Thursday 10th March 2016 Sunderland Virgin Active Health & Racquet Club

“FLO – Telehealth with a Human Touch”

Welcome & Introduction

Kim Hinshaw (on behalf of the speakers & organisers)

Sunderland

Tyne & Wear

Funded by the Sunderland CCG & the Health Foundation

‘Florence’ is a secure NHS server - Stoke CCG

- ‘Florence’ runs an SMS-based simple telehealth system

‘Florence’ is a secure NHS server - clinicians develop the pathway & alerts

GP Practices

Hospital Clinicians

Community & Specialist Nursing

Develop clinical pathways & alerts

SMS

- prompts plus advice/support

Basic smart-phone technology

SMS

- responses (BP, stix results etc)

Supporting people at

home

Enhanced support at

home

Manage Crisis Effectively

Specialist acute input

Enhanced support at

home

Supporting People at

Home

Manage step down from acute

effectively

Crisis Acute Trf of care

Home Home Support* 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

Unstable

Hypertension

Newly diagnosed

hypertension

Medication

Reminders for: -

Hypertension /

Ashma inhaler /

pain management

Paediatric ashma

COPD

Diabetes (type1& 2)

Heart Failure

Palliative care carer

support/wellbeing

Falls prevention

Virtual Wards

Intermediate

care

Step down

facilities

Unstable vital

signs monitoring

Medication

management

As * Pregnancy induced

hypertension

Gestational diabetes

COPD

CHD

Diabetes

physiotherapy

Monitoring of pre op

patients to reduce

cancelled operations

Out patient acute

specialist follow up

DNA management

Support early discharge

EMAS unstable vital

signs monitoring

Oncology

Neurology

Speech therapy

Alcohol support

Learning disabilities

Mental health behaviour

Mental Health appt &

medication reminders/

supportive messages

Daily living/ medication

reminders for people

with Aspergers/autism

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

“Innovation is not always about new or more resources. It is usually about using existing

materials differently”

Lord Ara Darzi

Plans for the day – a full agenda

For you to consider throughout the day

• What do our patients want?

• Improving care

• Using resource efficiently & effectively • Thinking outside the box

Implementation & change management

Nick Sevdalis

Professor of Implementation Science & Patient Safety

March 2016

What does success look like?

Appropriate, effective & safe,

patient-focused care

… we hope to convince you

that Florence can help

“FLO – Telehealth with a Human Touch” Thursday 10th March 2016

Sunderland Virgin Active Health & Racquet Club

Using Simple Telehealth Technology to support home monitoring in gestational diabetes (GDM) & mild pregnancy-induced hypertension (PIH)

Kim Hinshaw Rahul Nayar Janette Johnson Paul Marriott

Plan

• Using MECS in PIH & GDM [Messaging Enabled Care Services]

• Evaluation – clinical outcomes/patient

satisfaction/health economics

• Breast-feeding pilot – outcomes & satisfaction • The future – limitations/potential

Rahul Nayar Department of Diabetes and Endocrinology City Hospitals Sunderland 10th March 2016

SMS

Prompts and

advice GP

Practices

Specialist Clinicians

Community

and Specialist

Nursing Smart Phone Technology

Public Health and Telecare Control Rooms

A Mobile Phone Based System was preferred as virtually all use mobile phones as part of their daily lives

The NHS Simple Telehealth System Florence was identified as providing the functions required. The system could be configured via algorithms to interpret incoming patient data and act upon it in compliance with the clinical pathway. Cost were between £57 and £80 per patient per year

Clinicians needed to monitor Blood Glucose levels, weight changes and advise on medication titration. The system had to be capable of asking the patient questions with the algorithm interpreting the received patient data. Alerts or critical breaches were passed forward directly to the Hospital Paging/Email System

Delivering a Telehealth Model for Out Patient Pregnancy Care

Definition:

First presentation of high blood glucose levels in pregnancy

Common condition affecting up to 5% of all pregnancies.

When?

Usually detected between 24 – 28 weeks but can be earlier

How?

Fasting glucose level > 5.6mmol/l or Oral Glucose Tolerance Test

Fasting > 5.6mmol/l or 2hr > 7.8mmol/l.

Risk factor screening – previous GDM – test earlier

32y Mother of 2 children

Previous poor fetal outcome

Morbid Obesity

Smoker 20 pack years

GDM diagnosed at 20 weeks

Enrolled onto Florence system.

Provide Support

Via SMS reminders, reassurance, encouragements for achieving targets for glucose and weight targets.

Dose adjustments of oral medication and insulin titration, In a timely manner

Maintenance of normal life

Fewer clinic visits

Good outcome

Test the feasibility of Simple Tele Health in women with Gestational Diabetes

Assess patients’ treatment satisfaction with this novel method of monitoring (DTSQ*)

Evaluate the economic benefit of enrolling onto this system in conjunction with routine antenatal diabetes care

*DTSQ © Clare Bradley 1.12.93: Diabetes Research Group, Department of Psychology, Royal Holloway, University of London, Egham, Surrey,

TW20 0EX

• A prospective pilot into the effectiveness of incorporating “Simple Telehealth”.

• Consecutive patients with gestational diabetes were offered enrolment along

with usual antenatal diabetes care.

• Outcomes were evaluated and the potential economic benefit from a reduction

in frequency of out patient attendance whilst maintaining a high degree of

safety.

