Background: South Ayrshire has a rapidly aging population with one of the highest dependency ratios in the world (reaching 88% by 2040). Traditional health and care models are no longer sustainable. South Ayrshire HSCP is working with communities to radically transform supports and improve outcomes.

Audience: The workshop is aimed at those who plan, commission and deliver health and care services and are looking to engage meaningfully with people throughout that process.

Approach: We will share our experience of empowering communities to move from passive engagement to active participation and leadership in developing ideas, implementing changes, refining improvements, providing oversight and measuring impact at a population and locality level and engage the audience in an appreciative inquiry into the approaches that they have used to engage communities to successfully transform upstream supports. Our Learning Disability Strategy was developed in partnership with our Learning Disability Community during 2021. A “League of Champions” was formed, made up of service users and carers to oversee the development and delivery of the strategy that emphasised health and wellbeing, choice and control, living independently and active citizenship. The strategy was delivered one year ahead of schedule thanks to the drive of the League of Champions. Taking the learning from this strategy we have taken the same approach in developing other strategies. Most recently in partnership with our third sector, we engaged over 150 older people through Champions Boards to drive the development of our multi-agency Ageing Well Strategy and “cultural movement” that aims to create places, spaces and communities that enable people to thrive into older age. In addition to these population level approaches we have engaged communities through a range of methods to develop Locality Plans. These locality plans aim to tailor service delivery and oversight to 6 distinct localities.

Outcomes: As a result of our approach we have delivered:
- voluntary and paid work for those with a learning disability.
- new accessible housing developments that will support people to stay independent into older age.
- private businesses providing seats and access to toilets for older people on the high-street.
- access to health and care services through mobile library vans in remote and rural communities.

We are working with two Universities to support the evaluation of our work and the Scottish Commission for People with Learning Disabilities is providing an independent evaluation of the impact of our Learning Disability Strategy including our approach to engagement.

Background: South Ayrshire has a rapidly aging population with one of the highest dependency ratios in the world (reaching 88% by 2040) and 30% of the population expected to be over 75yrs by 2040. Traditional health and care models are no longer sustainable. South Ayrshire HSCP is working with communities and system partners to radically transform supports and improve outcomes.

Audience: The workshop is aimed at anyone who lives, works or contributes to planning and delivering services in countries that have an ageing population.

Approach: We will share our experience of developing our "Ageing Well Strategy," commissioned by our Community Planning Partnership, with the aim of creating places, spaces and communities to enable people to thrive into older age. Built on strong partnerships between Health and Social Care Housing, Voluntary Sector, local private industry, police, fire service, transport and education the strategy has brought partners together to think differently, delivering cost neutral innovations that will deliver better outcomes and save system costs in the long term. With 150 older people sitting on three locality based champions boards, we are empowering communities to move from passive engagement to active participation and leadership in developing and delivering ideas to strengthen community and personal resilience. Leadership at all levels to build trusting relationships and a common sense of purpose have been key. The Community Planning Partnership has enabled partners to formalise the commissioning and oversight of the work. A 10min video captures the range of partners involved, the level of engagement at all levels and the impact that the work is having.

Outcomes: As a result of our approach we have delivered:
- 200 units fully accessible housing development with other council and private developments in the pipeline.
- private businesses providing seats and access to toilets for older people on the high-street.
- access to community activities and information about services through our CONNECT model.
- retirement planning conversations to enable people to continue to make a contribution to their community.
- entrepreneur support to enable people to transfer skills and set up micro-enterprises.

We are working with University of West of Scotland and Stirling University to support the evaluation of our work.

He Mauri o MyWai - The essence of MyWai
/ weaving the kete (basket) / co-creation – supporting collaborative care – at scale

This is the community building story of our ongoing work bringing together a linear data and digital project with Te Ao Māori (the Māori world view), people, whānau and community aspirations and easing burden for an overburdened workforce. Creating connections, dimensions and turning bits and bytes into navigating human complexity. Amplifying community resilience.

