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Admission avoidance

Service Area: Admission avoidance

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Client Group

Setting

Enablers

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

Setting(s)

All City Urban

Enabler(s)

All Technology Improvement capacity Management information Information sharing Aligned plans Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All Aberdeen City

Elements of Framework

All Reablement Live independently at home or in a homely setting
Angus - Intermediate (step-up) care

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Example of Good Practice

Intermediate (Step-up) Care

Client Group(s)

All Older adults

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Angus

Elements of Framework

All Short-term, targeted interventions to meet more complex needs Enhanced care in care homes and supported accommodation Fully integrated community teams
Argyll and Bute - Physical activity and frailty during COVID-19 pandemic

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Example of Good Practice

Client Group(s)

All Older adults

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute

Elements of Framework

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

Setting(s)

All Urban Remote and rural Corporate

Enabler(s)

All Improvement capacity Culture and values Well developed lead professional roles Management information Information sharing Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Clackmannanshire and Stirling

Elements of Framework

All Connect with communities
Clackmannanshire and Stirling - Stirling Health and Care Village

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Example of Good Practice

Stirling Health and Care Village

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Clackmannanshire and Stirling

Elements of Framework

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

Setting(s)

All City Urban

Enabler(s)

All Technology Infrastructure Well developed lead professional roles Information sharing Collaborative leadership

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
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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Agile working Aligned plans Shared accountability Collaborative leadership

Integration Authority

All Dumfries and Galloway

Elements of Framework

All Reablement Live independently at home or in a homely setting
East Dunbartonshire - Enhanced clinical support for care homes

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Example of Good Practice

Enhanced clinical support for care homes

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All Culture and values Well developed relationships Collaborative leadership

Integration Authority

All East Dunbartonshire

Elements of Framework

All Teams aligned to general practice 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

Setting(s)

All Remote and rural

Enabler(s)

All Technology Infrastructure Culture and values Well developed lead professional roles Information sharing Agile working Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

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 - Short Term Assessment and Rehabilitation

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Example of Good Practice

Short Term Assessment and Rehabilitation

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All East Lothian

Elements of Framework

All First point of contact Reablement Connect with communities Manage own care Seamless working with acute care Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Edinburgh City - Three Conversations

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Example of Good Practice

Three Conversations

Client Group(s)

All Younger adults Older adults

Setting(s)

All City Urban

Enabler(s)

All Technology Infrastructure Improvement capacity Well developed lead professional roles Agile working Aligned plans Team ethos Clarity of vision Shared accountability Collaborative leadership

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

Setting(s)

All Remote and rural

Enabler(s)

All Information sharing Clinical and care governance Team ethos Well developed relationships

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
Fife - Care at Home Collaborative

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Example of Good Practice

Care at Home Collaborative

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All Infrastructure Improvement capacity Culture and values Management information Information sharing Agile working Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Fife

Elements of Framework

All Reablement Live independently at home or in a homely setting
Fife - High Health Gain

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Example of Good Practice

Fife High Health gain

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Fife

Elements of Framework

All First point of contact Teams aligned to general practice Seamless working with acute care
Aberdeen City - Frailty pathway, Rosewell House

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Example of Good Practice

Frailty Pathway, Rosewell House

Client Group(s)

All Older adults

Setting(s)

All City

Enabler(s)

All Culture and values Fit for purpose premises Aligned plans Clarity of vision Collaborative leadership

Integration Authority

All Aberdeen City

Elements of Framework

All Reablement Live independently at home or in a homely setting Short-term, targeted interventions to meet more complex needs
Highland - Enhancing community services

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Example of Good Practice

Enhancing community services, Inverness

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All Infrastructure Improvement capacity Culture and values Management information Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Highland

Elements of Framework

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

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

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
Local area coordination, England

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Example of Good Practice

Local area coordination in Derby and Isle of Wight

Client Group(s)

All Younger adults Older adults

Setting(s)

All City Remote and rural

Enabler(s)

All Culture and values Well developed relationships Collaborative leadership

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 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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Infrastructure Improvement capacity Culture and values Management information Information sharing Agile working Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Improvement capacity Well developed lead professional roles Information sharing Agile working Clinical and care governance Team ethos Well developed relationships Clarity of vision

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

Setting(s)

All Urban

Enabler(s)

All Technology Infrastructure Improvement capacity Culture and values Well developed lead professional roles Management information Information sharing Fit for purpose premises Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

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

Setting(s)

All Corporate

Enabler(s)

All Improvement capacity Culture and values Management information Information sharing Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Infrastructure Improvement capacity Culture and values Information sharing Agile working Team ethos Well developed relationships Collaborative leadership

Integration Authority

All North Lanarkshire

Elements of Framework

All First point of contact Connect with communities Manage own care
North Lanarkshire - High Resource User Project

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Example of Good Practice

High Resource User Project

Client Group(s)

All Younger adults Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All North Lanarkshire

Elements of Framework

All Connect with communities Assets based approach 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

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

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

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

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

Setting(s)

All Remote and rural

Enabler(s)

All Technology Infrastructure Well developed lead professional roles Agile working Team ethos

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
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

Setting(s)

All Remote and rural

Enabler(s)

All Infrastructure Culture and values Information sharing Agile working Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Shetland

Elements of Framework

All Manage own care Short-term, targeted interventions to meet more complex needs
Shetland - Intermediate Care Team

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Example of Good Practice

Intermediate Care Team

Client Group(s)

All Older adults

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Shetland

Elements of Framework

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

Setting(s)

All City Remote and rural

Enabler(s)

All Culture and values Information sharing Agile working Team ethos Well developed relationships Clarity of vision Collaborative leadership

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

Setting(s)

All City Remote and rural

Enabler(s)

All Culture and values Information sharing Agile working Team ethos Well developed relationships Clarity of vision Collaborative leadership

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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Well developed lead professional roles Information sharing Agile working Aligned plans Clinical and care governance Team ethos Well developed relationships Shared accountability Collaborative leadership

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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Well developed lead professional roles Information sharing Aligned plans Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All Live independently at home or in a homely setting
West Dunbartonshire - Intensive support at home

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Example of Good Practice

Intensive support at home

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Dunbartonshire

Elements of Framework

All Short-term, targeted interventions to meet more complex needs Fully integrated community teams