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Client Group: Older adults

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Service Area

Setting

Enablers

Integration Authority

Element of Framework

Aberdeen City - Granite Care Consortium

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Example of Good Practice

Granite Care Consortium

Service Area(s)

All Social care services Rehabilitation Physical disabilities Learning disabilities Community care Mental health Physical health Admission avoidance Management team

Setting(s)

All City Urban

Enabler(s)

All Technology Improvement capacity Management information Information sharing Aligned plans Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All Aberdeen City

Elements of Framework

All Reablement Live independently at home or in a homely setting
Aberdeen City - Social prescribing

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Example of Good Practice

Social prescribing

Service Area(s)

All Mental health Physical health

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Aberdeen City

Elements of Framework

All Connect with communities Manage own care Teams aligned to general practice
Aberdeenshire - MDT working in locality based teams COVID-19

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Example of Good Practice

Aberdeenshire - MDT working in locality based teams COVID-19

Service Area(s)

All Primary care Intermediate care incl Hospital at Home Community care

Setting(s)

All Urban Remote and rural Corporate

Enabler(s)

All Information sharing Agile working Clinical and care governance Team ethos Well developed relationships Collaborative leadership

Integration Authority

All Aberdeenshire

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
Aberdeenshire - Residential Care Home: New Opportunities

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Example of Good Practice

Residential Care Home: New Opportunities

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Aberdeenshire

Elements of Framework

All Reablement Enhanced care in care homes and supported accommodation Fully integrated community teams
Ageing well, New Zealand

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Example of Good Practice

Ageing well with LifeCurve in New Zealand

Service Area(s)

All Rehabilitation Physical health

Setting(s)

All Remote and rural

Enabler(s)

All Technology

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
Angus - Check TEC Out

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Example of Good Practice

Check TEC Out

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Angus

Elements of Framework

All Live independently at home or in a homely setting
Angus - Intermediate (step-up) care

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Example of Good Practice

Intermediate (Step-up) Care

Service Area(s)

All Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Angus

Elements of Framework

All Short-term, targeted interventions to meet more complex needs Enhanced care in care homes and supported accommodation Fully integrated community teams
Angus - Monifieth Integrated Care

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Example of Good Practice

Monifieth Integrated Team

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Community care Supported discharge Physical health

Setting(s)

All Corporate

Enabler(s)

All Improvement capacity Information sharing Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Angus

Elements of Framework

All Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
Approach to social prescribing, Northern Ireland

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Example of Good Practice

Asset based community development approach to social prescribing (IMPACT Age Well) in Northern Ireland

Service Area(s)

All Primary care Physical health

Setting(s)

All Remote and rural

Enabler(s)

All Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Connect with communities Manage own care Assets based approach Teams aligned to general practice
Argyll and Bute - Attend Anywhere

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Example of Good Practice

Attend Anywhere

Service Area(s)

All Mental health Physical health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting
Argyll and Bute - HSCP Huddle

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Example of Good Practice

Service Area(s)

All Management team

Setting(s)

All Remote and rural Corporate

Enabler(s)

All Infrastructure Culture and values Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Argyll and Bute

Elements of Framework

All
Argyll and Bute - Living Well

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Example of Good Practice

Living Well in Argyll and Bute

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute

Elements of Framework

All Reablement Connect with communities Manage own care Assets based approach
Argyll and Bute - Physical activity and frailty during COVID-19 pandemic

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Example of Good Practice

Service Area(s)

All Rehabilitation Physical health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute

Elements of Framework

All Connect with communities Manage own care Live independently at home or in a homely setting
Clackmannanshire and Stirling - Commissioning consortium

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Example of Good Practice

Commissioning Consortium

Service Area(s)

All Social care services Justice Day services Housing incl homelessness Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Admission avoidance

Setting(s)

All Urban Remote and rural Corporate

Enabler(s)

All Improvement capacity Culture and values Well developed lead professional roles Management information Information sharing Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Clackmannanshire and Stirling

