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Client Group

Enablers

Service Area

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

Service Area(s)

All Social care services Rehabilitation Physical disabilities Learning disabilities Community care Mental health Physical health Admission avoidance Management team

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
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
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
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

Service Area(s)

All Supported discharge Admission avoidance

Enabler(s)

All

Integration Authority

All Clackmannanshire and Stirling

Elements of Framework

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

Service Area(s)

All Intermediate care incl Hospital at Home Community care Physical health Admission avoidance

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

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
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 Ayrshire - Right Support, Right Place, Right Time

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Example of Good Practice

Right Support, Right Place, Right Time

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All East Ayrshire

Elements of Framework

All Manage own care Assets based approach Live independently at home or in a homely setting
East Ayrshire - Thinking Differently Programme

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Example of Good Practice

Thinking Differently Programme

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Enabler(s)

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

Integration Authority

All East Ayrshire

Elements of Framework

All Connect with communities Manage own care Assets based approach Live independently at home or in a homely setting
East Dunbartonshire - Caring Together

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Example of Good Practice

Caring Together

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All East Dunbartonshire

Elements of Framework

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

Service Area(s)

All Admission avoidance

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 Dunbartonshire - Integrated working across EDADS and Criminal Justice

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Example of Good Practice

Integrated Working across EDADS and Criminal Justice

Client Group(s)

All Younger adults

Service Area(s)

All Justice Addictions

Enabler(s)

All

Integration Authority

All East Dunbartonshire

Elements of Framework

All 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

Service Area(s)

All Supported discharge Admission avoidance

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
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
East Renfrewshire - Building the integrated environment

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Example of Good Practice

Building the integrated environment

Client Group(s)

All

Service Area(s)

All Community care Mental health

Enabler(s)

All

Integration Authority

All East Renfrewshire

Elements of Framework

All Connect with communities Teams aligned to general practice Live independently at home or in a homely setting
East Renfrewshire - Community Led Support - Talking Points

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Example of Good Practice

Community Led Support - Talking Points

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All East Renfrewshire

Elements of Framework

All Connect with communities Assets based approach Teams aligned to general practice Live independently at home or in a homely setting
East Renfrewshire - Healthier Minds

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Example of Good Practice

Healthier Minds

Client Group(s)

All Children and young people

Service Area(s)

All Mental health

Enabler(s)

All Technology Infrastructure Culture and values Well developed lead professional roles Management information Agile working Team ethos Well developed relationships Clarity of vision Collaborative leadership

Integration Authority

All East Renfrewshire

Elements of Framework

All First point of contact Connect with communities Short-term, targeted interventions to meet more complex needs
Edinburgh City - Three Conversations

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Example of Good Practice

Three Conversations

Client Group(s)

All Younger adults Older adults

Service Area(s)

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

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

Service Area(s)

All Intermediate care incl Hospital at Home Rehabilitation Community care Supported discharge Physical health

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

Service Area(s)

All Community care Physical health

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
Falkirk - Transforming day services

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Example of Good Practice

Transforming day services

Client Group(s)

All Younger adults

Service Area(s)

All Physical disabilities Learning disabilities

Enabler(s)

All

Integration Authority

All Falkirk

Elements of Framework

All Connect with communities Assets based approach Live independently at home or in a homely setting
Fife - Care at Home Collaborative

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Example of Good Practice

Care at Home Collaborative

Client Group(s)

All Older adults

Service Area(s)

All Social care services Community care Admission avoidance

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

Service Area(s)

All Admission avoidance

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
Fife - SAMH Sam's Cafe

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Example of Good Practice

SAMH Sam's Cafe

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Enabler(s)

All Culture and values Agile working Team ethos Well developed relationships Clarity of vision Shared accountability

Integration Authority

All Fife

Elements of Framework

All First point of contact Connect with communities Manage own care
Glasgow City - Mental Health Assessment Units

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Example of Good Practice

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Mental health

Enabler(s)

All Information sharing Well developed relationships Clarity of vision

Integration Authority

All Glasgow City

Elements of Framework

All First point of contact Seamless working with acute care 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

