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The purpose of this paper is to describe the development, implementation and early impact of a national action plan for active and healthy ageing in Scotland.

The Joint Improvement Team, NHS Health Scotland, the Scottish Government and the Health and Social Care Alliance Scotland (ALLIANCE) co-produced the action plan with older people from the Scottish Older People’s Assembly. Together they supported partnerships to embed the action plan as an important element of the reshaping care for older people transformation programme in Scotland.

A cross-sector improvement network supported health, housing and care partnerships to use a £300 million Change Fund to implement evidence based preventative approaches to enable older people to live well. Older people in Scotland spent over two million days at home than would have been expected based on previous balance of care and impact of ageing.

Improving the health and wellbeing of older people is not just the responsibility of health and social care services. Enabling older people to live independent, active and fulfilling lives requires coordinated effort that spans national and local government policy areas, mobilises all sectors of society, and involves all health and care disciplines. Success starts with listening to what matters to older people, and working together, and with older people and local communities, to make that a reality.

This case study from Scotland offers transferable learning for other systems who have an ageing population and an ambitions to enable them to live well in later life.

This viewpoint piece will highlight the contribution of trained lay community health workers to the integrated workforce in rural, remote and island settings, drawing on experience from a system strengthening project involving community health agents (CHAs) in four municipalities in Litoral Norte, a remote coastal and island region in the state of São Paulo, Brazil.

This viewpoint reflects on experiential learning from a unique north–south collaboration that spanned the period of a global pandemic. It adds to the international literature on the value of community health workers in public health and chronic disease management and highlights their potential pivotal role as integrators at point of care.

CHAs took forward actions that touched the lives of thousands of vulnerable families with low income and complex needs in communities with high levels of social and health inequalities. They acted as a bridge between patients and families at home, primary healthcare professionals and wider community partners and services. Their valuable insight into the healthcare issues and social challenges experienced by the community informed and supported family centred practice and population health goals. The CHAs rapidly pivoted to became an essential public health workforce during the Covid-19 pandemic.

As the authors establish integrated care systems and embrace proactive care and population health, the conditions are favourable for introducing a similar role in the UK. For psychological safety and avoidance of burnout people in such new roles will require training, supervision and full integration within community teams.

This viewpoint reflects experiential learning from a unique north–south collaboration that spanned the period of a global pandemic. It adds to the international literature on the value of community health workers in public health and chronic disease management and highlights their potential pivotal role as integrators at point of care.

To identify transitional palliative care (TPC) interventions for older adults with non-malignant chronic diseases and complex conditions.

A systematic review of the literature was conducted. CINAHL, Cochrane Library, Embase and Pubmed databases were searched for studies reporting TPC interventions for older adults, published between 2002 and 2019. The Crowe Critical Appraisal Tool was used for quality appraisal.

A total of six studies were included. Outcomes related to TPC interventions were grouped into three categories: healthcare system-related outcomes (rehospitalisation, length of stay [LOS] and emergency department [ED] visits), patient-related outcomes and family/carer important outcomes. Overall, TPC interventions were associated with lower readmission rates and LOS, improved quality of life and better decision-making concerning hospice care among families. Outcomes for ED visits were unclear.

Positive outcomes related to healthcare services (including readmissions and LOS), patients (quality of life) and families (decision-making) were reported. However, the number of studies supporting the evidence were limited.

Studies examining the effectiveness of existing care models to support transitions for those in need of palliative care are limited. This systematic literature review identified and appraised interventions aimed at improving transitions to palliative care in older adults with advanced non-malignant diseases or frailty.

Polypharmacy, the concurrent use of multiple medicines by one individual, is a common and growing challenge driven by an ageing population and the growing number of people living longer with chronic conditions. Up to 11% of unplanned hospital admissions in the UK are attributable to, mostly avoidable, harm from medicines. However, this topic is not yet central to integrated practice. This paper reviews the challenge that polypharmacy presents to the health and care system and offers lessons for integrated policy and practice.

Two commonly encountered scenarios illustrate the relevance of addressing inappropriate polypharmacy to integrated practice. An overview of the literature on polypharmacy and frailty, including two recent large studies of policy and practice in Europe, identifies lessons for practitioners, managers, policy makers and commissioners.

Comprehensive change strategies should extend beyond pharmacist led deprescribing initiatives. An inter-professional and systems thinking approach is required, so all members of the integrated team can play their part in realising the value of holistic prescribing, appropriate polypharmacy and shared decision making.

Awareness and education about polypharmacy should be embedded in inter-professional training for all practitioners who care for people with multimorbidity or frailty.

This paper will help policy makers, commissioners, managers and practitioners understand the value of addressing polypharmacy within their integrated services. Best practice national guidance developed in Scotland illustrates how to target resources so those at greatest risk of harm from polypharmacy can benefit from effective pharmaceutical care as part of holistic integrated care.

Managed care networks enable virtual integration of health, social care and housing service delivery. When focused on outcomes and experience for service users and carers, they can provide integrated support for improvement in the pathways, processes and experience of care and support for older people. This paper provides a case study of the development of a managed care network of health and social care partners in Lanarkshire in the context of current policy drivers in Scotland.

In many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of disease. The interface between primary and secondary care has been identified as a problem area. This paper aims to undertake a scoping review to gain a deeper understanding of the markers of integration across the primary–secondary interface.

A search was conducted of PubMed, SCOPUS, Cochrane Library and the grey literature for papers published in English using the framework described by Arksey and O'Malley. The search process was guided by the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA).

The initial database search identified 112 articles, which were screened by title and abstract. A total of 26 articles were selected for full-text review, after which nine articles were excluded as they were not relevant to the research question or the full text was not available. In total, 17 studies were included in the review. A range of study designs were identified including a systematic review (n = 3), mixed methods study (n = 5), qualitative (n = 6) and quantitative (n = 3). The included studies documented integration across the primary–secondary interface; integration measurement and factors affecting care coordination.

Many studies examine individual aspects of integration. However, this study is unique as it provides a comprehensive overview of the many perspectives and methodological approaches involved with evaluating integration within the primary–secondary care interface and primary care itself. Further research is required to establish valid reliable tools for measurement and implementation.