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Service Area: Physical health

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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
Aberdeen City - Social prescribing

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Example of Good Practice

Social prescribing

Client Group(s)

All Younger adults Children and young people Older adults

Setting(s)

All City

Enabler(s)

All

Integration Authority

All Aberdeen City

Elements of Framework

All Connect with communities Manage own care Teams aligned to general practice
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

Setting(s)

All Remote and rural

Enabler(s)

All Technology

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
Angus - Monifieth Integrated Care

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Example of Good Practice

Monifieth Integrated Team

Client Group(s)

All Older adults

Setting(s)

All Corporate

Enabler(s)

All Improvement capacity Information sharing Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

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

Setting(s)

All Remote and rural

Enabler(s)

All Team ethos Well developed relationships Shared accountability 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 Teams aligned to general practice
Argyll and Bute - Attend Anywhere

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Example of Good Practice

Attend Anywhere

Client Group(s)

All Younger adults Children and young people Older adults

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Argyll and Bute

Elements of Framework

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

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Example of Good Practice

East Lothian - Wellwynd Hub

Client Group(s)

All Older adults

Setting(s)

All Urban Remote and rural

Enabler(s)

All Technology Well developed lead professional roles Information sharing Fit for purpose premises Team ethos Well developed relationships

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
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
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

Setting(s)

All Urban

Enabler(s)

All Well developed lead professional roles Team ethos

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
Falkirk - Living Well

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Example of Good Practice

Living Well Falkirk

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All Technology Aligned plans Clarity of vision

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
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
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

Setting(s)

All City

Enabler(s)

All 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 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

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
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

Setting(s)

All City Urban Remote and rural

Enabler(s)

All Well developed lead professional roles Team ethos Well developed relationships

Integration Authority

All Other health and social care providers

Elements of Framework

All Manage own care Assets based approach Teams aligned to general practice
Integrated community care for older people, Canada

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Example of Good Practice

Integrated community care for older people in Toronto, Canada

Client Group(s)

All Older adults

Setting(s)

All City

Enabler(s)

All Infrastructure Clinical and care governance Well developed relationships Shared accountability

Integration Authority

All Other health and social care providers

Elements of Framework

All First point of contact Connect with communities 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 Enhanced care in care homes and supported accommodation Fully integrated community teams
Inverclyde - Re-attenders at ED

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Example of Good Practice

Re-attenders at ED

Client Group(s)

All Younger adults Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Inverclyde

Elements of Framework

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

Setting(s)

All Urban

Enabler(s)

All Technology Well developed lead professional roles Information sharing Agile working Well developed relationships Shared accountability

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

Setting(s)

All Urban

Enabler(s)

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

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 - First Responders aligned to Primary Care

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Example of Good Practice

First Responders Aligned to Primary Care

Client Group(s)

All Younger adults Older adults

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Orkney

Elements of Framework

All Connect with communities Teams aligned to general practice
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
Renfrewshire - Supportive and Palliative Action Register in the community

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Example of Good Practice

Supportive and Palliative Action Register in the community

Client Group(s)

All Younger adults Children and young people Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All Renfrewshire

Elements of Framework

All Anticipatory care planning Connect with communities Manage own care Teams aligned to general practice Seamless working with acute care 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
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

Setting(s)

All Urban Remote and rural

Enabler(s)

All Information sharing Team ethos Well developed relationships Shared accountability

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
Western Isles - Integrated primary care

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Example of Good Practice

Integrated primary care

Client Group(s)

All Younger adults Children and young people Older adults

Setting(s)

All Remote and rural

Enabler(s)

All

Integration Authority

All Western Isles

Elements of Framework

All Teams aligned to general practice
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

Setting(s)

All Remote and rural

Enabler(s)

All Technology Clinical and care governance Team ethos Clarity of vision Collaborative leadership

Integration Authority

All Western Isles

Elements of Framework

All Teams aligned to general practice