Year Of Care

Year of Care is an NHS organisation offering commissioners and providers expertise, practical support and training to embed care and support planning as a more personalised way to deliver care for people with living with long term conditions, encouraging meaningful conversations between practitioners and patients based on what is important to the person to live well with their condition

 Oviva

Oviva is a provider of remote NHS services. Diabetes Support is a structured education programme, delivered on a one-to-one basis by a Diabetes Specialist Dietitian in multiple languages.

Citizen

Citizen bring tools, techniques and thinking from the world of consumer marketing to help create patient communication that positively nudges people to change behaviour including through the use of Personalised Video Messaging, by linking personal health data and information to care planning goals

Healum

Healum have created an app that will enable people with type 2 diabetes to build a care plan that includes personalised goals, resources and information that is available to them 24/7

Insight Health Improvement

Insight Health Improvement will be managing the evaluation of the project throughout all phases

South West London Health and Care Partnership

The South West London Health and Care Partnership is comprised of the organisations providing health and care in the six south west London boroughs.

We are working together in four local partnerships, acting as one team to keep people healthy and well in Croydon, Sutton, Kingston & Richmond, and Merton & Wandsworth.

Our Healthier South East London

Our Healthier South East London (OHSEL) is the NHS Sustainability and Transformation Partnership (STP) for south east London.

We aim to address three problems in local healthcare:

• The health and wellbeing gap – people should be helped to lead healthier and longer lives
• The care and quality gap – variation in the accessibility and quality of care should be improved
• The funding and efficiency gap – the NHS must become more efficient and make better use of the money available

HIN

The Health Innovation Network is the Academic Health Science Network (AHSN) for south London, one of 15 AHSNs across England.

As the only bodies that connect NHS and academic organisations, local authorities, the third sector and industry, we are catalysts that create the right conditions to facilitate change across whole health and social care economies, with a clear focus on improving outcomes for patients.

This means we are uniquely placed to identify and spread health innovation at pace and scale; driving the adoption and spread of innovative ideas and technologies across large populations.

Over 5,000 patients with Type 2 diabetes set to benefit from NHS funding

Cutting-edge technology transforms diabetes care across south London

Test Bed Projects to be shared to improve type 2 diabetes management

30th October 2019 – Diabetes Professional Conference

Dr Neel Basudev will be speaking about You & Type 2.

18th – 20th March 2020 – Diabetes UK Conference

Dr Neel Basudev will be speaking about You & Type 2.

Please find our data privacy notice and that of the partners here.

Care and Support Planning

What is care and support planning?

Care and support planning (CSP) is a systematic process which replaces current planned reviews for people with long term conditions, and is focussed on creating the opportunity for a ‘better conversation’ between the person with LTC/s and a care professional, enabled by preparation.

The CSP process begins with an information gathering appointment in which tasks and tests are collected ahead of the CSP conversation. The results of any information gathered, together with reflective prompts, are sent to the person 1- 2 weeks before the CSP conversation (preparation).

Link to ‘What is care and support planning’ factsheet

What evidence is there that care and support planning works?

Please read the below document to see the evidence for care and support planning.

Download (PDF, 322KB)

What is the process for care and support planning?

Please see the below document explaining what care and support planning is, in a nutshell.

Download (PDF, 415KB)

Please see the below document for a factsheet on care and support planning.

Download (PDF, 349KB)

Will I get training on care and support planning?

SWL to complete

Where else has Year of Care care and support planning been implemented?

Year of Care has been involved in the implementation of care and support planning at over 40 sites across the UK and abroad.

Has anywhere else in the UK used digital technologies alongside YOC process?

Practice IT systems have supported care and support planning since its inception however the You & Type 2 project is the first time software, apps and videos have been developed to support the care and support planning process.

What conditions can be included in the YOC care and support planning process?

The You & Type 2 project focusses on people with type 2 diabetes. However, care and support planning is beneficial for people with other single long term conditions as well as for people living with multiple long term conditions and complexity. People with multiple long term conditions can have one care and support planning consultation that focuses on them as a person rather than their individual long term conditions.

