Remote monitoring mental health pathway: standard operating procedure

In 2023, Digital and Health Care Scotland launched the Remote Monitoring Mental Health Pathway, a significant step forward in supporting mental health through digital innovation.

This initiative is centred on the use of validated, evidence-based Patient-Rated Outcome Measures (PROMs) standardised tools that empower individuals to self-report on their health status, symptoms, and quality of life. These insights are gathered without the need for clinician interpretation, enabling more responsive and person-centred care.

Key benefits of the pathway include:

• Earlier detection and intervention in the management of certain health conditions.
• Increased knowledge and confidence among individuals in managing their own health.

You can learn more about the pathway by visiting: Mental Health | Turas | Learn.

Purpose

This SOP outlines aims to establish a clear and consistent approach to the application of PROMs within the Remote Monitoring Mental Health Pathway, delivered through the Connect Me platform.

This SOP will undergo a comprehensive review every 2 years to ensure it remains current and effective. While the primary audience is internal staff, the SOP will be accessible to external stakeholders with an interest in how digital technologies are enhancing health and care outcomes across NHS Ayrshire and Arran.

Scope

This SOP applies to all staff groups involved in integrating Mental Health PROMs into their clinical practice through the Remote Monitoring Mental Health Pathway.

Staff are reminded they may have patients who require communication in a form other than English e.g. other languages or British Sign Language (BSL). Additionally, some patients may have difficulties with written material. At all times, communication and material should be available in the patients preferred format. This may also apply to patients with learning difficulties. In some circumstances there may be religious and/or cultural issues which impact this SOP e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have physical disabilities which may make it difficult for them to be treated/examined as set out in the SOP, requiring adaptations to be made. Patients’ sexuality may or may not be relevant to the implementation of this SOP; however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

PROMs are standardised tools which enable individuals to self-report on their health status, symptoms, and quality of life, providing critical insights without clinician interpretation.

The Remote Monitoring Mental Health Pathway is designed to allow patients to submit clinical outcome measures digitally. This option is not meant to replace existing methods, such as completing PROMs through platforms like Care Partner or using paper forms. Instead, it provides a digital alternative which empowers patients to take greater ownership of their health data and encourages more active collaboration with their mental health professionals as part of their ongoing care.

The Remote Monitoring Mental Health Pathway currently offers access to the following PROMs:

• CORE-10
• DERS-18
• GAD-7
• GASS / GASS Clozapine
• Work and Social Adjustment Scale (WSAS)
• IAPT Phobia Scales
• PHQ-9
• Clinical Global Impression – Improvement (CGI-I)
• Clinical Global Impression – Severity (CGI-S)
• Patient Global Impression – Improvement (PGI-I)
• KIDSCREEN-10 / KIDSCREEN-10 (Parent Version)

Please refer to Appendix 1 for a detailed overview of the purpose and application of each PROM.

NB: Clinicians can select as many PROMs as needed for completion. As the pathway evolves, it is expected that additional PROMs will be incorporated.

PROMs are typically introduced at the start of treatment to establish a baseline and are subsequently repeated at pre-determined intervals thereafter. Some of these outcome measures include direct questions regarding the presence of suicidal thoughts, self-harm, or other distressing experiences. Patient safety remains the top priority, while also empowering staff and clinical teams to confidently offer the Remote Monitoring Mental Health Pathway as a digital alternative to existing methods like Care Partner or paper forms, for PROMs currently in use or under consideration.

PROMs should be fully integrated into existing care pathways, with clearly defined roles and responsibilities for their use. This includes specifying how and when individual staff and clinical teams should monitor and respond to PROMs, ensuring consistency and timely clinical action. Additionally, where able patients and carers should be provided with clear information on self-management strategies, as well as guidance on when and how to access urgent or additional support services.

To support safe digital completion of PROMs via the Remote Monitoring Mental Health Pathway, all patient-facing materials and notifications will clearly state the following as an additional safeguard:

When evaluating a patient’s suitability for onboarding to the Remote Monitoring Mental Health Pathway for PROMs completion, clinicians should additionally assess key factors such as the patient’s digital literacy, cognitive capacity, and access to suitable technology (e.g., a computer, tablet, or smartphone) and necessary support.

NB: Some local libraries and community groups are known to offer digital support and access to devices, helping patients to engage more confidently with digital health tools.

On occasion, either a Team Administrator or a Clinician may be responsible for registering a patient onto the pathway, to gain access to the Remote Monitoring Mental Health Pathway on Connect Me, users must complete the System Access Form, available in Appendix 2.

