The Diabetes Specialist Nursing (DSN) Team at Derbyshire Community Health Services NHS Foundation Trust (DCHS) provides services for patients with Type 1 & Type 2 diabetes in the north of Derbyshire.
The team supports patients with overall management of their condition, helping to avoid both short and long term complications. The DSN team assist patients by altering existing treatment plans and initiating new ones, as well as providing advice around lifestyle, diet and so on.
The team also provides a selection of short educational courses to patients and other practitioners and care staff to improve knowledge and understanding of diabetes.
Michelle Denyer, Lead Specialist Nurse with the DSN team has captured some of her patients’ experiences.
The stories below highlight examples of how clinicians have used Flo to augment best practice care, the positive impact this has had on patients’ lives and the value that Flo adds to the team as an enabling tool to support their patients in a different way.
Case study 1
BG remote monitoring results in no further hospital admissions or ambulance call outs
Patient 1 was a 77 year old with type 2 diabetes. The patient lived in a residential care home, and their diabetes was difficult to control, with blood glucose readings anywhere between 2mmol and 30mmol being recorded. This poor control led to the patient being hospitalized for a total of four weeks from 14th August 2017, while various methods were attempted to control their blood glucose.
The patient’s HbA1c in June 2017 was 8.4%.
Upon discharge and returning to the residential home, it was requested by the hospital that the patients’ blood glucose be monitored four times a day, and these readings continued to fluctuate. To counteract high blood glucose levels, the home was advised to administer quick acting insulin. The diabetes specialist nurse visited the care home and found that the patient’s care plan was very complicated, and felt somewhat uneasy about this.
The patient’s blood glucose before going bed was around 2.4mmol, and this rose to between 24-30mmol in the morning – no explanation could be found for this as the patient had no access to food during the night time. As of 18th September, the patient’s blood glucose remained unstable, leading to an ambulance being called out and a subsequent hospital admission on 20th September.
The patient began a basal bolus regime, which meant that the patient was having 4 injections daily – not particularly ideal for a patient of this age. At this point, the DSN spoke to the patient’s son about having a mobile phone to use with Florence, and also spoke to the care home about telehealth.
The patient was set up on Flo via a telephone call, and the patient’s son did the initial text confirmation to opt in. The patient was put on to a simple protocol which asked for readings and recorded them. This enabled the DSN to remotely monitor the patient’s blood glucose levels, and contact the care home to provide advice and support when necessary.
The care home staff reacted positively to the use of Florence, as they felt reassured that a clinician was checking the patient’s readings remotely. From the clinician’s perspective, using Flo has created time savings, as they can now log into Florence and check the patient’s readings.
If the readings are within range the DSN nurse doesn’t need to contact the home, whereas before this was necessary to find out what the readings were. On the other hand, if the DSN sees that the readings are too high or low, they can intervene in a timely manner, and avoid further ambulance call outs or hospital admissions for the patient.
There have been no further admissions or ambulance call outs to the patient to date.
Main benefits:
- Reduction in contact time resulting in increased capacity for clinician.
- Timely intervention by clinicians helping to avoid admissions and ambulance call outs.
- Patient and care home staff felt reassured.
- Improved blood glucose control.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
Case study 2
BG control allowed surgery to go ahead as planned
The patient was a 53 year old with type 2 diabetes, who was found to have a tumor in their bladder. Surgery was scheduled for 29th August 2017 to remove the tumor, and the patient began to take insulin. As the patient was going in for surgery, it was key that their blood glucose was kept within tight targets. At this time, the patient’s HbA1c was 9%.
The patient was put onto a basal bolus regime and set up on Florence to help them to monitor their blood glucose. They would receive advice and feedback from Florence depending on their readings, and the diabetes specialist nurse would receive alerts if the patient’s readings were of concern.
The DSN did not need to arrange any face to face appointments with the patient due to the fact that she was able to remotely monitor their readings using Florence. Instead, the DSN made three phone calls to the patient to give them extra advice based on their readings.
This saved time for the DSN, and also meant that the patient didn’t need to go to further appointments, which was more convenient for them. The patient has also commented that using Florence was helpful and reassuring for them.
The patient’s blood glucose levels are not as stable since surgery, this is to be expected and so they are continuing to use Florence for added support and guidance for the time being.
Main benefits:
- Blood Glucose controlled to allow surgery to continue as planned.
