NHS Stoke on Trent

1. NHS Stoke on Trent • 270,000 registered patients, 54 GP practices • 2 new GP practices and GP led Health Centre planned for 2009 • Some of the most deprived wards in England, • 5 PBC clusters closely aligned with the Local Authority neighbourhood areas Flo telehealth: a key element of integrated care Professor Ruth Chambers OBE, GP & Clinical Telehealth Lead, Stoke-on-Trent CCG and Phil O’Connell, NHS Innovator of the Year Staffordshire and Lancs CSU

2. I see it hasn’t taken you long to get up to speed with the new mobile telehealth service

3. It’s about the basicsimproving delivery ofbest practice care

4. Simple Telehealthdeveloping the eco-system = NHS enabler 4

5. simple & instinctive, helping patients to help themselves £ free to txt all my teams Readings & answers patients mobile phone Closed loop Opt-in/out, prompts, questions, feedback, advice, education clinician smartphone Alerts if needed web

7. Working with industryDesigned for collaboration Enabling an industry & academia eco-structure, building on the core

8. Behaviour change techniques via Flo across patient pathways • individual feedback on personal health measures • social support – ‘Flo’ • information on consequences of behaviour • information on tailoring behaviour • tailoring – selected messages to patient, timing, frequency • goal setting (behaviour, outcomes) • relapse prevention • follow up prompts • clinician overview – giving assurance, titrating treatment • prompted self monitoring of behaviour(Free C, Phillips G, Galli L et al. The effectiveness of mobile-health technology based health behaviour….. PLOS Medicine 2013; 10 (1) )

9. Asthma/COPD inhaler reminder protocols x 2 (key elements):• Inhaler reminder (adult- asthma or COPD) x 2 reminders per day• Inhaler reminder (child/parent) x 2 reminders per day(Phase 2 when NHS team confident – poor control asthma (adult); poor control (child/parent); COPD (support and trigger standby rescue medication if early warning of deterioration): all interactive for 3 months + health promotion information messaging

12. That’s Flo reminding me to give you your inhaler. Now, if only she could sort out your gym kit and packed lunch, too...

13. Risk profiling your COPD patients Low cost, large-scale: ‘simple telehealth’

14. Flo says my oxygen level’s normal today, so I think I’ll have a fag...just kidding!

15. How Flo Simple Telehealth can support the whole patient pathway Supporting People at Home Manage step down from acute effectively Enhanced support at home Home Home Support* Crisis Acute Trf of care 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 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 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 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 Virtual Wards Intermediate care Step down facilities Unstable vital signs monitoring Medication management As * Manage Crisis Effectively Supporting people at home Enhanced support at home Specialist acute input

16. Palliative Care HF Nurse Tier 3 Service MDT Inpatient Care Cardiac Rehab Consultant Assessment Accredited GP/ PN HF Nurse Support Education/Training/Support Community Matron Primary Care Core GP Service Out patient Cardiology Rapid Access CP Clinic ECHO Practice Nurse District Nurse GP Home SC Diuretics Patient Self Care Weight Management Fluid Restriction Symptom Monitoring Lifestyle Changes Urine Analysis Full Blood History Examination Manage Co-morbidities ECG BNP CXR A/E Education Drug Therapy Manage Co-morbidities Organise Follow-up Individual Management Plans None Pharmacological Interventions Individual Management Plans Worsening Symptoms Despite Treatment

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18. Any risks from increased focus on remote monitoring of clinical conditions? Enriching self care as agreed shared management The Flo effect: helping people to help themselves – as agreed with their clinicians – throughout all tiers of care

19. Integrated care: right treatment, right delivery, right time, right team, right intensity Secondary care (tier 3, tier 4) Community care & social care Primary care (esp general practice, pharmacy) Personal responsibility & self care

20. What can AHSN investment achieve by March 31st 2014 (midnight!) via Flo Telehealth exemplar?• Model, trial & disseminate Flo across patient pathways for asthma – self care, schools, general practice, acute care, community care settings, includes: * inhaler reminder * step up Rx * step down Rx • Model, trial & disseminate Flo across patient pathways for COPD – self care, care homes, general practice, acute care, community care settings, includes: *inhaler reminder *trigger standby rescue medication *lifestyle advice• Model, trial & disseminate Flo across patient pathways for hypertension – self care, care homes, general practice, acute care, community care settings, includes: * opportunistic findings of raised blood pressure * enhanced control of hypertension eg pre-operation, after myocardial infarction