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Seamless working with acute care

Element of Framework: Seamless working with acute care

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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
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
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

Client Group(s)

All Older adults

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
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
Edinburgh City - Delayed discharge leadership

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Example of Good Practice

Delayed discharge leadership

Client Group(s)

All Older adults

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
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
Fife - High Health Gain

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Example of Good Practice

Fife High Health gain

Client Group(s)

All Older adults

Service Area(s)

All Admission avoidance

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Fife
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 - 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
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
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
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
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
West Lothian - Integrated discharge planning

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Example of Good Practice

Integrated discharge planning

Client Group(s)

All Older adults

Service Area(s)

All Supported discharge

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