Cocreating a connected care software platform that spans Secondary, Primary, Community, NGO, cross (government) agencies, kaupapa Māori, non regulated workforce and informal support networks (including unpaid friends and family) that prioritise self-determined choice, consent and safety for a person and their whānau (family)

Setting the kaupapa (mission) and recognising the acute needs of the present, whilst aiming for the evolving realisation of what's possible and managing the expectations of a diverse set of partners. All while building and maintaining trusted relationships across networks.

MyWai is the result of years worth of trust building and co-creation between the Northland Community of New Zealand and a project to integrate teams and allow the people themselves to be owners of their own wellness journey. It has attempted to bridge the gap between traditional community health services (read Hospital and Health services outward ) and the bottom-up community organisations and initiatives that support their people.

Along the journey, this has traversed the rapids of information governance, trust, measurement, multi-disciplinary and inter-agency teams and, most importantly, people’s self determination of their health journey.

This presentation will describe how the project has had to traverse from the perspective of data and digital to the human dimension – and learning a way through engagement that puts the community at the forefront of its design to support their people.

How do we create an environment in the digital world that allows the various waters (in their various states) to express their natural form and, at the same time, safely support a lifelong journey for people and whanau through hau ora (self determination)?

Background: Many integrated community care (ICC) approaches exist at the neighborhood level aiming to improve the health and well-being of inhabitants, yet their specific components, their way of implementation, and the similarities and differences remain unclear. Approach: We conducted a multiple case study of ICC approaches in the Netherlands and Belgium, comprising a document study and expert interviews. Initially, we identified ICC approaches using expert suggestions and Google searches. The approaches had to meet at least three out of four criteria: 1) collaboration across multiple domains or sectors, including at least health and social care; 2) some form of citizen involvement; 3) a holistic approach to health; and 4) published scientific articles. We excluded approaches that focused on specific target groups rather than the entire population. For the document study, we included scientific articles, reports and grey literature. Semi-structured interviews were conducted with purposively selected experts, such as researchers, process facilitators, and others involved in these ICC approaches, to complement and validate findings from the document study. The data extraction and the interview topic list were based on the WHO Framework on Integrated, People-Centered Health Services (IPCHS) and included the topics: empowerment and engagement of people and communities; strengthening governance and accountability; reorientating the model of care; coordinating services within and across sectors; creating an enabling environment; and learning and monitoring. All qualitative data, from documents and interviews were thematically analyzed, guided by the WHO IPCHS Framework, to draw cross-case conclusions on the components, similarities, differences, and implementation of ICC approaches. Throughout the steps, we followed an iterative approach, enabling the identification of new approaches and inclusion of additional literature based on suggestions from the interviews. Results: In total, seven ICC neighborhood-level approaches were identified, six in the Netherlands and one in Flanders, Belgium. Most approaches were conducted as pilot studies: while half were discontinued after the pilot, stakeholders in several regions managed to continue aspects of the approaches as part of regular practice. All approaches aimed to integrate not just health but also social care and housing, with inhabitants actively involved in the planning, implementation, and evaluation. The degree and form of citizen participation varied, from low to high involvement. In a few approaches, citizens themselves initiated and implemented interventions and activities in a bottom-up manner. Most approaches followed a systematic approach to implementation, often facilitated by one or more process facilitators, with structured steps using methods specifically developed for each approach. Common steps included, among others, creating a shared vision and mission and conducting a needs assessment of the neighborhood, serving as the foundation of the plans made for the neighborhood. Implications: The results of our multiple case study contribute to the growing international interest in ICC, offering insights into how these approaches are applied in practice, along with their similarities, differences, and way of implementation. The results might be valuable to researchers, health and social care professionals, and other stakeholders involved in ICC, supporting the design, implementation and evaluation of ICC approaches across various contexts.

