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Short-term, targeted interventions to meet more complex needs

Element of Framework: Short-term, targeted interventions to meet more complex needs

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Client Group

Service Area

Setting

Enablers

Integration Authority

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
Clackmannanshire and Stirling - Stirling Health and Care Village

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Example of Good Practice

Stirling Health and Care Village

Client Group(s)

All Older adults

Service Area(s)

All Supported discharge Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Clackmannanshire and Stirling
Dundee City - The ASPEN Project

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Example of Good Practice

The ASPEN Project: Embedding specialist trauma informed care and treatment within Dundee Women's Aid

Client Group(s)

All Younger adults

Service Area(s)

All Addictions Mental health

Setting(s)

All City

Enabler(s)

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

Integration Authority

All Dundee City
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 Renfrewshire - Healthier Minds

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Example of Good Practice

Healthier Minds

Client Group(s)

All Children and young people

Service Area(s)

All Mental health

Setting(s)

All Urban

Enabler(s)

All Technology Infrastructure Culture and values Well developed lead professional roles Management information Agile working Team ethos Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All East Renfrewshire
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
Aberdeen City - Frailty pathway, Rosewell House

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Example of Good Practice

Frailty Pathway, Rosewell House

Client Group(s)

All Older adults

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
Glasgow City - Complex Needs Service response to COVID-19

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Example of Good Practice

Complex Needs Service - response to COVID-19

Client Group(s)

All Younger adults

Service Area(s)

All Social care services Housing incl homelessness Addictions Mental health Physical health

Setting(s)

All City

Enabler(s)

All Culture and values 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 Glasgow City
Glasgow City - Mental Health Assessment Units

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Example of Good Practice

Client Group(s)

All Younger adults Older adults

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
Hospice at Home, Isle of Man

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Example of Good Practice

Hospice at Home in Isle of Man

Client Group(s)

All Younger adults Older adults

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
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 - 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
Local area coordination, England

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Example of Good Practice

Local area coordination in Derby and Isle of Wight

Client Group(s)

All Younger adults Older adults

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
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 - 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 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
Proactive telecare, Wales

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Example of Good Practice

Proactive telecare with Delta CONNECT in Wales

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 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
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
Scottish Borders - Renew Service

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Example of Good Practice

Renew Service

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All Well developed lead professional roles Information sharing Well developed relationships Clarity of vision

Integration Authority

All Scottish Borders
Shetland - Compassionate Distress Response Service and DBI

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Example of Good Practice

Compassionate Disress Response Service and DBI

Client Group(s)

All Younger adults

Service Area(s)

All Mental health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All Infrastructure Culture and values 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 Shetland
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 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
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