Elements of Framework

All Connect with communities
Clackmannanshire and Stirling - Stirling Health and Care Village

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Example of Good Practice

Stirling Health and Care Village

Service Area(s)

All Supported discharge Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Clackmannanshire and Stirling

Elements of Framework

All Short-term, targeted interventions to meet more complex needs
Community care (Wigan Deal), England

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Example of Good Practice

Community care in Wigan, England

Service Area(s)

All Community care

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
Compassionate community, Spain

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Example of Good Practice

'All with you' - approach to palliative and end of life care, Seville

Service Area(s)

All

Setting(s)

All City Urban Remote and rural

Enabler(s)

All Culture and values Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
Digital hub support for care homes, England

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Example of Good Practice

Digital hub support for care homes in Tameside and Glossop, England

Service Area(s)

All Intermediate care incl Hospital at Home Community care Physical health Admission avoidance

Setting(s)

All City Urban

Enabler(s)

All Technology Infrastructure Well developed lead professional roles Information sharing Collaborative leadership

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Seamless working with acute care Enhanced care in care homes and supported accommodation
Dumfries and Galloway - Good conversations

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Example of Good Practice

Good conversations

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Dumfries and Galloway

Elements of Framework

All Assets based approach
Dumfries and Galloway - Response to care and support at home during COVID-19

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Example of Good Practice

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Agile working Aligned plans Shared accountability Collaborative leadership

Integration Authority

All Dumfries and Galloway

Elements of Framework

All Reablement Live independently at home or in a homely setting
Dumfries and Galloway - Transforming learning disability services

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Example of Good Practice

Transforming learning disability services

Service Area(s)

All Learning disabilities

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Dumfries and Galloway

Elements of Framework

All First point of contact Connect with communities Assets based approach Fully integrated community teams
Dundee City - Integrated Care Home Team

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Example of Good Practice

Integrated Care Home Team

Service Area(s)

All Community care

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Dundee City

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
Dundee City - Turriff House Intermediate Care Suite

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Example of Good Practice

Turriff House Intermediate Care Suite

Service Area(s)

All Intermediate care incl Hospital at Home

Setting(s)

All City

Enabler(s)

All Improvement capacity Culture and values Well developed lead professional roles Collaborative leadership

Integration Authority

All Dundee City

Elements of Framework

All Reablement Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation
East Ayrshire - Collaborative commissioning with third sector partners

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Example of Good Practice

Collaborative commissioning with third sector partners

Service Area(s)

All Primary care Social care services Addictions Mental health

Setting(s)

All Urban Remote and rural

Enabler(s)

All Culture and values Well developed relationships Clarity of vision

Integration Authority

All East Ayrshire

Elements of Framework

All Connect with communities
East Ayrshire - Right Support, Right Place, Right Time

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Example of Good Practice

Right Support, Right Place, Right Time

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Ayrshire

Elements of Framework

All Manage own care Assets based approach Live independently at home or in a homely setting
East Ayrshire - Thinking Differently Programme

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Example of Good Practice

Thinking Differently Programme

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All Culture and values Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All East Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting
East Dunbartonshire - Caring Together

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Example of Good Practice

Caring Together

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Dunbartonshire

Elements of Framework

All Anticipatory care planning Enhanced care in care homes and supported accommodation Fully integrated community teams
East Dunbartonshire - Enhanced clinical support for care homes

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Example of Good Practice

Enhanced clinical support for care homes

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All Culture and values Well developed relationships Collaborative leadership

Integration Authority

All East Dunbartonshire

Elements of Framework

All Teams aligned to general practice Enhanced care in care homes and supported accommodation
East Lothian - Integrated Care Assessment Team (ICAT)

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Example of Good Practice

Integrated Care Assessment Team (ICAT)

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Physical health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All Technology Infrastructure Culture and values Well developed lead professional roles Information sharing Agile working Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All East Lothian

Elements of Framework

All Reablement Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
East Lothian - Short Term Assessment and Rehabilitation

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Example of Good Practice

Short Term Assessment and Rehabilitation

Service Area(s)