I have to treat patients with multiple comorbidities, can I still use the YOC process?

Yes. Care and support planning is beneficial for people with single long term conditions as well as for people living with multiple long term conditions and complexity. People with multiple long term conditions can have one care and support planning consultation that focuses on them as a person rather than their individual long term conditions.

What does a personalised care plan for patients include?

One of the aims of care and support planning is that each person has a personalised care and support plan. The contents of the plan will vary widely however depending on the conversation that the person and the healthcare professionals have had. The plan may focus on medical aspects such as medication changes or referral to other NHS services.  Alternatively, the focus of the plan may be on the ‘more than medicine’ aspects of care.

What other benefits does YOC care and support planning have?

Please see the below document.

Download (PDF, 322KB)

Can care plans be printed for people who have not used the app?

A printed copy of the person’s results with preparation prompts has always been part of the Year of Care process following the first information gathering appointment. There is a care plan proforma which is completed with the person at the second ‘conversation’ appointment, therefore, the person will leave with their own personalised care plan and a copy of this will be saved in the medical record.

Software and the App

How do the software and mobile app work?

Healum software is designed for Healthcare professionals to support, educate and manage their patients through a mobile app, that supports behavioural change for long-term conditions

I have to treat patients with multiple comorbidities, can I still use Healum?

Yes, you can treat patients with multiple comorbidities and long term conditions

What conditions can you manage through Healum?

• Obesity (All four tiers of weight management)
• Pre-Diabetes
• Type 2 Diabetes
• Cardiovascular Diseases
• Musculoskeletal
• Integrated Health and Lifestyle

Check out the Solutions page for further information

Which system and devices integration does Healum provide?

Currently, Healum provides integration with following systems and devices

• Patient health record systems (EMIS)
• Fitness wearables (Fitbit, Google Fit & Withings)

We take a consultative approach to solutions. If you are interested in any specific integrations, please get in touch to see how we can help you.

What method of behavioural change does Healum follow?

Our product uses COM-B model of behaviour change, which forms one of the cornerstones of any solution that we develop and our entire product offering including the software, apps and the platform.

What does a personalised care plan for patients include?

The personalised care plans include access, sharing and tracking of articles, videos, recipes, exercises, local services and monitoring & tracking the patient progress – all in one place

Will I get training on the software?

Yes, you will. Both the Project team along with the tech partners (Healum) will be training you on the software.

What additional training is to be expected?

You will not be requiring additional training. However, if need be you can always contact Healum team or the project team. There are also software walkthrough videos that you can refer to.

How do I update a patient’s records?

Go on to EMIS > Select You & Type 2 on bottom left > Select patient > Enter relevant data about the patient

Where else has Healum been?

Healum has worked with the NIHR, Rotherham Institute of Obesity, BeeZee Bodies, and is currently working on an AI project in Manchester with Vernova CIC.

What other benefits does Healum provide?

Healum provides a white label solution that can be customised to the requirements for behavioural change programmes for long-term conditions. Healum is currently developing the AI capabilities of its technology.

Can care plans be printed for non-digital users?

Healum provides an option to directly print the care plans within its software with a simple click under Patients profile > Care planning summary > Print care plan

How often am I expected to update my patients’ records?

During the appointment and maybe once a month for a few minutes if you would like to.

Personalised Videos

What do I do if my patient has not received their video?

Report it to the You & Type 2 service desk

What do I do if my patient was served incorrect data?

Report it to the You & Type 2 service desk

Can I view my patient’s video?

Only if the patient shares it with you. Data protection means that only the patient can view their video unless they choose to share it with anyone else.

Where have you been successful before?

Personalised video messaging has been around since 2007. In the UK organisations like; Tesco, Sky, O2, Lloyds Bank and Barclays bank are using personalised video as part of their routine customer communication. The You & Type 2 service is the first time that this approach to communication has been used within the NHS.