THINK Hauora is a Primary Health Organisation (PHO) that supports community development by providing essential primary health care services and promoting well-being in the MidCentral District, New Zealand. They achieve this through direct services, supporting General Practice teams, and collaborating with other organizations to address health inequities and improve overall community health.
Here's a more detailed look at how THINK Hauora supports community development:
1. Providing Essential Primary Health Care:
THINK Hauora ensures everyone in the MidCentral District has access to primary health services through a network of General Practice teams.
They offer a range of services, including diagnosis and treatment, health education, counselling, disease prevention, and screening.
This ensures that individuals and families can access the care they need to stay healthy and well.
2. Supporting General Practice Teams:
THINK Hauora supports General Practice teams by providing them with the resources and support they need to deliver high-quality care.
They also facilitate continuing professional development for health professionals, ensuring they have the knowledge and skills to meet the evolving needs of the community.
3. Working with Communities:
THINK Hauora actively engages with local communities and enrolled populations to identify and address health inequities.
They offer services tailored to the specific needs of different populations, including Hauora Māori, Pasifika health services, and services for older people.
This ensures that everyone in the community has the opportunity to access the services and support they need to achieve their health goals.
4. Promoting Health Equity:
THINK Hauora is committed to achieving health equity by addressing disparities in health outcomes.
They work to remove barriers to accessing care and ensure that everyone has the opportunity to live a healthy life.
They collaborate with other organizations and community groups to address the social determinants of health, such as poverty, education, and housing.
5. Fostering Collaboration and Innovation:
THINK Hauora actively collaborates with other health providers, Iwi, and community groups to improve health outcomes.
They are also involved in research and innovation, seeking new ways to improve the delivery of primary health care.
This collaborative approach ensures that the community benefits from the expertise and resources of multiple organizations.
In essence, THINK Hauora plays a vital role in community development by investing in the health and well-being of the people they serve. They achieve this through a variety of strategies, including providing essential primary health care, supporting General Practice teams, working with communities, promoting health equity, and fostering collaboration and innovation.

Background

The Patient Medical Home (PMH) model, also called the ‘medical home’ or ‘health home,’ has been globally recognized for strengthening interprofessional primary health care (PHC) delivery. This model provides integrated, team-based, and patient-centred care tailored to the community’s needs and preferences, thereby enhancing the patient experience and improving the quality of care. In Alberta, Canada, the Indigenous Primary Health Care and Policy Research (IPHCPR) Network convened experts to explore ways to adapt the PMH model to better serve Indigenous patients, ensuring culturally relevant and effective PHC delivery.

Approach

This research is built on a transdisciplinary research paradigm characterized by a collaborative approach to co-design and implementation. Addressing the conference theme of “Collaborative Approaches to Integrated Care,” PHC experts, Indigenous-focused clinician physicians, and Indigenous Knowledge Holders were engaged in the critical and reflexive exploration of the mainstream PMH Model implemented in Alberta’s Primary Care Networks. Idea generation techniques, including small group discussions, communicating and reflecting on ideas, and brainstorming future directions, were applied for an in-depth exploration of the PMH model. In small groups, participants explored three questions: (1) What resonates with you in the PMH model? (2) What features or components of the model are critical to exploring or advocating for Indigenous PHC delivery? (3) What are some concerns about the model? Following small group and roundtable discussions, participants learned from an adapted evidence-based Indigenous PMH model in Queensland, Australia.

Results

Four themes emerged regarding key features of the PMH model that are critical to implement for Indigenous PHC delivery: (1) Relational continuity; (2) Incorporation of localized Indigenous perspectives and ways of knowing; (3) Being adaptable and flexible to fit the local context and meet the needs of the communities it serves; and (4) Exploring workforce and leadership characteristics required to guide the development, implementation, and daily functioning of an Indigenous PMH. Concerns about the PHM model include its focus on individual rather than community health, its need for more attention to upstream health determinants, and possible conflicts with Indigenous worldviews during implementation. These findings align with several pillars of integrated care: population health needs and local context, people as partners in health and care, and workforce capacity and capability.

Implications

The expert gathering is an initial step toward adapting the PMH model for Indigenous PHC delivery in Alberta, Canada, which is Indigenous-led and co-designed, grounded in community needs, priorities, and Indigenous knowledge to foster relational integrated care. This work aligns with the province’s Modernizing Alberta’s Primary Health Care System reform strategy, which presents a window of opportunity to share our findings with decision-makers. A recent report published by the Indigenous Advisory Panel provided 22 recommendations to strengthen Indigenous PHC in the province, with the top priority being to connect Indigenous peoples to a culturally safe medical home2. We will apply lessons from collaboration with experts to develop design features and implementation aspects for an Indigenous PMH Model in Alberta.