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Live independently at home or in a homely setting

Element of Framework: Live independently at home or in a homely setting

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Client Group

Service Area

Setting

Enablers

Integration Authority

Aberdeen City - Granite Care Consortium

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Example of Good Practice

Granite Care Consortium

Client Group(s)

All Older adults

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
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
Angus - Check TEC Out

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Example of Good Practice

Check TEC Out

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Community care

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
Argyll and Bute - Attend Anywhere

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Example of Good Practice

Attend Anywhere

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Mental health Physical health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute
Argyll and Bute - Physical activity and frailty during COVID-19 pandemic

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Example of Good Practice

Client Group(s)

All Older adults

Service Area(s)

All Rehabilitation Physical health Admission avoidance

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute
Dumfries and Galloway - Response to care and support at home during COVID-19

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Example of Good Practice

Client Group(s)

All Younger adults Older adults

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
Dundee City - Turriff House Intermediate Care Suite

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Example of Good Practice

Turriff House Intermediate Care Suite

Client Group(s)

All Older adults

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
East Ayrshire - Right Support, Right Place, Right Time

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Example of Good Practice

Right Support, Right Place, Right Time

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Ayrshire
East Ayrshire - Thinking Differently Programme

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Example of Good Practice

Thinking Differently Programme

Client Group(s)

All Younger adults Children and young people Older adults

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
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 - 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
East Renfrewshire - Building the integrated environment

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Example of Good Practice

Building the integrated environment

Client Group(s)

All

Service Area(s)

All Community care Mental health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Renfrewshire
East Renfrewshire - Community Led Support - Talking Points

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Example of Good Practice

Community Led Support - Talking Points

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

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
Falkirk - Living Well

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Example of Good Practice

Living Well Falkirk

Client Group(s)

All Older adults

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
Falkirk - Transforming day services

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Example of Good Practice

Transforming day services

Client Group(s)

All Younger adults

Service Area(s)

All Physical disabilities Learning disabilities

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Falkirk
Fife - Care at Home Collaborative

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Example of Good Practice

Care at Home Collaborative

Client Group(s)

All Older adults

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
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 - Housing First Project

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Example of Good Practice

Housing First Project

Client Group(s)

All Younger adults

Service Area(s)

All Housing incl homelessness Addictions Mental health

Setting(s)

All City

Enabler(s)

All Aligned plans Well developed relationships Collaborative leadership

Integration Authority

All Glasgow City
Highland - Developing flexible care in MacKenzie Centre

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Example of Good Practice

Developing flexible care in MacKenzie Centre

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Highland
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
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 - 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
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
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
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 - 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 - 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
Person centred anticipatory care, Spain

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Example of Good Practice

ProPCC Person centred anticipatory care in Barcelona, Spain

Client Group(s)

All Younger adults Older adults

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
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
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 - 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
South Lanarkshire - Rapid telecare alarm rollout through COVID-19

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Example of Good Practice

Client Group(s)

All Younger adults Older adults

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
South Lanarkshire - Shifting the balance of care and resource

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Example of Good Practice

Shifting the balance of care and resource

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All South Lanarkshire
West Lothian - Integrated daily flow huddle

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Example of Good Practice

Integrated daily flow huddle

Client Group(s)

All Younger adults Older adults

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
Western Isles - Barra and Vatersay Integrated Social Care Services

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Example of Good Practice

Barra and Vatersay Integrated Social Care Services

Client Group(s)

All Younger adults Older adults

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
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