Summary

Community Diabetes Nurses at Derbyshire Community Health Service have embraced the Florence (FLO) telehealth texting system to support the patients that they see with diabetes. This is a free texting service for the patient and has been used for medication reminders and glucose results; with impressive results both in terms of patient outcomes and in changing the way that the diabetes nurses are working. Over 250 patients with both type 1 and type 2 diabetes are using this technology following identification from the community team. The system allows the specialist nurses to monitor patients remotely, to set individual target ranges for patients and receive e mail alerts if the patient is out of an agreed individual target range. Patients have responded positively to this cost-effective system and it has reduced the number of face-to-face contacts required. Patients report that they feel more supported.

Results

The Community Diabetes Team in North Derbyshire have been using this system for the past two years, with over 250 patients registered, aged from 18 to 80. Coverage is across 39 GP practices and the Derbyshire Florence project is issuing over 23,000 text messages a month. The workload of one of the community diabetes nurses was assessed over a one month period with 70 patient contacts due to the system, to understand the impact on their workload. The outcomes were:

• 18 face-to-face consultations that were not required and released nine hours of specialist nurse time
• 42 patients were advised to change their treatment by text or phone eg increase their dose
• 45 patients had earlier intervention
• Seven patients that would have expected to have to phone were avoided as the system demonstrated they had good control

It also showed the impact on other health providers:

• Two hospital admissions were avoided
• Six avoided GP appointments.

Data shows that 68% of patients on the system have had a repeat HbA1c. From these patients 78% have had a reduction in their HbA1c and 18% had an increase, 3% planned increase.

Challenge

With the increasing numbers of patients developing diabetes (Diabetes UK states it will increase to fi ve million in 2025 from 3.2 million in 2012) and without additional resources for clinical staff, new ways of working need to be embraced by the health service. The use of digital technology is an additional tool that can be used effectively as part of a diabetes care package.

Objectives

To use technology to support patients managing their diabetes and how this would impact service delivery. To see how and whether the telehealth service could improve patient experience and outcomes, and reduce the number of face-to-face contacts needed.

Solution

FLO was designed by professionals within the NHS, to provide clinically approved remote support and guidance to patients. The community diabetes nurses developed local protocols on the system for patients with diabetes, with support from the project team. Before any patients were added to the system the diabetes nurses added themselves as "a patient" to test the system and familiarise themselves with it. Initially 12 patients were identified and started as a pilot to see how this could work locally and if any modifications were needed following feedback. Governance issues were highlighted at this time and were progressed and resolved prior to the roll out on a wider scale. The enthusiasm of the community diabetes team was shared during their support visits to GP practices when they could highlight the benefits to the clinicians, significantly increasing the number of practices using the system.

Learnings

The use of FLO has been widespread across different age ranges: the eldest is an 80 year old who learnt how to text. Feedback from an experienced diabetes specialist nurse has been surprise at the effectiveness of a telehealth system. In its simplest form medication reminders can be used to prompt patients to take their medication, requiring no other input from the clinician apart from setting the individual up on the system. Patients often report forgetting their medication so a text reminder can make a big difference to their compliance. The issue of responsibility and governance was of concern to the organisation, in case a patient misunderstood the message. A text response advises the patient to contact their GP or diabetes nurse as the default and initial concerns voiced have proved not to be a problem.

Evaluation

Following the initial audit and patient feedback the diabetes nurses changed several aspects of the service. The national protocols were not used as some of the motivational messages were inappropriate and not well received by patients. The high alert levels were too low, highlighting the need for local protocols to be written by the DSNs with the project manager. Although this felt time consuming, verbal feedback from patients improved. DSNs recorded their experience of the system and any practical issues they had which were fed back to the project team - for example, it was not clear if a patient had been added or not and easy for the patient to be added several times, so a message was set up to inform that the patient had been successfully added. Patients also found the # symbol complicated to use, this was changed to "yes".