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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
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

Service Area(s)

All Mental health Physical health

Enabler(s)

All

Integration Authority

All Aberdeen City

Elements of Framework

All Connect with communities Manage own care Teams aligned to general practice
Community care (Wigan Deal), England

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Example of Good Practice

Community care in Wigan, England

Client Group(s)

All Younger adults Children and young people Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Other health and social care providers

Elements of Framework

All Connect with communities Manage own care Assets based approach
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
Dundee City - Integrated Care Home Team

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Example of Good Practice

Integrated Care Home Team

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Dundee City

Elements of Framework

All Enhanced care in care homes and supported accommodation Fully integrated community teams
Dundee City - The ASPEN Project

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Example of Good Practice

The ASPEN Project: Embedding specialist trauma informed care and treatment within Dundee Women's Aid

Client Group(s)

All Younger adults

Service Area(s)

All Addictions Mental health

Enabler(s)

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

Integration Authority

All Dundee City

Elements of Framework

All First point of contact Connect with communities Short-term, targeted interventions to meet more complex needs
Dundee City - Turriff House Intermediate Care Suite

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Example of Good Practice

Turriff House Intermediate Care Suite

Client Group(s)

All Older adults

Service Area(s)

All Intermediate care incl Hospital at Home

Enabler(s)

All Improvement capacity Culture and values Well developed lead professional roles Collaborative leadership

Integration Authority

All Dundee City

Elements of Framework

All Reablement Live independently at home or in a homely setting Enhanced care in care homes and supported accommodation
Edinburgh City - Delayed discharge leadership

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Example of Good Practice

Delayed discharge leadership

Client Group(s)

All Older adults

Service Area(s)

All Community care Management team

Enabler(s)

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

Integration Authority

All Edinburgh City

Elements of Framework

All Seamless working with acute care
Edinburgh City - Improving falls in Edinburgh care homes

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Example of Good Practice

Improving falls in Edinburgh care homes

Client Group(s)

All Older adults

Service Area(s)

All Community care

Enabler(s)

All

Integration Authority

All Edinburgh City

Elements of Framework

All Enhanced care in care homes and supported accommodation 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

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
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

Service Area(s)

All Community care Supported discharge

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

Service Area(s)

All Supported discharge Physical health Admission avoidance

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 - Children's services transformation programme

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Example of Good Practice

Client Group(s)

All Children and young people

Service Area(s)

All Social care services

Enabler(s)

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

Integration Authority

All Glasgow City

Elements of Framework

All Connect with communities Assets based approach
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

Service Area(s)

All Social care services Housing incl homelessness Addictions Mental health Physical health

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
Glasgow City - Housing First Project

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Example of Good Practice

Housing First Project

Client Group(s)

All Younger adults

Service Area(s)

All Housing incl homelessness Addictions Mental health

Enabler(s)

All Aligned plans Well developed relationships Collaborative leadership

Integration Authority

All Glasgow City

Elements of Framework

All Connect with communities Manage own care Live independently at home or in a homely setting
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
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
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

Service Area(s)

All Primary care Social care services Intermediate care incl Hospital at Home Rehabilitation Day services Housing incl homelessness Physical disabilities Community care Supported discharge Mental health Physical health

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
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
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
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
West Dunbartonshire - My Life Assessment

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Example of Good Practice

My Life Assessment

Client Group(s)

All Older adults

Service Area(s)

All Social care services

Enabler(s)

All Technology Culture and values Well developed lead professional roles Management information Information sharing Aligned plans Team ethos Well developed relationships Clarity of vision Shared accountability

Integration Authority

All West Dunbartonshire

Elements of Framework

All Anticipatory care planning Manage own care Assets based approach