- Reduced appointments for patients.
- Reduction in contact time resulting in increased capacity for clinician.
- Patient felt reassured.
Case study 3
Carers and DSN help patient to reduce hypoglycaemia episodes and as a result reduce ambulance call outs
The patient was a 53 year old with type 1 diabetes. The patient lived in a supported unit, and had previously had problems with alcohol. They were experiencing episodes of hypoglycaemia leading to unconsciousness. Staff at the supported unit would then have to handle these incidents. The patient’s HbA1c was measured at 6.4%.
The patient began to use Flo in July 2015 and initially carers were texting Florence on their behalf. The carers found using Florence to be a positive experience; they felt reassured that the diabetes specialist nurse could monitor the results, and that Florence would let them know if they should contact the DSN.
They also found the advice such as when to check for ketones, or treatment of hypos helpful.
Prior to using Florence the ambulance service had attended the patient during their episodes of hypoglycaemia, but since using Florence this has not been necessary as the DSN can react to the patient’s readings and provide support.
Recently the DSN and carers have been looking into providing the patient with their own phone to text Florence to increase their independence. The DSN still has face to face appointments with the patient, as it can be difficult communicating with carers, but these are appropriate, and resources are being saved by the fact that paramedics are no longer having to be called to the patient.
Further investigation into weight loss led to supplements being used which raised the glucose level significantly, which the DSN has been able to monitor remotely and alter insulin doses as needed.
Main benefits:
- Care staff reassured and found advice from Flo helpful.
- Improved blood glucose control.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
- Reduction of ambulance call outs due to episodes of hypoglycaemia.
Case study 4
Improved medication compliance results in BG within target range and avoidance of insulin
The patient was a 52 year old woman with type 2 diabetes. She was seen jointly by the GP and the diabetes specialist nurse. The GP wanted the patient to start taking either GLP-1 or insulin, but the GLP1 medication can cause nausea. At the time of the consultation, the patient’s HbA1c was 10.3%.
The patient was set up on Florence for medication reminders, as she were having difficulty remembering to take her tablets during the day.
The patient did not want to use Florence to monitor their blood glucose levels, so they were set up on a meter to monitor this, which would automatically download to the patient’s mobile phone, these readings could then be sent to DSN. The DSN has received 2 sets of readings for the patient since the beginning of August.
Having used Florence to improve medication adherence, the patient’s BG readings have been below 10mmol, which was within her target range, HbA1c 7.6% within 3 months.
The patient has also started to remember to take her medication, as shown by her blood glucose being within the target range. The patient’s blood glucose is mostly controlled now thanks to the medication prompts from Florence.
This means that there is a cost saving as the lady has not needed to start taking insulin or GLP-1. Additionally, the patient feels that having Florence is like having someone keeping an eye on her and her health.
Main benefits:
- Improved medication compliance.
- Improved blood glucose control.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
- Cost saving associated with patient not needing to begin taking insulin or GLP-1.
- Patient feels reassured.
Case study 5 Timely and appropriate intervention reduces A&E admissions and consultations
The patient was a 60 year old with type 1 diabetes who was living in supported care due to profound learning disabilities. The patient was having difficulty in controlling their blood glucose levels, leading to episodes of hypoglycaemia which required medical intervention.
In the 12 months prior to the patient starting to use Florence, they had a total of 10 consultations and 2 A&E visits. At this time, the patient’s HbA1c was 10.1%.
The patient was signed up to Florence via their carers, who would take blood glucose readings at mealtimes and send the results back to Florence. The diabetes specialist nurse would then receive alerts when readings were of concern. This allowed the DSN to intervene in a timely and appropriate manner to avoid episodes of hypoglycaemia.
Alerts are also received by the DSN via email, so intervention with insulin doses can be recommended if needed.
Since the patient began to use Florence, they have had no further admissions to A&E, demonstrating an efficient use of resources and an obvious cost benefit, and reducing stress for the patient. The patient’s HbA1c has reduced 9%.
Main benefits:
- Improved blood glucose control.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
- Timely intervention by clinicians helping to avoid admissions and ambulance call outs.
- Reduction in contact time resulting in increased capacity for clinician.
