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Manage own care

Element of Framework: Manage own care

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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
Ageing well, New Zealand

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Example of Good Practice

Ageing well with LifeCurve in New Zealand

Client Group(s)

All Older adults

Service Area(s)

All Rehabilitation Physical health

Setting(s)

All Remote and rural

Enabler(s)

All Technology

Integration Authority

All Other health and social care providers
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
Argyll and Bute - Living Well

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Example of Good Practice

Living Well in Argyll and Bute

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 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
Community care (Wigan Deal), England

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Example of Good Practice

Community care in Wigan, England

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Other health and social care providers
Compassionate community, Spain

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Example of Good Practice

'All with you' - approach to palliative and end of life care, Seville

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All

Setting(s)

All City Urban Remote and rural

Enabler(s)

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

Integration Authority

All Other health and social care providers
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 - 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 - Three Conversations

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Example of Good Practice

Three Conversations

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Social care services Rehabilitation Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance Management team

Setting(s)

All City Urban

Enabler(s)

All Technology Infrastructure Improvement capacity Well developed lead professional roles Agile working Aligned plans Team ethos 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
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
Fife - Partnership working with discharge hub and Fife Carers Centre

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Example of Good Practice

Partnership working with discharge hub and Fife Carers Centre

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Community care Supported discharge

Setting(s)

All City Corporate

Enabler(s)

All Well developed lead professional roles Information sharing Agile working Well developed relationships

Integration Authority

All Fife
Fife - SAMH Sam's Cafe

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Example of Good Practice

SAMH Sam's Cafe

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Setting(s)

All Urban

Enabler(s)

All Culture and values Agile working Team ethos Well developed relationships Clarity of vision Shared accountability

Integration Authority

All Fife
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
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 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
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
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 - Mental Health Access Point

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Example of Good Practice

Mental Health Access Point

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Midlothian
Moray - Community Wellbeing Development Team: Rich conversations

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Example of Good Practice

Rich conversations

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Setting(s)

All Remote and rural

Enabler(s)

All

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
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 - Community Solutions Programme

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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 Rehabilitation Day services Addictions Physical disabilities Learning disabilities Supported discharge Mental health Physical health Admission avoidance

Setting(s)

All Urban Remote and rural

Enabler(s)

All Infrastructure Improvement capacity Culture and values Information sharing Agile working Team ethos Well developed relationships 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
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 - Mental Health and Addictions Recovery Hub

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Example of Good Practice

Renfrewshire Mental Health and Addictions Recovery Hub

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Addictions Mental health

Setting(s)

All Urban

Enabler(s)

All Technology Infrastructure Culture and values Information sharing Agile working Fit for purpose premises Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Renfrewshire
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
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
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 - The Beacons

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Example of Good Practice

The Beacons

Client Group(s)

All Older adults

Service Area(s)

All Addictions

Setting(s)

All Urban Remote and rural

Enabler(s)

All Improvement capacity Well developed lead professional roles Agile working Fit for purpose premises Well developed relationships Clarity of vision 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 - My Life Assessment

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Example of Good Practice

My Life Assessment

Client Group(s)

All Older adults

Service Area(s)

All Social care services

Setting(s)

All City

Enabler(s)

All Technology Culture and values Well developed lead professional roles Management information Information sharing Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability

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