What evidence do you have that this service is successful?

A range of case studies from the commercial sector has shown the measurable effect personalised video messaging has on behaviour change. Through this testbed project, we will gain objective evaluation as to its effectiveness in a health setting.

Is patient data protected?

Yes before being able to launch this service the technology had to pass a rigorous assurance process overseen by NHS England

How does the app work?

Oviva Diabetes Support is much more than an app!

Oviva provides remote lifestyle and behaviour change services, harnessing technology to improve outcomes. The Oviva app is one way we enable service users to track diet, weight and monitor goals. Through the Oviva app, patients are able to have high frequency, personalised coaching with their dietitian. All of our learning content (including podcasts and videos) can be accessed on the app, as well as via PC and tablet too.

There are lots of people who would benefit from a remote structured education programme who don’t have smartphones, these people can choose to receive telephone support instead, with a hard copy available of all the learning resources.

What does a personalised care plan for patients include?

The diabetes specialist dietitian will work with the person to develop short and long term goals. They will identify motivators and create a plan which works towards the person’s goals while fitting in with their lifestyle.

Will I get training on the software?

Once the person begins their programme with Oviva, they choose a digital or non-digital pathway. For the people choosing a digital pathway, they will be guided through using the Oviva App to help monitor their progress and interact with their dietitian. They are also provided with an app guide for the different features.

The referring Healthcare Professional does not need to interact with the app, this is managed entirely by the diabetes specialist dietitian at Oviva.

How do I update a patient’s records?

Oviva reports directly into the National Diabetes Audit. This is aimed at reducing the pressures on Primary Care. A discharge letter is sent to the person’s GP at the conclusion of their programme. This will include all relevant information and a summary of care received.

Diabetes Structured Education Programme

What is Diabetes Support?

Oviva Diabetes Support is a 100% remote Type 2 diabetes structured education and behaviour change programme, delivered 1-to-1 by a diabetes specialist dietitian over 9 weeks plus tailored digital support to 12 months.

It is proven to widen access to education, increase participants confidence in self-managing their condition as well as helping people achieve a healthy weight, blood glucose, blood pressure & lipid levels.

How is Oviva regulated in the UK?

All Oviva dietitians are registered with the Health and Care Professionals Council and undergo regular reviews and training with our Clinical Director.

Is patient data protected?

Patient medical records, including personal information such as name, address, and the content of any communication with the dietitian will be kept strictly confidential and will not be sold to third parties, nor distributed. Please read more about how we keep patient data secure in our Privacy Statement.

Have you got any evidence to support your service?

Yes.

Alongside various studies that have proven that remote structured education services have better uptake, and similar clinical outcomes, we published our 12-month outcomes (below) at the 2018 Diabetes UK Conference.

• HbA1c reduction from baseline – 12mmol/mol
• Weight reduction from baseline – 3.3kg (3.9%)
• Diabetes remission rate – 24%
• Increase in confidence in self-management – 4/10 to 8/10
• Extremely likely or likely to recommend to friends and family (FFT) – 97%

How many people have gone through your service?

Over 5,000 people have been treated by Oviva Diabetes Support. 78% of people who are referred to Oviva attend their programme, whilst the national average around 10%.

We often deliver our remote service alongside local face to face services. For some people (around 60%), face to face group services are not appropriate. It might be that time off work, childcare, embarrassment are all barriers to access, and we find that rather than Oviva’s presence taking activity from the local face to face provider, we actually increase uptake.

Where else has Oviva been implemented?

Oviva provides clinically-led services in over 81 CCGs and 19 STPs across the United Kingdom. Oviva specialises in Type 2 Diabetes, and offers programmes for prediabetes (Diabetes Prevent), newly diagnosed diabetes (Diabetes Support), and diabetes remission (Diabetes 800).

Our Diabetes Prevent programme is part of the NHS England National Diabetes Prevention Programme Framework, and is available across South London.