Case study 6
Patient caring for her sister regains control of her diabetes leading to a stop in taking insulin, weight loss and enabling her to live a healthier life
Diane is a 62 year old with type 2 diabetes. She is the main carer for her sister who she takes to hospital for renal dialysis 3 times each week. Due to her commitments as a carer, Diane had no time for appointments to help her manage her diabetes.
Diane’s blood glucose levels were not well controlled, with HbA1c 8.7% and due to her insulin regime she had experienced some weight gain. The diabetes specialist nurse discussed changing Diane’s type of insulin, as well as exercise, and suggest that she try using Florence to help her to self-manage her condition.
Diane felt hugely reassured by using Florence, and was confident that someone was looking out for her. In January 2017 Diane reduced her insulin dosage, and in February 2017 she was able to stop it completely as her glycaemic control had improved with an HbA1c of 7.9%.
Diane was able to communicate with her DSN via free Flo texts, and felt this didn’t impact on her role as a carer. This was great for Diane as she found it difficult to see her DSN face-to-face due to her time commitments caring for her sister. Instead, it meant that she could take care of her own health at times that fit around her schedule.
Diane felt that the improvement in her health gave her more energy, and can do things for herself , that she had previously been unable to do. With help from her DSN and Florence, Diane has lost a fantastic 22kg!
Diane:
“I am 54 years old and was diagnosed with Type 2 Diabetes when I was 40. I started on tablets but was soon put on insulin. I thought that was it for the rest of my life and so stupidly I plodded on, not eating brilliantly and gradually increasing my insulin until I got up to 56 every morning and 56 every evening! Then I met Louise, the Diabetic Nurse from my Surgery, and Michelle, Lead Diabetes Specialist Nurse.
I was overweight and felt very lethargic and so knew I should start to do something about it. Louise and Michelle were absolutely brilliant – they advised me on what to eat and how to exercise – and so it began! I cannot pretend it has been easy but with Louise and Michelle’s support, it has been achievable. In approximately the last 6 months I have lost over 2 stone and have come off insulin.
I feel so much better – I now eat very healthily and exercise every day. I would recommend anyone on insulin to do this as the results are amazing. I would like to say a very big thank you”
Diane’s practice nurse: “
The confidence and self belief that Diane has now got has been very evident; she had something to work towards with a plan of care; including the goal of reducing her weight and being able to stop her insulin.”
“Many patients with type 2 diabetes are treated with insulin; the doses are increased over a period of time and patients fall into a cycle of more insulin, increasing weight and increasing insulin. The change in Diane’s confidence has been amazing; she felt very supported with the telehealth system [Flo] and having both her Practice Nurse, Louise, for support in surgery and having regular phone calls from DSN.
She was delighted when she stopped insulin. The outcomes are not just about improved HbA1c and the associated health benefits of this, but also the quality of patients’ lives. When I spoke to Diane this week she told me how thrilled she was as she had been able to repaint her own garden fence; she has more energy for activities and also for continuing the care of her sister.” Michelle Denyer, Lead Community Diabetes Nurse (May 2017)
Main benefits:
- Improved blood glucose control.
- Patient able to stop taking insulin; associated cost savings with this.
- Convenient for patient whose time was limited due to being a carer.
- Patient feels reassured and more confident.
- Patient has also lost weight which has associated health benefits.
Case study 7
Previously disengaged patient reduces HbA1c from 13.5% to 6.9% with Flo
The patient was a 68 year old man with type 2 diabetes. He was disengaged with his health; he didn’t really want to attend appointments, or discuss his diabetes in general. The patient was also not taking his medicine, so initially he was set up on Florence to receive medication reminders to try and improve his adherence.
However, after a short time he began to use Florence to help him monitor his blood glucose levels. Due to complications with his diabetes, the patient also developed a foot ulcer which required treatment.
Since beginning to use Florence, the patient’s HbA1c has dropped from between 13.5% – 12.9% to 6.9%. Additionally, during the 2 years that the patient has been using Florence, they have only had 2 face-to-face appointments, with potential cost and time savings.
The patient has expressed his gratitude for the help received from his DSN and Florence towards improving his health. The longer term savings with improved control are also significant. This man still continues to use Flo.
Main benefits:
- Improved blood glucose control, resulting in a HbA1c reduction by around 50%.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
- Reduction in contact time resulting in increased capacity for clinician.
Case study 8
Patient controls diabetes and reaches weight loss goal Mick was diagnosed with type 2 diabetes 10 years ago. He first started taking tablets for his diabetes, at which point he began to gain weight. He continued to gain weight which resulted in Mick needing to begin to inject insulin, which in turn caused further weight gain.
