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Supporting Self-Management: Florence Changes the way Dieticians Interact with their Patients – 75% of IBS patients agree

Self-Management: The Florence Low FODMAP Diet was developed to provide additional support and symptom tracking to IBS patients following the Low FODMAP diet.

The protocol was specifically designed for patients with a confirmed IBS diagnosis who have been seen for initial dietary advice either one-to-one or in a group setting. The protocol is unique among NHSH protocols in that it includes an “Ask a Question” function which allows for patients to ask specific questions directly to their dieticians via Florence.

First patient signed up in June 2016 and was a nine week protocol.

The number of patients using the low FODMAP protocol increased steadily between June 2016 and November 2017 with an average of four new patients enrolled each month. The lack of sign ups since November can be attributed to both clinicians being absent from work. C3 has been on maternity leave since December and C2 has had two months of absence in 2018.

Case study Low FODMAP Diet

The anticipated outcomes were as follows:

  • Personal responsibility (NHW outcome)
    • by assisting patients to take responsibility for their own health by self-reporting their symptoms
  • Quality of life (NHW outcome)
    • by contributing to better management of the patient’s health condition
  • Cost effective (NHW outcome)
    • by increasing the number of patients who can be seen by using group sessions
  • Improved access to services (HMHM outcome)
    • by enabling patients to report their symptoms more regularly and ask questions directly to their dietician
  • Better adherence (HMHM output)
    • by reminding patients to report their symptoms and follow medical advice
  • Staff engagement (NHW outcome)
    • by allowing the clinician to look at patient trends and make appointments when needed
  • Increase in self-management (HMHM outcome)
    • by supporting more IBS patients to look after their own health
  • Reduced waiting times (HMHM output)
    • enabling group sessions to be held which have shortened waiting times

Improved compliance with complex dietary intervention through tips and advice

Three out of the four people (75%) who have completed Paper Questionnaire B agreed that Florence was supportive and helped them remember health information and advice. 50% agreed that Florence helps them comply with health advice.

75% of patients who responded to the evaluation delivered by text message agreed that Florence supports them while they are on the Low FODMAP diet and helps them track their symptoms.

Clinician Interview
C2 offers Florence to all IBS patients, except in circumstances when there is a significant reason not to do so. C2 cited lack of mobile phone signal, educational and geographical barriers as possible reasons for not offering Florence.

Clinician Feedback –

We have a higher return rate, fewer DNAs in people that interact and engage with Florence”

“Florence enables us to look back and see how many patients the intervention was successful for”

Patient Feedback –

“Flo gives me guidance on how to correct what I was doing wrong”

“It clearly illustrated with the repeat questioning that my condition was improving by following the advice given

“Helpful reminders for self-management and good assessment of progress”

“I found the tips really helpful. It was also really good to have that extra piece of encouragement and motivation. It was a welcome little boost which I sometimes needed. I was great to know the support was there and I felt I wasn’t on my own”

Easier access to direct dietetic support through question function

Clinicians Feedback –

“We’ve ended up in a time-neutral situation, which is really nice. Because patients can ask questions on Florence they are not phoning me, and I don’t have lots of messages to phone patients back, or six emails needed a response. Instead you’re in the moment responding to the questions rather than stories; this is much better”

Patient Feedback –

“If questions are seen on the system someone answers them”

Ability to direct timely and effective patient care on the basis of Florence data readings

Clinician Feedback –

“It can take up to six weeks for the Low FODMAP diet to make a difference to a patient….there are also some potential risk if a patient follows the diet for an extended period of time. What we were finding is that we introduced the diet to patients, but were unable to follow-up at the appropriate time.

Now we set them up on Florence, and we don’t make a follow-up appointment until Florence alerts us that the patient is ready to move onto the reintroduction stage of the diet. This means we’re making the appointment at the right time for that patient.”

“We are able to spend more time improving the Florence service because we’ve ended up in a time-neutral situation”

“There is a higher return in the people who interact with Florence [who attend the group session]”

Easier access to direct dietetic support through question function

Clincian Feedback –

We’ve ended up in a time-neutral situation, which is really nice. Because patients can ask questions on Florence they are not phoning me, and I don’t have lots of messages to phone patients back, or six emails needed a response. Instead you’re in the moment responding to the questions rather than stories; this is much better”

Clinician will be able to remotely monitor the symptoms of a large number of patients at one time

Clinician Feedback –

“Florence is one of the reasons we can do the group sessions, because we now have the capacity to monitor a larger number of patients at any one time so we’re able to see more people, so I can see twelve to fourteen patients in a couple hour period in comparison to two over two hours”

Reduced amount of time spent by the clinician doing email and telephone follow-ups with patients.

“Because patients can ask a question using Florence it means they are not phoning me, I’m not getting lots of messages or emails waiting for me. Instead of there being paragraphs and paragraphs, I’m now responding to questions and not stories, which is much better”

Changes in practice

C2 reported that Florence is one of the reasons they have seen a reduction in the departmental waiting list since Florence enables the clinician to see a larger cohort of patients at one time due to its monitoring capability.

C2 also reported a reduced number of DNAs, stating that there is additional departmental evidence to back this up. This data has been requested from the department, but has not yet been seen by the Technology Enabled Care team.

Florence has changed the way dieticians interact with their patients. The “Ask a Question” function has allowed patients to ask a personalised question directly to the clinician in a streamlined way.

C2 prefers this method of interacting with their patients as it takes less time than phone calls and emails, yet the patients still feel they are being supported.

Results Summary

Overall, the patients who participated in the evaluation reported a positive experience of Florence.
75% of patients who responded to the text evaluation agreed that Florence supports them while they
are on the Low FODMAP diet and 60% of those who completed the first paper questionnaire would
recommend Florence to other people in their circumstances.

Patients believe that Florence has helped them significantly change the way they manage their health,
though some patients reported no change in the way they look after themselves. Although no patients
reported an overall negative experience with Florence, there is a near 50-50 split between patients
who find it very useful and those who have a neutral opinion.

There is substantial scope available to collect additional evaluation evidence, as some patients have provided details to be contacted for
further feedback.

The Low FODMAP Florence protocol is unique in NHS Highland as it is currently the only Florence
protocol which enables patients to ask questions directly of the clinician and allows the clinician to
give a personalised answer. The protocol is also only one of a few across NHS Highland where the
department has fully embedded Florence into their service, and thus changing and improving how
their service is delivered to patients.

The success of this protocol can be attributed to the following:

  • Staff attitudes – the clinicians involved with this protocol have fully embraced Florence and
    make improvements to the protocol following staff or patient feedback
  • Florence enables dietetic staff to see larger numbers of patients at once, thereby reducing
    waiting lists
  • Patients using Florence feeling more supported and are more likely to comply with health
    advice, therefore improving personal outcomes
  • Florence enables clinicians to answer patient queries directly, reducing the time clinicians
    spend answering patient queries, and streamlining their responses

See the full report –

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