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Service Area: Primary care

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Client Group

Setting

Enablers

Integration Authority

Element of Framework

Aberdeenshire - MDT working in locality based teams COVID-19

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Example of Good Practice

Aberdeenshire - MDT working in locality based teams COVID-19

Client Group(s)

All Older adults

Setting(s)

All Urban Remote and rural Corporate

Enabler(s)

All Information sharing Agile working Clinical and care governance Team ethos Well developed relationships Collaborative leadership

Integration Authority

All Aberdeenshire

Elements of Framework

All Seamless working with acute care 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
East Ayrshire - Collaborative commissioning with third sector partners

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Example of Good Practice

Collaborative commissioning with third sector partners

Client Group(s)

All Children and young people Older adults

Setting(s)

All Urban Remote and rural

Enabler(s)

All Culture and values Well developed relationships Clarity of vision

Integration Authority

All East Ayrshire

Elements of Framework

All Connect with communities
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
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
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
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 - 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
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
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
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