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Client Group

Service Area

Setting

Integration Authority

Element of Framework

Aberdeen City - Granite Care Consortium

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Example of Good Practice

Granite Care Consortium

Client Group(s)

All Older adults

Service Area(s)

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

Setting(s)

All City Urban

Integration Authority

All Aberdeen City

Elements of Framework

All Reablement Live independently at home or in a homely setting
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

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
Digital hub support for care homes, England

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Example of Good Practice

Digital hub support for care homes in Tameside and Glossop, England

Client Group(s)

All Older adults

Service Area(s)

All Intermediate care incl Hospital at Home Community care Physical health Admission avoidance

Setting(s)

All City Urban

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Seamless working with acute care Enhanced care in care homes and supported accommodation
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
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

Integration Authority

All Falkirk

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting
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
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 - 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
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
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

Integration Authority

All Other health and social care providers

Elements of Framework

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