Service Area(s)

All Social care services Community care Supported discharge Admission avoidance

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
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
Inverclyde - Home first interface arrangements

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Example of Good Practice

Home first interface arrangements

Client Group(s)

All Younger adults Older adults

Service Area(s)

All Management team

Enabler(s)

All Information sharing Aligned plans Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Inverclyde

Elements of Framework

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

Service Area(s)

All Addictions Mental health Physical health

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
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
Midlothian - Mental Health Access Point

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Example of Good Practice

Mental Health Access Point

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All Midlothian

Elements of Framework

All Connect with communities Manage own care
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
North Ayrshire - Integrated Drug and Alcohol Recovery Service

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Example of Good Practice

Integrated Drug and Alcohol Recovery Service

Client Group(s)

All Younger adults

Service Area(s)

All Addictions

Enabler(s)

All

Integration Authority

All North Ayrshire

Elements of Framework

All Fully integrated community teams
North Ayrshire - Schools Based Challenge Team

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Example of Good Practice

Schools Based Challenge Team

Client Group(s)

All Children and young people

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All North Ayrshire

Elements of Framework

All Connect with communities 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

Service Area(s)

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

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 - 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
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

Service Area(s)

All Admission avoidance

Enabler(s)

All

Integration Authority

All North Lanarkshire

Elements of Framework

All Connect with communities Assets based approach Fully integrated community teams
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

Service Area(s)

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

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 - Integrated Rehabilitation Teams

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Example of Good Practice

Integrated Rehabilitation Teams

Client Group(s)

All Older adults

Service Area(s)

All Rehabilitation

Enabler(s)

All

Integration Authority

All North Lanarkshire

Elements of Framework

All Reablement 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

Service Area(s)

All Primary care Social care services Physical disabilities Community care Mental health Physical health

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

Service Area(s)

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

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
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
Perth and Kinross - Multi-Agency Substance Use Joint Assessment Clinic

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Example of Good Practice

Multi-Agency Substance Use Joint Assessment Clinic

Client Group(s)

All Younger adults

Service Area(s)

All Justice Addictions

Enabler(s)

All Information sharing Agile working Well developed relationships Clarity of vision Shared accountability

Integration Authority

All Perth and Kinross

Elements of Framework

All Connect with communities 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
Renfrewshire - Mental Health and Addictions Recovery Hub

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Example of Good Practice

Renfrewshire Mental Health and Addictions Recovery Hub

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Addictions Mental health

Enabler(s)

All Technology Infrastructure Culture and values Information sharing Agile working Fit for purpose premises Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability Collaborative leadership

Integration Authority

All Renfrewshire

Elements of Framework

All Connect with communities Manage own care Assets based approach
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

Service Area(s)

All Physical health

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 - 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 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 - Shifting the balance of care and resource

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Example of Good Practice

Shifting the balance of care and resource

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All South Lanarkshire

Elements of Framework

All Seamless working with acute care 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
South Lanarkshire - The Future of Care

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Example of Good Practice

The Future of Care

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All South Lanarkshire

Elements of Framework

All Enhanced care in care homes and supported accommodation
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
West Dunbartonshire - Focussed Intervention Team

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Example of Good Practice

Focussed Intervention Team

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All West Dunbartonshire

Elements of Framework

All Teams aligned to general practice Enhanced care in care homes and supported accommodation Fully integrated community teams
West Dunbartonshire - Intensive support at home

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Example of Good Practice

Intensive support at home

Client Group(s)

All Older adults

Service Area(s)

All Admission avoidance

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
West Lothian - Community Wellbeing Hubs

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Example of Good Practice

Community Wellbeing Hubs

Client Group(s)

All Younger adults

Service Area(s)

All Mental health

Enabler(s)

All

Integration Authority

All West Lothian

Elements of Framework

All Connect with communities Manage own care Teams aligned to general practice Fully integrated community teams
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

Service Area(s)

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

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

Service Area(s)

All Supported discharge

Enabler(s)

All

Integration Authority

All West Lothian

Elements of Framework

All Seamless working with acute care