All Supported discharge Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Lothian

Elements of Framework

All First point of contact Reablement Connect with communities Manage own care Seamless working with acute care Short-term, targeted interventions to meet more complex needs Fully integrated community teams
East Lothian - Wellwynd Hub

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Example of Good Practice

East Lothian - Wellwynd Hub

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Housing incl homelessness Physical disabilities Physical health

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Well developed lead professional roles Information sharing Fit for purpose premises Team ethos Well developed relationships

Integration Authority

All East Lothian

Elements of Framework

All First point of contact Reablement Assets based approach Live independently at home or in a homely setting Fully integrated community teams
East Renfrewshire - Community Led Support - Talking Points

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Example of Good Practice

Community Led Support - Talking Points

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Renfrewshire

Elements of Framework

All Connect with communities Assets based approach Teams aligned to general practice Live independently at home or in a homely setting
Edinburgh City - Delayed discharge leadership

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Example of Good Practice

Delayed discharge leadership

Service Area(s)

All Community care Management team

Setting(s)

All City

Enabler(s)

All Culture and values Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Edinburgh City

Elements of Framework

All Seamless working with acute care
Edinburgh City - Improving falls in Edinburgh care homes

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Example of Good Practice

Improving falls in Edinburgh care homes

Service Area(s)

All Community care

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Edinburgh City

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
Edinburgh City - Three Conversations

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Example of Good Practice

Three Conversations

Service Area(s)

All Social care services Rehabilitation Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance Management team

Setting(s)

All City Urban

Enabler(s)

All Technology Infrastructure Improvement capacity Well developed lead professional roles Agile working Aligned plans Team ethos Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Edinburgh City

Elements of Framework

All Connect with communities Manage own care Assets based approach
Enhanced intermediate care, England

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Example of Good Practice

Enhanced intermediate care in Torbay and South Devon, England

Service Area(s)

All Primary care Intermediate care incl Hospital at Home Rehabilitation Mental health Physical health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All Information sharing Clinical and care governance Team ethos Well developed relationships

Integration Authority

All Other health and social care providers

Elements of Framework

All Reablement Manage own care Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Enhanced transitional care, Singapore

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Example of Good Practice

Enhanced transitional care in Singapore

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Physical health

Setting(s)

All Urban

Enabler(s)

All Well developed lead professional roles Team ethos

Integration Authority

All Other health and social care providers

Elements of Framework

All Reablement Seamless working with acute care Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Falkirk - COVID-19 Mobilisation Centre

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Example of Good Practice

COVID-19 Mobilisation Centre

Service Area(s)

All Management team

Setting(s)

All Corporate

Enabler(s)

All Information sharing Collaborative leadership

Integration Authority

All Falkirk

Elements of Framework

All Connect with communities Enhanced care in care homes and supported accommodation
Falkirk - Living Well

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Example of Good Practice

Living Well Falkirk

Service Area(s)

All Community care Physical health

Setting(s)

All Urban

Enabler(s)

All Technology Aligned plans Clarity of vision

Integration Authority

All Falkirk

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting
Fife - Care at Home Collaborative

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Example of Good Practice

Care at Home Collaborative

Service Area(s)

All Social care services Community care Admission avoidance

Setting(s)

All Urban

Enabler(s)

All Infrastructure Improvement capacity Culture and values Management information Information sharing Agile working Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Fife

Elements of Framework

All Reablement Live independently at home or in a homely setting
Fife - High Health Gain

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Example of Good Practice

Fife High Health gain

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Fife

Elements of Framework

All First point of contact Teams aligned to general practice Seamless working with acute care
Fife - Partnership working with discharge hub and Fife Carers Centre

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Example of Good Practice

Partnership working with discharge hub and Fife Carers Centre

Service Area(s)

All Community care Supported discharge

Setting(s)

All City Corporate

Enabler(s)

All Well developed lead professional roles Information sharing Agile working Well developed relationships

Integration Authority

All Fife

Elements of Framework

All Connect with communities Manage own care
Aberdeen City - Frailty pathway, Rosewell House

