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Remote and rural

Setting: Remote and rural

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Client Group

Enablers

Service Area

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

Service Area(s)

All Primary care Intermediate care incl Hospital at Home Community care

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
Aberdeenshire - Residential Care Home: New Opportunities

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Example of Good Practice

Residential Care Home: New Opportunities

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Aberdeenshire

Elements of Framework

All Reablement Enhanced care in care homes and supported accommodation Fully integrated community teams
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

Service Area(s)

All Rehabilitation Physical health

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 - Check TEC Out

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Example of Good Practice

Check TEC Out

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Angus

Elements of Framework

All 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

Service Area(s)

All Admission avoidance

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
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

Service Area(s)

All Primary care Physical health

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

Service Area(s)

All Mental health Physical health

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 - HSCP Huddle

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Example of Good Practice

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Management team

Enabler(s)

All Infrastructure Culture and values Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Argyll and Bute

Elements of Framework

All
Argyll and Bute - Living Well

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Example of Good Practice

Living Well in Argyll and Bute

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Argyll and Bute

Elements of Framework

All Reablement Connect with communities Manage own care Assets based approach
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

Service Area(s)

All Rehabilitation Physical health Admission avoidance

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

Service Area(s)

All Social care services Justice Day services Housing incl homelessness Addictions Physical disabilities Learning disabilities Community care Supported discharge Mental health Admission avoidance

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
Compassionate community, Spain

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Example of Good Practice

'All with you' - approach to palliative and end of life care, Seville

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All

Enabler(s)

All Culture and values Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
Dumfries and Galloway - Good conversations

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Example of Good Practice

Good conversations

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Dumfries and Galloway

Elements of Framework

All Assets based approach
Dumfries and Galloway - Improving access to CAMHS

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Example of Good Practice

Improving access to CAMHS

Client Group(s)

All Children and young people

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Dumfries and Galloway

Elements of Framework

All Teams aligned to general practice
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

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Admission avoidance

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
Dumfries and Galloway - Transforming learning disability services

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Example of Good Practice

Transforming learning disability services

Client Group(s)

All Older adults

Service Area(s)

All Learning disabilities

Enabler(s)

All

Integration Authority

All Dumfries and Galloway

Elements of Framework

All First point of contact Connect with communities Assets based approach Fully integrated community teams
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

Service Area(s)

All Primary care Social care services Addictions Mental health

Enabler(s)

All Culture and values Well developed relationships Clarity of vision

Integration Authority

All East Ayrshire

Elements of Framework

All Connect with communities
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

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Physical health Admission avoidance

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

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Housing incl homelessness Physical disabilities Physical health

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
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

Service Area(s)

All Primary care Intermediate care incl Hospital at Home Rehabilitation Mental health Physical health Admission avoidance

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
Highland - Developing flexible care in MacKenzie Centre

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Example of Good Practice

Developing flexible care in MacKenzie Centre

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Highland

Elements of Framework

All Connect with communities Assets based approach Live independently at home or in a homely setting
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

Service Area(s)

All Intermediate care incl Hospital at Home Supported discharge Physical health Admission avoidance

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

Service Area(s)

All Primary care Mental health Physical health

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
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

Service Area(s)

All Social care services Physical disabilities Learning disabilities Mental health Physical health Admission avoidance

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

Service Area(s)

All Primary care Social care services Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Admission avoidance

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 - Community Wellbeing Development Team: Rich conversations

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Example of Good Practice

Rich conversations

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Moray

Elements of Framework

All Connect with communities Manage own care Assets based approach
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

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Physical disabilities Supported discharge Physical health Admission avoidance

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
Moray - Integrated Mental Health Services

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Example of Good Practice

Integrated Mental Health Services

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Moray

Elements of Framework

All Connect with communities Manage own care Assets based approach Fully integrated community teams
Moray - Outreach Service and third sector integration

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Example of Good Practice

Outreach Service and third sector integration

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Moray

Elements of Framework

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

Service Area(s)

All Social care services Rehabilitation Day services Addictions Physical disabilities Learning disabilities Supported discharge Mental health Physical health Admission avoidance

