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Teams aligned to general practice

Element of Framework: Teams aligned to general practice

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Client Group

Service Area

Setting

Enablers

Integration Authority

Aberdeen City - Social prescribing

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Example of Good Practice

Social prescribing

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Mental health Physical health

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Aberdeen City
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
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

Client Group(s)

All Older adults

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
Dumfries and Galloway - Improving access to CAMHS

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Example of Good Practice

Improving access to CAMHS

Client Group(s)

All Children and young people

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Dumfries and Galloway
East Dunbartonshire - Enhanced clinical support for care homes

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Example of Good Practice

Enhanced clinical support for care homes

Client Group(s)

All Older adults

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
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
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
Integrated behavioural health, USA

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Example of Good Practice

Integrated behavioural health in California, USA

Client Group(s)

All Younger adults Older adults

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
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 - First Responders aligned to Primary Care

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Example of Good Practice

First Responders Aligned to Primary Care

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Physical health

Setting(s)

All Remote and rural

Enabler(s)

All

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
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 - 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
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
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 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 - Integrated primary care

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Example of Good Practice

Integrated primary care

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Physical health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Western Isles
Western Isles - Transformation of Dressings Service

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Example of Good Practice

Transformation of Dressings Service

Client Group(s)

All Younger adults Children and young people Older adults

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