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Team ethos

Enablers: Team ethos (OD)

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Client Group

Service Area

Setting

Integration Authority

Element of Framework

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

Integration Authority

All Aberdeenshire

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All Angus

Elements of Framework

All Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Connect with communities Manage own care Assets based approach Teams aligned to general practice
Argyll and Bute - HSCP Huddle

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Example of Good Practice

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Management team

Setting(s)

All Remote and rural Corporate

Integration Authority

All Argyll and Bute

Elements of Framework

All
Clackmannanshire and Stirling - Commissioning consortium

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Example of Good Practice

Commissioning Consortium

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Social care services Justice Day services Housing incl homelessness Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Admission avoidance

Setting(s)

All Urban Remote and rural Corporate

Integration Authority

All Clackmannanshire and Stirling

Elements of Framework

All Connect with communities
Dundee City - The ASPEN Project

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Example of Good Practice

The ASPEN Project: Embedding specialist trauma informed care and treatment within Dundee Women's Aid

Client Group(s)

All Younger adults

Service Area(s)

All Addictions Mental health

Setting(s)

All City

Integration Authority

All Dundee City

Elements of Framework

All First point of contact Connect with communities Short-term, targeted interventions to meet more complex needs
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

Integration Authority

All East Lothian

Elements of Framework

All Reablement Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
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

Integration Authority

All East Lothian

Elements of Framework

All First point of contact Reablement Assets based approach Live independently at home or in a homely setting Fully integrated community teams
East Renfrewshire - Healthier Minds

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Example of Good Practice

Healthier Minds

Client Group(s)

All Children and young people

Service Area(s)

All Mental health

Setting(s)

All Urban

Integration Authority

All East Renfrewshire

Elements of Framework

All First point of contact Connect with communities Short-term, targeted interventions to meet more complex needs
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

Integration Authority

All Edinburgh City

Elements of Framework

All Connect with communities Manage own care Assets based approach
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Reablement Manage own care Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Reablement Seamless working with acute care Short-term, targeted interventions to meet more complex needs Fully integrated community teams
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

Integration Authority

All Fife

Elements of Framework

All Reablement Live independently at home or in a homely setting
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

Integration Authority

All Fife

Elements of Framework

All First point of contact Connect with communities Manage own care
Glasgow City - Complex Needs Service response to COVID-19

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Example of Good Practice

Complex Needs Service - response to COVID-19

Client Group(s)

All Younger adults

Service Area(s)

All Social care services Housing incl homelessness Addictions Mental health Physical health

Setting(s)

All City

Integration Authority

All Glasgow City

Elements of Framework

All First point of contact Connect with communities Short-term, targeted interventions to meet more complex needs
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Anticipatory care planning Connect with communities Manage own care Assets based approach Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Manage own care Assets based approach Teams aligned to general practice
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

Integration Authority

All Midlothian

Elements of Framework

All First point of contact Connect with communities Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All Moray

Elements of Framework

All Reablement Seamless working with acute care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
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

Integration Authority

All North Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Seamless working with acute care Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation Fully integrated community teams
North Lanarkshire - Care Academy

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Example of Good Practice

Care Academy

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Primary care Social care services Intermediate care incl Hospital at Home Justice Rehabilitation Day services Housing incl homelessness Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance Management team

Setting(s)

All Corporate

Integration Authority

All North Lanarkshire

Elements of Framework

All First point of contact Connect with communities
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

Integration Authority

All North Lanarkshire

Elements of Framework

All First point of contact Connect with communities Manage own care
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

Integration Authority

All North Lanarkshire

Elements of Framework

All Anticipatory care planning Connect with communities Assets based approach Teams aligned to general practice Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All Orkney

Elements of Framework

All Reablement Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Reablement Anticipatory care planning Manage own care Teams aligned to general practice Seamless working with acute care Live independently at home or in a homely setting
Perth and Kinross - Local Care Home Oversight Group

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Example of Good Practice

Client Group(s)

All Older adults

Service Area(s)

All Community care

Setting(s)

All Urban Remote and rural

Integration Authority

All Perth and Kinross

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
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

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Reablement Manage own care Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs Fully integrated community teams
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

Integration Authority

All Renfrewshire

Elements of Framework

All Connect with communities Manage own care Assets based approach
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

Integration Authority

All Shetland

Elements of Framework

All Manage own care Short-term, targeted interventions to meet more complex needs
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

Integration Authority

All South Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation Fully integrated community teams
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

Integration Authority

All South Ayrshire

Elements of Framework

All Manage own care Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All South Ayrshire

Elements of Framework

All Manage own care Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All South Lanarkshire

Elements of Framework

All Manage own care Assets based approach Short-term, targeted interventions to meet more complex needs Fully integrated community teams
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

Integration Authority

All South Lanarkshire

Elements of Framework

All Teams aligned to general practice Live independently at home or in a homely setting Fully integrated community teams
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

Integration Authority

All South Lanarkshire

Elements of Framework

All Live independently at home or in a homely setting
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach Teams aligned to general practice Fully integrated community teams
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

Integration Authority

All West Dunbartonshire

Elements of Framework

All Anticipatory care planning Manage own care Assets based approach
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

Integration Authority

All West Lothian

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting
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

Integration Authority

All Western Isles

Elements of Framework

All Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation
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

Integration Authority

All Western Isles

Elements of Framework

All Teams aligned to general practice