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Example of Good Practice

Frailty Pathway, Rosewell House

Service Area(s)

All Supported discharge Physical health Admission avoidance

Setting(s)

All City

Enabler(s)

All Culture and values Fit for purpose premises Aligned plans Clarity of vision Collaborative leadership

Integration Authority

All Aberdeen City

Elements of Framework

All Reablement Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs
Glasgow City - Mental Health Assessment Units

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Example of Good Practice

Service Area(s)

All Mental health

Setting(s)

All City Urban

Enabler(s)

All Information sharing Well developed relationships Clarity of vision

Integration Authority

All Glasgow City

Elements of Framework

All First point of contact Seamless working with acute care Short-term, targeted interventions to meet more complex needs
Highland - Developing flexible care in MacKenzie Centre

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Example of Good Practice

Developing flexible care in MacKenzie Centre

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Highland

Elements of Framework

All Connect with communities Assets based approach Live independently at home or in a homely setting
Highland - Enhancing community services

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Example of Good Practice

Enhancing community services, Inverness

Service Area(s)

All Social care services Community care Supported discharge Admission avoidance

Setting(s)

All Urban

Enabler(s)

All Infrastructure Improvement capacity Culture and values Management information Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Highland

Elements of Framework

All Live independently at home or in a homely setting Fully integrated community teams
Hospice at Home, Isle of Man

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Example of Good Practice

Hospice at Home in Isle of Man

Service Area(s)

All Intermediate care incl Hospital at Home Supported discharge Physical health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All Technology Agile working Clinical and care governance Team ethos Well developed relationships

Integration Authority

All Other health and social care providers

Elements of Framework

All Anticipatory care planning Connect with communities Manage own care Assets based approach Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs
Integrated behavioural health, USA

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Example of Good Practice

Integrated behavioural health in California, USA

Service Area(s)

All Primary care Mental health Physical health

Setting(s)

All City Urban Remote and rural

Enabler(s)

All Well developed lead professional roles Team ethos Well developed relationships

Integration Authority

All Other health and social care providers

Elements of Framework

All Manage own care Assets based approach Teams aligned to general practice
Integrated community care for older people, Canada

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Example of Good Practice

Integrated community care for older people in Toronto, Canada

Service Area(s)

All Primary care Social care services Intermediate care incl Hospital at Home Rehabilitation Day services Housing incl homelessness Physical disabilities Community care Supported discharge Mental health Physical health

Setting(s)

All City

Enabler(s)

All Infrastructure Clinical and care governance Well developed relationships Shared accountability

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Connect with communities Manage own care Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Enhanced care in care homes and supported accommodation Fully integrated community teams
Inverclyde - Home first interface arrangements

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Example of Good Practice

Home first interface arrangements

Service Area(s)

All Management team

Setting(s)

All Urban

Enabler(s)

All Information sharing Aligned plans Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Inverclyde

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
Inverclyde - Re-attenders at ED

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Example of Good Practice

Re-attenders at ED

Service Area(s)

All Addictions Mental health Physical health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Inverclyde

Elements of Framework

All Connect with communities Seamless working with acute care Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Local area coordination, England

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Example of Good Practice

Local area coordination in Derby and Isle of Wight

Service Area(s)

All Social care services Physical disabilities Learning disabilities Mental health Physical health Admission avoidance

Setting(s)

All City Remote and rural

Enabler(s)

All Culture and values Well developed relationships Collaborative leadership

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs
Midlothian - Home first approach

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Example of Good Practice

Home first approach

Service Area(s)

All Primary care Social care services Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Infrastructure Improvement capacity Culture and values Management information Information sharing Agile working Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Midlothian

Elements of Framework

All First point of contact Connect with communities Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
Moray - Community Wellbeing Development Team: Rich conversations

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Example of Good Practice

Rich conversations

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Moray

Elements of Framework

All Connect with communities Manage own care Assets based approach
Moray - Discharge to assess pilot project

