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