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Anticipatory care planning

Element of Framework: Anticipatory care planning

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Client Group

Service Area

Setting

Enablers

Integration Authority

East Dunbartonshire - Caring Together

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Example of Good Practice

Caring Together

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Dunbartonshire
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
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
Shetland - Post diagnostic support in primary care

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Example of Good Practice

Post diagnostic support in primary care

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Shetland
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