Aims:

Methods:

Dating Scan

16 week Scan

20 week Anomaly Scan

24 - 28 week OGTT

26 week Scan

30 week Growth Scan

34 – 38 weeks Weekly Growth Scans +/- Bio Physical Profile

Management of Gestational Diabetes: 1: Blood Glucose Testing - Pre and Post Meals 2: Life style Changes - Healthy Eating Plan - Weight Management 3: Oral Medication - Metformin 4: Subcutaneous Insulin - Regimes vary in degrees of complexity once a day to 4times

Intervention Points with Simple Tele Health

Information Leaflet – at 1st visit

Enrolment – in clinic Consent obtained & Communicated to GP Supportive Text Messaging Service & Alerts

Blood Glucose Testing Pre and Post meals Targets and alert thresholds pre-determined

Pre Meal < 5.5mmol &

2 Hr Post Meal < 6.5 mmol/l

Fortnightly weight recorded via SMS DTSQ at 4 weeks and post natal.

Average recruitment: 6 new patients per month. Mean duration of use was 12 weeks (range 6 – 22).

Patient Treatment: Up titration of medication occurred via SMS & at clinic

35% Diet only, 40% Diet + Metformin, 25% Diet + Metformin + Insulin.

DTSQ results: showed high figures for satisfaction, convenience, flexibility with treatment and enhanced understanding of diabetes with all patients.

There were no adverse outcomes reported during the pilot to mother or baby.

Cost saving attained: - Total cost of ‘Simple Telehealth’ £80/patient/yr. - Average number of hospital visits prevented per

patient 3.2 during a single pregnancy. - Assuming a single attendance costs £80/visit

giving total saving of £1,024/pt/yr. ??

NHS Carbon Foot Print Reduction

Patient - delivered home monitoring for Gestational Diabetes using Simple Telehealth technology is deliverable.

Pregnant women find the technology easy to use and the concept highly acceptable. “maintenance of normality”

Initial data suggest the approach provides a high degree of vigilance, safety & there may be cost-benefits to the NHS.

Assessment of safety, economic benefit & patient acceptability underway with an AHSN grant.

Future potential – Diabetes Prevention, weight management, call – re-call methodology, other aspects of diabetes management – hypoglycaemia, post discharge follow up.

http://www.nescn.nhs.uk/group/

Pregnancy-induced hypertension (PIH)

• ‘Mild PIH’ is common – affects 5% of pregnancies

• Need to watch for preeclampsia (2-3%) but ‘severe pre- eclampsia’ only affects 0.5% (1/200)

• ‘Mild PIH’ contributes a significant workload to NHS: – referred for ANTENATAL DAY UNIT assessment – multiple home visits by COMMUNITY MIDWIFE – further visits to HOSPITAL ANTENATAL CLINIC

29

2012 – Pregnancy care & telehealth - multi-partner teams

PIH Hospital Team GDM Hospital Team

….supported by the NHS Northern Senate Telehealth team

1. Clinical team develop safe inclusion/exclusion criteria

2. Telehealth team developed the ‘Florence’ text system for the project:

– texting information ‘to & from’ patient – appropriate ‘patient alerts’ – procured necessary monitoring equipment – developed patient information sheets (PIS)

Developing clinical pathways

• Inclusion criteria: – 20 to 38 weeks pregnant – no significant symptoms (eg headache, flashing lights etc) – normal blood results – no significant proteinuria (urinary P:Cr)

• Exclusion criteria: – symptomatic or BP (see table) or preeclampsia – essential hypertension, twins etc

Level of

Proteinuria

Systolic Diastolic

Upper limit for inclusion

to Telehealth

All women who develop any

symptoms will be informed by

Florence text to: contact

ANDU or Delivery suite the

same day for 1:1 discussion

and management irrespective

of BP and urine measurement.

No

proteinuria

140-150 90-100

149/99

with no protein

+

proteinuria

<146 <96

145/95

with + protein

++/+++

proteinuria

<140 < 90

139/89

with ++/+++ protein

Developing PIH clinical pathway – based on NICE

Level of

Proteinuria

Systolic Diastolic

Upper limit for inclusion

to Telehealth

All women who develop any

symptoms will be informed by

Florence text to: contact

ANDU or Delivery suite the

same day for 1:1 discussion

and management irrespective

of BP and urine measurement.

No

proteinuria

140-150 90-100

149/99

with no protein

+

proteinuria

<146 <96

145/95

with + protein

++/+++

proteinuria

<140 < 90

139/89

with ++/+++ protein

• Inclusion criteria: – 20 to 38 weeks pregnant – no significant symptoms (eg headache, flashing lights etc) – normal blood results – no significant proteinuria (urinary P:Cr)

• Exclusion criteria: – symptomatic or BP (see table) or preeclampsia – essential hypertension, twins etc

Developing the PIH clinical pathway

Microlife ‘WatchBPhome’ digital BP Monitor

Meditest ‘Protein2’ urine dipstix (£3.27 for 50)

(supplied by BHR Pharmaceuticals Ltd) www.bhr.co.uk

• cheap ( £100 ) • portable • easy to use • validated for pregnancy

Equipment – cheap & simple

+

AHSN-funded service evaluation

• £76,000 • Embedded across 3 (subsequently 5) Trusts • Evaluation – outcomes/limitations/potential

• Outcomes:

• Clinical outcomes • Patient satisfaction • Level of control • Health economics