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Example of Good Practice

Discharge to assess pilot project

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Physical disabilities Supported discharge Physical health Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Improvement capacity Well developed lead professional roles Information sharing Agile working Clinical and care governance Team ethos Well developed relationships Clarity of vision

Integration Authority

All Moray

Elements of Framework

All Reablement Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Moray - Integrated Mental Health Services

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Example of Good Practice

Integrated Mental Health Services

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Moray

Elements of Framework

All Connect with communities Manage own care Assets based approach Fully integrated community teams
North Ayrshire - Trindlemoss Court and Warrix Avenue

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Example of Good Practice

Trindlemoss Court and Warrix Avenue

Service Area(s)

All Social care services Rehabilitation Day services Housing incl homelessness Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance

Setting(s)

All Urban

Enabler(s)

All Technology Infrastructure Improvement capacity Culture and values Well developed lead professional roles Management information Information sharing Fit for purpose premises Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All North Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Seamless working with acute care Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation Fully integrated community teams
North Lanarkshire - Care Academy

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Example of Good Practice

Care Academy

Service Area(s)

All Primary care Social care services Intermediate care incl Hospital at Home Justice Rehabilitation Day services Housing incl homelessness Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance Management team

Setting(s)

All Corporate

Enabler(s)

All Improvement capacity Culture and values Management information Information sharing Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All North Lanarkshire

Elements of Framework

All First point of contact Connect with communities
North Lanarkshire - Community Solutions Programme

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Example of Good Practice

Service Area(s)

All Social care services Rehabilitation Day services Addictions Physical disabilities Learning disabilities Supported discharge Mental health Physical health Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Infrastructure Improvement capacity Culture and values Information sharing Agile working Team ethos Well developed relationships Collaborative leadership

Integration Authority

All North Lanarkshire

Elements of Framework

All First point of contact Connect with communities Manage own care
North Lanarkshire - High Resource User Project

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Example of Good Practice

High Resource User Project

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Lanarkshire

Elements of Framework

All Connect with communities Assets based approach Fully integrated community teams
North Lanarkshire - Integrated Rehabilitation Team

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Example of Good Practice

Integrated Rehabilitation Team

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Rehabilitation Physical disabilities Community care Supported discharge Physical health

Setting(s)

All Urban

Enabler(s)

All Technology Well developed lead professional roles Information sharing Agile working Well developed relationships Shared accountability

Integration Authority

All North Lanarkshire

Elements of Framework

All Reablement Assets based approach Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
North Lanarkshire - Integrated Rehabilitation Teams

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Example of Good Practice

Integrated Rehabilitation Teams

Service Area(s)

All Rehabilitation

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Lanarkshire

Elements of Framework

All Reablement Fully integrated community teams
North Lanarkshire - Primary Care Frailty MDTs: Facilitating a person-centred anticipatory care approach

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Example of Good Practice

Primary Care Frailty MDTs: Facilitating a person-centred anticipatory care approach

Service Area(s)

All Primary care Social care services Physical disabilities Community care Mental health Physical health

Setting(s)

All Urban

Enabler(s)

All Technology Improvement capacity Information sharing Aligned plans Team ethos Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All North Lanarkshire

Elements of Framework

All Anticipatory care planning Connect with communities Assets based approach Teams aligned to general practice Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
Orkney - First Responders aligned to Primary Care

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Example of Good Practice

First Responders Aligned to Primary Care

Service Area(s)

All Physical health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Orkney

Elements of Framework

All Connect with communities Teams aligned to general practice
Orkney - Home First approach

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Example of Good Practice

Home First approach

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Community care Supported discharge

Setting(s)

All Remote and rural

Enabler(s)

All Technology Culture and values Information sharing Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Orkney

Elements of Framework

All Reablement Live independently at home or in a homely setting Fully integrated community teams
Person centred anticipatory care, Spain

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Example of Good Practice

ProPCC Person centred anticipatory care in Barcelona, Spain

Service Area(s)

All Primary care Intermediate care incl Hospital at Home Rehabilitation Physical health Admission avoidance

Setting(s)

