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Idea Description
Supplementary Information
Innovation 'Elevator Pitch':
Flo-Tone CR is a tool helping patients acquire good Maintenance & Technique in using Pressurised Inhalers, teaching how to Inhale SLOWLY and STEADILY. Inhaler Technique Skills are important and a major theme in BTS, GINA and NICE guidance.
Overview of Innovation:
Flo-Tone MDI (also known as Flo-Tone CR) uses a ‘Positive’ Coaching Whistle to help patients learn to inhale SLOWLY and STEADILY. Whistle Signal is a prompt for the canister to be pressed releasing the medication & the duration of the Whistle helps the professional to coach the patient towards correct use.
Pressurised inhaler mouthpieces come in a variety of shapes, accordingly Flo-Tone was originally produced in ‘Circular’ & ‘Regular’ Models. A new improved Flo-Tone CR now fits all mouthpiece shapes by fitting inside the pMDI mouthpiece. The new design ensures all pMDIs produce a whistle at the same flow rate, helping standardise technique.
Studies have been conducted with the new Flo-Tone to ensure that it delivers the full dose. The first study detailing the development of the improvement & its performance was presented at BTS 2015 & subsequently at DDL26.
Available on prescription, the improved Flo-Tone CR can be used with a pMDI simulator (Trainhaler) for training & with the Patient pMDI. It incorporates a cap so that it can be left in situ on the Inhaler. It also includes a rim on the mouthpiece to help patients get their teeth out of the way of the aerosol spray.
We have tested Flo-Tone CR with a variety of inhaled medications (Flutiform, Clenil, Ventolin, QVAR and Sirdupla) – in each case the respirable dose (ie that part that reaches the lungs) delivered for the medication plus Flo-Tone closely matched that of the device alone & in each case unwanted throat deposition was reduced.
•Flo-Tone CR controls the resistance of the pMDI, thereby standardising the flow rate at which  
  Flo-Tone CR whistles
•Provide inhalation & coordination guidance
•Sounds (20-25 L/min)
•Drug delivery improvement = Therapeutic Improvement
•Less throat deposition – potentially less unwanted Throat Side-Effects
•Better control - less breakthrough – less SABA needed
•Better control – less hospitalisation 


• Spacer & Mask with anti-Microbial & anti-static properties
Collapsible – helps with storage & travel
• Visible valve movement - see that the drug is being Inhaled
• Suitable for adults & children
• Performance validated with pMDI’s
• Accepts all pMDI’s available
• Available with small & medium mask


• Ideal for emergency services use, schools & within General Practice & Hospitals for reversibility testing
• Single patient use
• Economical & environmentally friendly
• Performance validated with pMDI’s
• Available in bulk pack 
 
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)
Similar Content1
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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