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Mental health – Innovating for improvement

East London 

NHS Foundation Trust


Raguraman Padmanabhan Telehealth/Care Navigators Clinical and Service Lead 

ELFT is committed to continuously driving forward the integration of care, and ensuring that our patients have access to best practice technology to support their management in the community.  As mentioned in my previous blog in June 2017, Flo has proven to have a significant and positive effect on patients by her providing the opportunity to experience the benefits of supported self-management and receive seamless care.
Flo has previously been used successfully at ELFT to monitor patients in mental health settings and plays an important role in facilitating and integrating care in the wider community, with the initial pilot study aiming to explore the feasibility and the potential clinical benefits of an enhanced community care intervention such as Florence (Flo).

East London NHS Foundation Trust (ELFT) Telehealth’s project REFRAME is led by Dr.Frank Rohricht, Mobile Technology Health Manager for Patients with Severe Mental Illness, as a feasibility Randomised Control Trial innovation project, vitally supported by the Health Foundation. We at ELFT-REFRAME believe that the project will have significant effects both in terms of consecutive research projects, but also immediately within ELFT as an important contribution to our quality improvement (QI) work in the area of community recovery care.

Severe mental illness (SMI), in particular chronic psychosis (Schizophrenia, Schizoaffective Disorder, Bipolar Disorder), is associated with poor clinical and psychosocial outcomes.  Due to the complexity of the disorder, service users require multidisciplinary flexible care arrangements involving different providers, often resulting in poor treatment adherence and problems with therapeutic engagement as well as a lack of empowerment.
This pilot study was aiming to explore the feasibility and the potential clinical benefits of an enhanced community care intervention, that uses an interactive simple technology based (SMS text messaging) communication system.  The intervention is provided in the spirit of recovery oriented care and supports service users gaining more control over their problem monitoring, as well as the necessary appointment arrangements with health professionals.
Flo as an intervention provides a user friendly, easy to use and non-stigmatising add-on to the patient’s current care pathway at low cost, managed by service users free of charge on their own mobile phones.
The recovery care intervention provided via Flo has three components: medication and appointment reminders, daily individually defined wellbeing scores and optionally coded keyword requests for help across psychosocial and medical care needs.

The Feasibility Trial MethodWe conducted a randomised controlled trial to test the feasibility and evaluate the effectiveness (six months after baseline) of the intervention in comparison with routine care (treatment as usual) for service users with severe mental illness (i.e. psychosis).

The Innovation – The Intervention

Flo was already being used by other clinical teams within ELFT (specifically by Community Health services in Newham) for long-term condition physical health care management in the community.

The intervention utilises the anticipated benefits of Flo for service user’s treatment adherence/therapeutic engagement. We created an innovative mental health care protocol that enables service users to develop and monitor their individually agreed own wellbeing scores in collaboration with the clinicians. Simple messaging language and keywords are utilised to foster service user-clinician communication outside routine appointments.
The intervention consists of three elements designed for the innovation project:
1. Flo interacts with service users via four SMS text messages daily: two prompts for medication adherence or appointments, and two asking service users to send their wellbeing indicators.
2. Service users develop their own wellbeing indicator based on three individually defined main issues / relapse signs (e.g. sleep, anxiety, voice-hearing intensity).  Depending on the scores, automated response messages designed within Flo’s protocols provide positive feedback, advice and will motivate service users to contact their Care Coordinator to discuss any challenges that they are facing.
3. At any time, service users can send a message to Flo requesting support using a predefined lists of keywords.  In response, the Care Coordinator contacts the service users to understand the nature of the issue further with a view to agreeing appropriate actions to take. 

Emerging evidence suggests that 70% of service users who have used Flo, opt to continue beyond their involvement with the project.  Of those who have opted to discontinue using Flo, their feedback suggests that they do not feel a need for it, rather than feeling that Flo was intrusive or unhelpful.

The project will be formally launched as a QI project in 2018.  Unlike many QI projects, this poses an unusual situation where patients have actively requested this quality improvement measure, rather than being driven by clinicians.Through learning from other projects through the Health Foundation, it is clear that video feedback is a powerful means to embed and spread an effective intervention.  As a result of this, we have routinely asked participants as a part of follow up assessments whether they would be interested in taking part.  The majority of participants have expressed interest in taking part to promote Flo’s intervention where they found her to be useful.  We are in liaison with the ELFT’s communications team and People Participation Lead with regards to the logistics of creating a service user testimonial video to support further spread and scale up of use.

The project received positive comments from the participants including:

I enjoyed that you could rely on it every day at specific time.
My mood is more stable, before I was more down now I’m happier.

It had done its job to get me to take my tablets and then I felt able to take my tablets on my own after that.
I was looking forward to the message, like a friend.

Staff feedback on the use of Flo was also positive:

It helped them to get to the point where they were independent taking their own medication rather than having to depend on family to do so.
Very useful reminder for service users and their Care Coordinator.

It also helped them to think about how they were doing from day-to-day in themselves, which in turn helped them further develop their reflective capacity and therefore recovery.
Participant has been able to individuate from [their] mother, by taking more responsibility for [their] own care, and this in turn has led to their relationship being more some symbiotic; mutually supportive.

A further update will be available once the final paper is published, in the meantime if you have any questions please contact Ram at 

Views & downloads (membership required)East London NHS Foundation Trust REFRAME Protocol flow chartELFT REFRAME message scheduleREFRAME telehealth study ELFT final HF report

#East London Foundation Trust #ELFT #REFRAME #Server Mental Illness #SMI #TotallyUnique

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