All City Urban

Enabler(s)

All Technology Well developed lead professional roles Information sharing Clinical and care governance Team ethos Well developed relationships

Integration Authority

All Other health and social care providers

Elements of Framework

All Reablement Anticipatory care planning Manage own care Teams aligned to general practice Seamless working with acute care Live independently at home or in a homely setting
Perth and Kinross - Local Care Home Oversight Group

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Example of Good Practice

Service Area(s)

All Community care

Setting(s)

All Urban Remote and rural

Enabler(s)

All Culture and values Well developed lead professional roles Clinical and care governance Team ethos Well developed relationships

Integration Authority

All Perth and Kinross

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
Proactive telecare, Wales

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Example of Good Practice

Proactive telecare with Delta CONNECT in Wales

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Community care Supported discharge Physical health Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Infrastructure Information sharing Well developed relationships Collaborative leadership

Integration Authority

All Other health and social care providers

Elements of Framework

All Anticipatory care planning Connect with communities Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs
Reablement and rehabilitation, Finland

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Example of Good Practice

Reablement and rehabilitation in Finland

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Physical disabilities Supported discharge Physical health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All Technology Infrastructure Well developed lead professional roles Agile working Team ethos

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Reablement Manage own care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Renfrewshire - Mental Health and Addictions Recovery Hub

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Example of Good Practice

Renfrewshire Mental Health and Addictions Recovery Hub

Service Area(s)

All Addictions Mental health

Setting(s)

All Urban

Enabler(s)

All Technology Infrastructure Culture and values Information sharing Agile working Fit for purpose premises Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Renfrewshire

Elements of Framework

All Connect with communities Manage own care Assets based approach
Renfrewshire - Supportive and Palliative Action Register in the community

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Example of Good Practice

Supportive and Palliative Action Register in the community

Service Area(s)

All Physical health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Renfrewshire

Elements of Framework

All Anticipatory care planning Connect with communities Manage own care Teams aligned to general practice Seamless working with acute care Fully integrated community teams
Scottish Borders - Care Home and Community Assessment Team

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Example of Good Practice

Care Home and Community Assessment Team

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Scottish Borders

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
Shetland - Intermediate Care Team

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Example of Good Practice

Intermediate Care Team

Service Area(s)

All Supported discharge Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Shetland

Elements of Framework

All Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Shetland - Post diagnostic support in primary care

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Example of Good Practice

Post diagnostic support in primary care

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Shetland

Elements of Framework

All Anticipatory care planning Assets based approach
South Ayrshire - Learning Disability Core and Cluster Model and community connections

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Example of Good Practice

LD Core and Cluster Model and community connections

Service Area(s)

All Social care services Housing incl homelessness Learning disabilities Supported discharge

Setting(s)

All Urban Remote and rural

Enabler(s)

All Improvement capacity Culture and values Well developed lead professional roles Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation Fully integrated community teams
South Ayrshire - Staying ahead of the Curve 1 - Addressing early frailty in localities, at a population level

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Example of Good Practice

Staying ahead of the Curve 1 - Addressing early frailty in localities, at a population level

Service Area(s)

All Primary care Physical health Admission avoidance

Setting(s)

All City Remote and rural

Enabler(s)

All Culture and values Information sharing Agile working Team ethos Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All South Ayrshire

Elements of Framework

All Manage own care Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
South Ayrshire - Staying ahead of the Curve 2 - Addressing frailty in localities via occupational therapy in primary care MDT

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Example of Good Practice

Staying ahead of the Curve 2 - Addressing frailty in localities via occupational therapy in primary care MDT

Service Area(s)

All Primary care Physical health Admission avoidance

Setting(s)

All City Remote and rural

Enabler(s)

All Culture and values Information sharing Agile working Team ethos Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All South Ayrshire

Elements of Framework

All Manage own care Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
South Lanarkshire - CAReS Community Addictions Recovery Service

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Example of Good Practice

CAReS: Community Addictions Recovery Service

Service Area(s)

All Addictions Mental health

Setting(s)

