Supporting Care Needs at Home

The Joint Strategic Needs Assessment identifies that the population of Angus is growing older and that the population of Angus will continue to age for the next 20 years. It is anticipated that this change in population demographics will place a further increase in demand on services if they continue to be delivered in the same way. The Strategic Commissioning Plan 2019/22 aims to continue to address demographic change by changing the way that services are provided and to shift the balance from care to supporting more people at home. The focus of the Strategic Commissioning Plan 2019/22 is to support care needs at home by enhancing opportunities for technology enabled care; further progressing self-directed support; and delivering change in care at home services through the Help to Live at Home project.

Our Measures




ore Detail on the measures can be found here.

Our Practice

Angus Health and Social Care Partnership (HSCP), manages the implementation of the Florence Home Mobile Health Monitoring (HMHM) system which uses a simple texting system that sends messages to peoples’ mobile phones reminding them to take their blood pressure reading or weigh themselves and then text back the results. The system receives the texts and people may then receive further texts providing advice and instructions if necessary. People with conditions such as high blood pressure, chronic pain and fatigue as well as those seeking support with weight management are participating in this HMHM initiative.

In April 2019 an evaluation report, Towards Scaling Up Home Mobile Health Monitoring in Taysidecommissioned by the Scottish Government, praised the home mobile health monitoring (HMHM) initiative led by Angus HSCP.

In 2019/20 Angus HSCP was awarded £139.456 to implement the Scale-Up (BP) Programme across Tayside. This is an example of how digital technology can be used to optimise care, support and enable increased self-management and improve health outcomes whilst helping Primary Care Services to make best use of available resources. Eight GP practices in Angus have signed up to this initiative. Technical challenges with integrating Flo data with GP systems has caused a delay with recruitment. One GP Practice in Forfar has recruited 31 patients to Flo to support with contraceptive advice and BP monitoring.

On 8th May 2019 Angus HSCP, supported by the Scottish Government Technology Enabled Care (TEC) Programme hosted an event to accelerate the update of HMHM across Tayside. NHS Tayside’s director of public health, Dr Drew Walker, said “Remote monitoring is just one of a range of digital approaches which can improve health and there is now a real need to push that much harder and further so that its full potential to improve health and reduce health inequalities can be realised.”

Near Me is a secure form of video consulting approved for use by the Scottish Government and NHS Scotland and provides appointments and consultations virtually meaning people do not need to travel to attend but can be seen by their service provider in the comfort of their own home, at work or while on the move.

Angus HSCP has been working closely with NHS Tayside who are working to embed the system into everyday work practise for outpatient and GP services. The aim is to have Near Me offered routinely as an option for appointments and consultations. By the 2nd of April 2020, all Angus GP’s were enabled with the Near Me kit and training links. The roll-out continues to be progressed.


In 2019 we were awarded £9696.46 from the TEC Programme to expand the Angus initiative called Check TEC Out which enables vulnerable older people to test a range of low cost, easy to use technology. In addition to LED Night Lights, Wireless Remote Control Sockets, Ownfone, Projection Clock we now offer Alexa Shows and associated set up equipment (Wi-Fi travel unit, SIM cards and support stands) and Echo Dots with Wi-Fi and SIM support.

In May 2019 we re-launched the Technology Enabled Care section of the Angus HSCP website.  This includes an interactive poster will illustrates the range of telecare available to support people and keep them safe within their own homes we created an interactive poster.

As part of our commitment to the Technology Charter for People with Dementia we have been actively promoting the uptake of the Purple Alter app across Angus. Purple Alert is a free mobile phone app designed by people living with dementia and their carers’ with Alzheimer’s Scotland, Police Scotland, Social Work, Dementia Friends, Dementia Friends Scotland, HSCPs and telecare services.  The app allows carers to share the person living with dementia’s profile if they lose their way and allows for others to report a sighting of that person. Staff have been enabled to use the app on their work phones so that as many people as possible are available to search in case of an alert. We have also been working closely with colleagues from NHS, Scottish Fire & Rescue service and Police Scotland (Tayside) to promote and encourage uptake in the use of this app.  The app is currently going through a major redesign and Alzheimer’s Scotland are looking to launch a new app in August 2020.

In November 2019 the North East and North West Locality Improvement Groups awarded funding to introduce Advanced Risk Modelling for Early Detection (ARMED). ARMED supports vulnerable people to participate in wearing a polar loop bracelet (fit bit) which monitors their health statistics and collates this information using a mobile phone app to build up a picture of the person’s general health and fitness levels. The polar loop also serves as a prompt to remind the person to move/exercise regularly to maintain and build upon their core strength, improve mobility and overall wellbeing.  The start of the project, originally planned for March 2020, has been put on hold due to the COVID-19 pandemic, but we are eager to commence as soon as possible because evidence suggests people are not moving as much whilst in lockdown and motor skills are deteriorating. Which increases the risk of falling.

The Analogue to Digital transition of the Community Alarm service in Angus was progressed towards the end of 2019 when tender for contracts was submitted and awarded.  Work is now in process to manage the upgrade to the Community Alarm Control Room and migration of all current dispersed alarm units with a digitally enhanced version.

An introductory E-Learning Induction Course on Technology Enabled Care incorporating both Home Mobile Health Monitoring and Telecare is now available to all HSCP staff.  The module helps to inform new and existing staff of the differing types of TEC and provides examples of how it utilises within their work practice.

A number of telecare promotion events have been staged throughout 2019/20 where we have tried to reach as many people as possible and raise awareness of the benefits of telecare.  Venues have ranged from shopping centres, leisure centres, libraries, Angus Community Hospitals and Sheltered Housing facilities. Meetings have also taken place at Angus Carers Group and a variety of staff meetings.  A rolling program of refresher training is currently in development to ensure staff are continually updated about the range of available telecare.

The FIRST (Falls Integrated Response and Support Technology) Falls Pathway was launched September 2019.  The aim being to improve the experience & outcomes for people living with frailty who fall, are uninjured and require assistance from services to get up from the floor. The FIRST pathway now ensures a response and support for people who do not need an ambulance response and have not subscribed to a community alarm response service and allows for follow up action to be taken in the event of concerns being raised regarding the person who has fallen.  Since the introduction of this pathway there have been 3 incidents recorded.

Access to long term social care support requires an assessment of need by Care Management Teams Individuals then make choices about what services would meet their needs and personal outcomes, how and when those supports will be delivered/accessed and who will provide them. Self-directed support is the mechanism by which these choices are provided. The options available are: Option 1 – direct payment Option 2 – person directs the available support Option 3 – local authority arranges the support Option 4 – mix of the above Self-Directed Support Uptake of Options
Indicator 2015/16 2016/17 2017/18 2018/19 2019/20
Option 1 4% 8% 6% 7% 7%
Option 2 13% 15% 22% 23% 25%
Option 3 79% 73% 67% 65% 61%
Option 4 4% 4% 5% 6% 7%
2646 people have care plans in place that include support that is subject to self-directed support options in 19/20. There has been a shift towards greater choice and control with a greater proportion of supported people accessing options 1, 2 and 4.  Most people in Angus continue to access option 3, asking Partnership staff to organise support on their behalf, although the proportion of people using option 3 continues to decrease. Option 1 (direct payments) give people the maximum amount of choice and control over the way their support is arranged. Angus HSCP commissions Dundee Carers Centre to provide support for those who wish to use option 1.
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