to cope and more confident about the future. Most importantly, it helps me cope with my situation.”
 
Sarah, Lead Nurse for respiratory medicine (general practice): “The app has excellent content, is quick to download and ensures patients have their asthma management plans with them all the time, rather than at the back of a drawer. Inhaler technique is key to managing asthma and the avatar demonstrates this perfectly. This app could help prevent hospital admissions and deaths.”
 
Dr Ruth Chambers OBE, GP principal, Stoke-on-Trent, Chair, Stoke-on-Trent Clinical Commissioning Group, Honorary Professor, Keele and Staffordshire Universities and Clinical Lead for Long Term Conditions, WMAHSN: “The importance of what we are trying to help teams deliver cannot be overstated. Demands on our services are continuing to increase. Utilising technology will not only enable us to shape services to suit the needs and preferences of individual patients; embracing it will also help us take on the challenges we face every day.”
Plans for the future:
  • To drive person-centred care through the use of TECs (with Flo as an exemplar) to span patient pathways across different healthcare settings with general practice teams and other providers prioritising applications that best meet the needs of their population, at specific points on those pathways
  • To drive regional spread/deployment of  Flo within organisations to disseminate the knowledge and learning achieved from previous deployment and successes to support the move towards a culture shift/perception of TECS for asthma, COPD, medication adherence and hypertension
  • Development of other Flo protocols ready for 2015/16 to support other LTCs beyond the project’s initial launch protocols.  
Tips for adoption:
To take TECS forward at pace we need to:
  • establish and support leaders and champions of TECS throughout the commissioning cycle to communicate the benefits and drive change
  • enable patient and public involvement and engagement
  • use digital modes of delivery such as Skype, telehealth, telecare, teleconsultations or telediagnostics to drive person-centred, integrated care rather than standalone solutions
  • focus digital delivery of care on areas in patient pathways where enhancing self-care has a substantial impact by improving patients’ clinical outcomes and/or reducing avoidable healthcare usage  
  • anticipate consequence costs such as increased frequency of clinician alerts
  • train health and social care professionals: enhance workforce competences and capabilities for the rollout of technology enabled care
  • match the mode of digital delivery of care to suit the patient population – selected mode or individualised for their needs and preferences
  • rigorously evaluate any implementation or trial of TECS and use this information to underpin any future business cases
  • utilise improvement tools to underpin commissioning and service improvement – leadership, transformational change and service redesign
work closely with all stakeholders to integrate technology in care to improve outcomes for all services; redress ongoing issues in constructive ways before progress with rollout is stalled.
Contact for further information:
Dr Ruth Chambers
ruth.chambers@stoke.nhs.uk
0121 371 8061
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