All Urban Remote and rural

Enabler(s)

All Culture and values Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All Manage own care Assets based approach Short-term, targeted interventions to meet more complex needs Fully integrated community teams
South Lanarkshire - Implementation of Near Me

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Example of Good Practice

Service Area(s)

All Social care services Justice Rehabilitation Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Well developed lead professional roles Information sharing Agile working Aligned plans Clinical and care governance Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
South Lanarkshire - Rapid telecare alarm rollout through COVID-19

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Example of Good Practice

Service Area(s)

All Social care services Rehabilitation Physical disabilities Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Well developed lead professional roles Information sharing Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All Live independently at home or in a homely setting
South Lanarkshire - Shifting the balance of care and resource

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Example of Good Practice

Shifting the balance of care and resource

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All South Lanarkshire

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting
South Lanarkshire - The Beacons

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Example of Good Practice

The Beacons

Service Area(s)

All Addictions

Setting(s)

All Urban Remote and rural

Enabler(s)

All Improvement capacity Well developed lead professional roles Agile working Fit for purpose premises Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All First point of contact Connect with communities Manage own care Assets based approach
South Lanarkshire - The Future of Care

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Example of Good Practice

The Future of Care

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All South Lanarkshire

Elements of Framework

All Enhanced care in care homes and supported accommodation
Transforming together with community health workers, Brazil

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Example of Good Practice

Transforming together with community health workers in Brazil

Service Area(s)

All Primary care Mental health Physical health

Setting(s)

All Urban Remote and rural

Enabler(s)

All Information sharing Team ethos Well developed relationships Shared accountability

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach Teams aligned to general practice Fully integrated community teams
West Dunbartonshire - Focussed Intervention Team

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Example of Good Practice

Focussed Intervention Team

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Dunbartonshire

Elements of Framework

All Teams aligned to general practice Enhanced care in care homes and supported accommodation Fully integrated community teams
West Dunbartonshire - Intensive support at home

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Example of Good Practice

Intensive support at home

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Dunbartonshire

Elements of Framework

All Short-term, targeted interventions to meet more complex needs Fully integrated community teams
West Dunbartonshire - My Life Assessment

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Example of Good Practice

My Life Assessment

Service Area(s)

All Social care services

Setting(s)

All City

Enabler(s)

All Technology Culture and values Well developed lead professional roles Management information Information sharing Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability

Integration Authority

All West Dunbartonshire

Elements of Framework

All Anticipatory care planning Manage own care Assets based approach
West Lothian - Integrated daily flow huddle

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Example of Good Practice

Integrated daily flow huddle

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Rehabilitation Supported discharge

Setting(s)

All Urban

Enabler(s)

All Infrastructure Improvement capacity Culture and values Well developed lead professional roles Management information Information sharing Agile working Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All West Lothian

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting
West Lothian - Integrated discharge planning

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Example of Good Practice

Integrated discharge planning

Service Area(s)

All Supported discharge

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Lothian

Elements of Framework

All Seamless working with acute care
Western Isles - Barra and Vatersay Integrated Social Care Services

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Example of Good Practice

Barra and Vatersay Integrated Social Care Services

Service Area(s)

All Social care services Day services Physical disabilities Learning disabilities Community care Mental health

Setting(s)

All Remote and rural

Enabler(s)

All Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Western Isles

Elements of Framework

All Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation
Western Isles - Integrated primary care

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Example of Good Practice

Integrated primary care

Service Area(s)

All Physical health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Western Isles

Elements of Framework

All Teams aligned to general practice
Western Isles - Supporting people with dementia

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Example of Good Practice

Supporting people with dementia

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Western Isles

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
Western Isles - Transformation of Dressings Service

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Example of Good Practice

Transformation of Dressings Service

Service Area(s)

All Physical health

Setting(s)

All Remote and rural

Enabler(s)

All Technology Clinical and care governance Team ethos Clarity of vision Collaborative leadership

Integration Authority

All Western Isles

Elements of Framework

All Teams aligned to general practice