1. The completed form should be submitted to Telehealthcare@aapct.scot.nhs.uk
2. Once approved, users will receive login credentials to access the pathway on Connect Me. An email will be sent containing their username and a link to set their own password.
3. Users can then log in to the system via a web browser using this link: https://portal.inhealthcare.thirdparty.nhs.uk/portal/login

If additional support is required to use the Remote Monitoring Mental Health Pathway, staff are encouraged to contact NHSAA TeC Team, who may be able to arrange a demonstration for you and your team.

The following steps detail the process for enrolling patients into the Remote Monitoring Mental Health Pathway. For convenience, a printable version is available in Appendix 3 which summarises the process.

Step 1: If the patient agrees to complete their PROMs via the Remote Monitoring Mental Health Pathway, the clinician should aim to provide them with then appropriate information leaflet.

• National resources and leaflets can be accessed through the Mental Health section on Turas Learn - Mental Health | Turas | Learn.
• In NHSAA, locally developed resources are available. These can be provided to the patient either as printed materials (Appendix 4) or by signposting them to the NHSAA TEC Team Public Site - Technology Enabled Care - NHS Ayrshire & Arran

Step 2: The patient will then be onboarded onto the Remote Monitoring Mental Health Pathway. Ensure you have the correct email address or mobile phone number for the patient.

Comprehensive guidance on the digital onboarding process can be found in Appendix 5.

Step 3: The Remote Monitoring Mental Health Pathway will integrate with SCI Store to download patient demographics (using their CHI number). It should be noted that patients may be assigned more than one PROM, depending on their individual clinical presentation, condition severity, or specific treatment goals as determined during assessment.

Step 4: After the patient is enrolled in the pathway, they will receive an email or text message with instructions (detailed below) on how to access the relevant PROM(s) via the Inhealthcare platform.

Remote Monitoring Mental Health Pathway notifications

• If the patient fails to respond to this initial communication, they will be sent a repeat notification in 2 days.
• After 7 days a 2nd reminder text message or email will be sent.
• The PROMs link will timeout after 14 days

If the PROMs times out a text message or email will be sent to the patient advising they have been unable to complete the outcome measure. An alert will be raised on the clinician portal informing the patient has not completed the PROM within the allotted 14 days. The PROMs can also be deactivated by the clinician, with the following options available as reasons: "Service is no longer required" or “Patient Opted Out”.

The service will deactivate automatically if the patient does not respond within 20 days or at the point the last clinical outcome measure has been completed. Once the service is deactivated, the patient no longer appears on the clinician’s patient list on Inhealthcare.

NB: If the patient has not responded to the link and it has expired, the clinician should revisit the matter at the next scheduled appointment and, if appropriate, offer alternative methods for completing the PROMs.

• A PDF output report will be generated showing the responses recorded by the patient and their scores.

A copy of the PDF report, including the generated PROMs scores, will be shared with the patient via email (if this is their preferred method of communication) upon completion.

• Clinicians are required to access the clinician portal prior to each scheduled patient appointment to review the relevant PROMs results. The timeframe for reviewing and responding to these results should align with local governance agreements established for the use of specific PROMs in clinical practice.
• Clinicians should ensure relevant electronic health records (e.g., Care Partner) are updated to ensure PROMs scores and outcomes are readily accessible to the wider care team. This may involve uploading the generated PDF output report to the appropriate framework or contact record.

NB: Enhanced functionality allows frequency alerts to be pre-set for PROMs which require completion at specific intervals such as weekly, monthly, or annually, ensuring timely follow-up and consistent monitoring.

The Remote Monitoring Mental Health Pathway is a dynamic and continuously evolving framework, underpinned by a strong commitment to innovation and continuous improvement. As part of this, patients may be invited to provide feedback on their experience through integrated surveys within the pathway, helping to inform future enhancements and ensure the service remains responsive to user needs.

NHS Education for Scotland (2023) TEC Remote Health Monitoring/Connect Me Equality Impact Assessment.[Accessed: 21 May 2025].

NHS Education for Scotland (NES). Remote Health Monitoring and Consulting. [Accessed: 19 May 2025].

Scottish Government (2024). Care in the Digital Age: Delivery Plan 2024–25. [Accessed 19 May 2025].

Current measures (May 2024)

System access request form - TEC system 

AA Technology Enabled Care (TEC) - Remote monitoring staff poster

AA Technology Enabled Care (TEC) Remote monitoring patient leaflet 

AA Technology Enabled Care (TEC) mental health clinician guide