Anticipatory care planning (ACP) is a way of ensuring that people and their carers, working with healthcare professionals, are able to make informed choices about the type of care they want to receive, including what’s important to them and how they are best able to manage their condition - the right thing at the right time by the right person.
Invidividual plans includes people's needs and wishes and the outcomes they desire.
An asset based approach places the emphasis on people’s and communities’ assets, alongside their needs. This involves person-centred conversations and building a picture of each person's individual strengths, preferences and aspirations, supporting social connectedness, and developing partnership and co-production approaches within local communities for local communities.
Clinical and care governance is the process by which accountability for the quality of health and social care is monitored and assured. It should create a culture where delivery of the highest quality of care and support is understood to be the responsibility of everyone working in the organisation - built upon partnership and collaboration within teams and between health and social care professionals and managers.
There are 31 health and social care partnerships (HSCPs) in Scotland. Each health and social care partnership works towards a set of nine national health and wellbeing outcomes. All HSCPs are responsible for adult social care, adult primary health care and unscheduled adult hospital care. Some are also responsible for children’s services, homelessness and justice social work services. HSCPs deliver services on behalf of their integration joint board (IJB).
Integration authorities were formed as part of the Public Bodies (Joint Working) (Scotland) Act 2014. The Act required local authorities and health boards to jointly prepare an integration scheme. Each integration scheme sets out the key arrangements for how services are planned, delivered and monitored within their local area.
There are 31 integration authorities in Scotland (30 IJBs and 1 lead agency model in Highland) and their aim is to bring together health and social care in to a single, integrated system.
The IJB membership is broad: it includes local authority councillors and NHS non-executive directors in all cases, plus other members including professional representatives, carers, people who use services and community and staff stakeholders. Each IJB produces a strategic plan and directs their local authority and NHS board to deliver services via the health and social care partnership (HSCP).
Intermediate care is provided to people (usually older people), after leaving hospital, or when they are at risk of going into hospital. The services can be provided in people's own homes or in a community hospital or allocated care home, and will include assessment, rehabilitation and support with the aim of helping people to stay as independent as possible.
MDTs are the mechanism for organising and coordinating health and care services to meet the needs of individuals with complex care needs. Each MDT brings together the expertise and skills of different professionals to assess, plan and manage care jointly.
Reablement is goal-focused intervention in people's own home or homely setting. It involves intensive, time-limited assessment and therapeutic work over a short period of a number of weeks. Reablement focuses on a person’s own strengths and abilities and what they are able to safely do, instead of what they are no longer able to do.