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
Orkney - Developing the local workforce: a career in social care (SCQF Level 5 - free course)

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Example of Good Practice

Developing the local workforce: a career in social care (SCQF Level 5 - free course)

Client Group(s)

All Younger adults

Service Area(s)

All Social care services

Enabler(s)

All Culture and values Aligned plans Well developed relationships Clarity of vision

Integration Authority

All Orkney

Elements of Framework

All Connect with communities
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

Service Area(s)

All Physical health

Enabler(s)

All

Integration Authority

All Orkney

Elements of Framework

All Connect with communities Teams aligned to general practice
Orkney - Home First approach

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Example of Good Practice

Home First approach

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Community care Supported discharge

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
Perth and Kinross - Local Care Home Oversight Group

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Example of Good Practice

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All Culture and values Well developed lead professional roles Clinical and care governance Team ethos Well developed relationships

Integration Authority

All Perth and Kinross

Elements of Framework

All Enhanced care in care homes and supported accommodation 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

Service Area(s)

All Social care services Intermediate care incl Hospital at Home Community care Supported discharge Physical health Admission avoidance

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

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Physical disabilities Supported discharge Physical health Admission avoidance

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
Scottish Borders - Care Home and Community Assessment Team

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Example of Good Practice

Care Home and Community Assessment Team

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Scottish Borders

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
Scottish Borders - Renew Service

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Example of Good Practice

Renew Service

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Enabler(s)

All Well developed lead professional roles Information sharing Well developed relationships Clarity of vision

Integration Authority

All Scottish Borders

Elements of Framework

All Manage own care Teams aligned to general practice Short-term, targeted interventions to meet more complex needs
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

Service Area(s)

All Mental health Admission avoidance

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

Service Area(s)

All Supported discharge Admission avoidance

Enabler(s)

All

Integration Authority

All Shetland

Elements of Framework

All Short-term, targeted interventions to meet more complex needs Fully integrated community teams
Shetland - Post diagnostic support in primary care

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Example of Good Practice

Post diagnostic support in primary care

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Shetland

Elements of Framework

All Anticipatory care planning Assets based approach
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

Service Area(s)

All Social care services Housing incl homelessness Learning disabilities Supported discharge

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 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

Service Area(s)

All Primary care Physical health Admission avoidance

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

Service Area(s)

All Primary care Physical health Admission avoidance

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 - CAReS Community Addictions Recovery Service

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Example of Good Practice

CAReS: Community Addictions Recovery Service

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Addictions Mental health

Enabler(s)

All Culture and values Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All Manage own care Assets based approach Short-term, targeted interventions to meet more complex needs 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

Service Area(s)

All Social care services Justice Rehabilitation Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance

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

Service Area(s)

All Social care services Rehabilitation Physical disabilities Learning disabilities Community care Supported discharge Mental health Physical health Admission avoidance

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
South Lanarkshire - The Beacons

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Example of Good Practice

The Beacons

Client Group(s)

All Older adults

Service Area(s)

All Addictions

Enabler(s)

All Improvement capacity Well developed lead professional roles Agile working Fit for purpose premises Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All South Lanarkshire

Elements of Framework

All First point of contact Connect with communities Manage own care Assets based approach
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

Service Area(s)

All Primary care Mental health Physical health

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 - Barra and Vatersay Integrated Social Care Services

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Example of Good Practice

Barra and Vatersay Integrated Social Care Services

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Social care services Day services Physical disabilities Learning disabilities Community care Mental health

Enabler(s)

All Team ethos Well developed relationships Shared accountability Collaborative leadership

Integration Authority

All Western Isles

Elements of Framework

All Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation
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

Service Area(s)

All Physical health

Enabler(s)

All

Integration Authority

All Western Isles

Elements of Framework

All Teams aligned to general practice
Western Isles - Supporting people with dementia

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Example of Good Practice

Supporting people with dementia

Client Group(s)

All Older adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Western Isles

Elements of Framework

All Seamless working with acute care Live independently at home or in a homely setting Fully integrated community teams
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

Service Area(s)

All Physical health

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