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Agile working

Enablers: Agile working (plan/deliver)

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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
Dumfries and Galloway - Response to care and support at home during COVID-19

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Example of Good Practice

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Admission avoidance

Setting(s)

All Urban Remote and rural

Integration Authority

All Dumfries and Galloway

Elements of Framework

All Reablement Live independently at home or in a homely setting
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 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
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 - 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

Integration Authority

All Fife

Elements of Framework

All Connect with communities Manage own care
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
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 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 - 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

Integration Authority

All North Lanarkshire

Elements of Framework

All Reablement 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 Fully integrated community teams
Perth and Kinross - Multi-Agency Substance Use Joint Assessment Clinic

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Example of Good Practice

Multi-Agency Substance Use Joint Assessment Clinic

Client Group(s)

All Younger adults

Service Area(s)

All Justice Addictions

Setting(s)

All Urban

Integration Authority

All Perth and Kinross

Elements of Framework

All Connect with communities 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 - 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 - 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 - 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

Integration Authority

All South Lanarkshire

Elements of Framework

All First point of contact Connect with communities 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