Mick also had problems with his driving license due to his health, and he was issued a temporary one by the DVLA. His HbA1c was 9.4%.
Following complications after treatment for cancer, Mick gained the motivation to begin to tackle his increasing weight. To do this, Mick spoke to his dietitian and started to eat healthily and count his carbs. He also signed up to Flo for additional motivation and support on his weight loss journey.
Mick’s hard work has paid off – he managed to lose a total of 27.8Kg (4st 7lb) over a period of 9 months. In addition to this, he has also been able to stop taking insulin, and now only has to take tablets for his diabetes.
The support that Mick received from clinicians, along with Flo, was really important in ensuring that he reached his weight loss goal. Mick even commented “I couldn’t have done it without Flo” – and he has been able to have his permanent driving license reissued by the DVLA!
In addition to this, Mick’s weight loss means that he has reduced his other risks related to being overweight, and as his diabetes is now better controlled with an HbA1c of 5.9% he has lowered the chance of other condition related complications going forward.
Mick now has a healthier future ahead of him, which will hopefully mean that he is able to seek less medical intervention than he would have if he continued to gain weight and struggle to control his diabetes. This demonstrates potential long term cost and resource savings due to the patient’s improved prognosis.
Mick was taken off the telehealth system [Flo] and his HbA1c has risen to 7.8%, the current plan is to offer the telehealth service again to see if this improves control.
Main benefits:
- Patient lost weight which has associated health benefits and potential cost saving benefits.
- Improved blood glucose control.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
- Patient able to stop taking insulin; associated cost savings with this.
- Patient has improved confidence.
Case study 9
Improved glycaemic control and weight loss has given patient confidence and more self-esteem
The patient was a 46 year old man with type 1 diabetes, he used Flo to help monitor his blood glucose levels. When the patient began to use Flo he was taking 120 units of insulin, but this was decreased to 60 as his glycaemic control improved, and his HbA1c went down from 10.1% to 9.3%.
While using Flo, the patient also started to use carb counting to help his glycaemic control, and also to try and lose some weight. The patient was able to reduce his weight from 14st 12lb to 13st, and has said “…it’s wonderful I have self-esteem for the first time in years!”.
From the patient’s perspective, it is reassuring to know that his blood glucose levels are okay, and if they are not then a clinician will be able to intervene in a timely manner. Flo has given the patient the confidence he needed to self-manage his condition.
From a clinician’s perspective, using Flo is great because it means that patients can receive the best ongoing care; if a clinician is on annual leave, it is easy for a colleague to check the patient’s readings and provide continuity of care.
Main benefits:
- Improved blood glucose control.
- Improved long term prospects due to improvement in control of blood glucose, and possible future savings associated with this.
- Patient able to significantly decrease insulin dosage; associated cost savings with this.
- Patient lost weight which has associated health benefits and potential cost saving benefits.
- Patient has improved confidence and self-esteem.
Case study 10
After losing Flo due to funding, patient is now disengaged with her health
Naomi’s story has previously been shared, but to summarise: Naomi was a patient with poorly controlled type 1 diabetes. She was diagnosed at the age of 10 years and then struggled to control her condition throughout her teenage years; Naomi was also concerned about how taking insulin could affect her weight.
Flo was used by Naomi to remind her to take her insulin and to help her keep track of her medications. At its highest in 2011, Naomi’s HbA1c was 16.4%. In June 2015 her HbA1c was 13.2%, but after using Flo for four months, Naomi’s HbA1c dropped to 8.6% which was a fantastic result. Using Flo really helped Naomi to self-manage her condition, and gave her the confidence and support she needed.
However, since Naomi’s story was shared, there have been some developments. Naomi was told that Flo was likely to be stopped due to funding. Although Naomi was offered to continue with Flo until it was actually stopped she decided to stop immediately, saying that Flo was the only thing that had really helped her. This caused Naomi to become withdrawn and upset.
Since then, Naomi has not engaged with the specialist diabetes team, and her HbA1c has risen back up to 13%.
Naomi’s story highlights how patients can be put at risk if services they have found useful in managing their health, such as Flo, are withdrawn – especially if the patient is particularly vulnerable. The DSN continues to try to re-engage with Naomi.
