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Supported discharge

Service Area: Supported discharge

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Client Group

Setting

Enablers

Integration Authority

Element of Framework

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
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
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 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 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
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

Setting(s)

All City Corporate

Enabler(s)

All Well developed lead professional roles Information sharing Agile working Well developed relationships

Integration Authority

All Fife

Elements of Framework

All Connect with communities Manage own 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
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
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 - 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
Orkney - 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 Remote and rural

Enabler(s)

All Technology Culture and values Information sharing Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Orkney

Elements of Framework

All Reablement Live independently at home or in a homely setting Fully integrated community teams
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 - 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 - Learning Disability Core and Cluster Model and community connections

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Example of Good Practice

LD Core and Cluster Model and community connections

Client Group(s)

All Younger adults Older adults

Setting(s)

All Urban Remote and rural

Enabler(s)

All Improvement capacity Culture and values Well developed lead professional roles Clinical and care governance Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation 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 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

Setting(s)

All Urban

Enabler(s)

All Infrastructure Improvement capacity Culture and values Well developed lead professional roles 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 West Lothian

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting
West Lothian - Integrated discharge planning

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Example of Good Practice

Integrated discharge planning

Client Group(s)

All Older adults

Setting(s)

All Urban

Enabler(s)

All

Integration Authority

All West Lothian

Elements of Framework

All Seamless working with acute care