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Fully integrated community teams

Element of Framework: Fully integrated community teams

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Client Group

Service Area

Setting

Enablers

Integration Authority

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

Client Group(s)

All Older adults

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
Aberdeenshire - Residential Care Home: New Opportunities

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Example of Good Practice

Residential Care Home: New Opportunities

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Aberdeenshire
Angus - Intermediate (step-up) care

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Example of Good Practice

Intermediate (Step-up) Care

Client Group(s)

All Older adults

Service Area(s)

All Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Angus
Angus - Monifieth Integrated Care

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Example of Good Practice

Monifieth Integrated Team

Client Group(s)

All Older adults

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
Dumfries and Galloway - Transforming learning disability services

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Example of Good Practice

Transforming learning disability services

Client Group(s)

All Older adults

Service Area(s)

All Learning disabilities

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Dumfries and Galloway
Dundee City - Integrated Care Home Team

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Example of Good Practice

Integrated Care Home Team

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Dundee City
East Dunbartonshire - Caring Together

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Example of Good Practice

Caring Together

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Dunbartonshire
East Dunbartonshire - Integrated working across EDADS and Criminal Justice

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Example of Good Practice

Integrated Working across EDADS and Criminal Justice

Client Group(s)

All Younger adults

Service Area(s)

All Justice Addictions

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Dunbartonshire
East Lothian - Integrated Care Assessment Team (ICAT)

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Example of Good Practice

Integrated Care Assessment Team (ICAT)

Client Group(s)

All Older adults

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
East Lothian - Short Term Assessment and Rehabilitation

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Example of Good Practice

Short Term Assessment and Rehabilitation

Client Group(s)

All Older adults

Service Area(s)

All Supported discharge Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Lothian
East Lothian - Wellwynd Hub

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Example of Good Practice

East Lothian - Wellwynd Hub

Client Group(s)

All Older adults

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
Edinburgh City - Improving falls in Edinburgh care homes

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Example of Good Practice

Improving falls in Edinburgh care homes

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Edinburgh City
Enhanced intermediate care, England

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Example of Good Practice

Enhanced intermediate care in Torbay and South Devon, England

Client Group(s)

All Younger adults Older adults

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
Enhanced transitional care, Singapore

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Example of Good Practice

Enhanced transitional care in Singapore

Client Group(s)

All Younger adults Older adults

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
Highland - Enhancing community services

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Example of Good Practice

Enhancing community services, Inverness

Client Group(s)

All Older adults

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
Integrated community care for older people, Canada

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Example of Good Practice

Integrated community care for older people in Toronto, Canada

Client Group(s)

All Older adults

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
Inverclyde - Home first interface arrangements

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Example of Good Practice

Home first interface arrangements

Client Group(s)

All Younger adults Older adults

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
Inverclyde - Re-attenders at ED

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Example of Good Practice

Re-attenders at ED

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Addictions Mental health Physical health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Inverclyde
Midlothian - Home first approach

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Example of Good Practice

Home first approach

Client Group(s)

All Younger adults Older adults

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
Moray - Discharge to assess pilot project

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Example of Good Practice

Discharge to assess pilot project

Client Group(s)

All Older adults

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
Moray - Integrated Mental Health Services

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Example of Good Practice

Integrated Mental Health Services

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Moray
Moray - Outreach Service and third sector integration

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Example of Good Practice

Outreach Service and third sector integration

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Moray
North Ayrshire - Integrated Drug and Alcohol Recovery Service

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Example of Good Practice

Integrated Drug and Alcohol Recovery Service

Client Group(s)

All Younger adults

Service Area(s)

All Addictions

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Ayrshire
North Ayrshire - Schools Based Challenge Team

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Example of Good Practice

Schools Based Challenge Team

Client Group(s)

All Children and young people

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Ayrshire
North Ayrshire - Trindlemoss Court and Warrix Avenue

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Example of Good Practice

Trindlemoss Court and Warrix Avenue

Client Group(s)

All Younger adults Older adults

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
North Lanarkshire - High Resource User Project

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Example of Good Practice

High Resource User Project

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Lanarkshire
North Lanarkshire - Integrated Rehabilitation Team

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Example of Good Practice

Integrated Rehabilitation Team

Client Group(s)

All Younger adults Children and young people Older adults

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
North Lanarkshire - Integrated Rehabilitation Teams

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Example of Good Practice

Integrated Rehabilitation Teams

Client Group(s)

All Older adults

Service Area(s)

All Rehabilitation

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Lanarkshire
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

Client Group(s)

All Older adults

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
Orkney - Home First approach

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Example of Good Practice

Home First approach

Client Group(s)

All Younger adults Older adults

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
Perth and Kinross - Local Care Home Oversight Group

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Example of Good Practice

Client Group(s)

All Older adults

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
Perth and Kinross - Multi-Agency Substance Use Joint Assessment Clinic

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Example of Good Practice

Multi-Agency Substance Use Joint Assessment Clinic

Client Group(s)

All Younger adults

Service Area(s)

All Justice Addictions

Setting(s)

All Urban

Enabler(s)

All Information sharing Agile working Well developed relationships Clarity of vision Shared accountability

Integration Authority

All Perth and Kinross
Reablement and rehabilitation, Finland

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Example of Good Practice

Reablement and rehabilitation in Finland

Client Group(s)

All Younger adults Older adults

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
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

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Physical health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Renfrewshire
Scottish Borders - Care Home and Community Assessment Team

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Example of Good Practice

Care Home and Community Assessment Team

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Scottish Borders
Shetland - Intermediate Care Team

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Example of Good Practice

Intermediate Care Team

Client Group(s)

All Older adults

Service Area(s)

All Supported discharge Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Shetland
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

Client Group(s)

All Younger adults Older adults

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
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

Client Group(s)

All Older adults

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
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

Client Group(s)

All Older adults

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
South Lanarkshire - CAReS Community Addictions Recovery Service

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Example of Good Practice

CAReS: Community Addictions Recovery Service

Client Group(s)

All Younger adults Older adults

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
South Lanarkshire - Implementation of Near Me

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Example of Good Practice

Client Group(s)

All Younger adults Children and young people Older adults

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
Transforming together with community health workers, Brazil

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Example of Good Practice

Transforming together with community health workers in Brazil

Client Group(s)

All Younger adults Children and young people Older adults

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
West Dunbartonshire - Focussed Intervention Team

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Example of Good Practice

Focussed Intervention Team

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Dunbartonshire
West Dunbartonshire - Intensive support at home

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Example of Good Practice

Intensive support at home

Client Group(s)

All Older adults

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Dunbartonshire
West Lothian - Community Wellbeing Hubs

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Example of Good Practice

Community Wellbeing Hubs

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Lothian
Western Isles - Supporting people with dementia

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Example of Good Practice

Supporting people with dementia

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Western Isles