The Trafford Care Co-ordination Centre
(TCCC) Solution:
What is it?
•
TCCC is a ‘care control tower’ for the health, social care
voluntary and community economy
•
Risk stratification is the ‘radar’ for the health social care voluntary
and community economy
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
The TCCC Solution:
What services will it provide and why?
Referral management
Discharge management
Complex
Care Co-ordination
Enquiry Management
Analytics
• 13% of all referrals have anomalies
• Variation in GP referrals
• Beds at UHSM / CMFT blocked by Trafford patients medically fit for discharge
• 30% of patients with chronic conditions use 70% of health and social care budget
and still suffer poor outcomes
• Patient empowerment, self care and signposting to voluntary and community
services
• To identify patients for complex care management
• To drive intelligent commissioning
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
The TCCC Solution:
What areas will TCCC focus on, what will it do and what outcomes and benefits is it targeting ?
GP referrals &
outpatient
appointments
TCCC IMPACT
Quality check and redirect referrals
OUTCOMES
BENEFITS
Reduced follow up
appointments
Increased
quality and
safety across
health and
social care
Reduced DNAs
All
250,000 Residents
Complex
Care Cord.
2,000 – 4,000
Patients
ENQ Mgmt.
3,000 Patients
Dis
Mgmt
Better utilisation of
community services
Inpatient stays and
social care
A&E visits
Patient self-care
Reduce length of stay
and reduced readmission
Co-ordinate discharge
between hospital, community
and social care services
Reduce unplanned
admissions and readmissions
Co-ordinate care for
frequent users (LTC,
frail, elderly, MH)
Signpost service
users
Reduce unplanned
A&E visits
Reduce unplanned
A&E visits, GP visits
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
Reduce unplanned
admissions
TCCC Analytics
All
250,000 Residents
Ref Mgmt.
FOCUS AREA
Reduction in
costly acute
services
Sustained
community
services
Improved
patient
outcomes
Intelligent
commissioning
across health &
social care
The TCCC Solution:
Impact so far ?
To end May 2016: Clinical outcomes
• 14,203 referrals in first five months
• Basic errors in referrals declined from 25% to 5%
of total within three months
• Reducing appointment DNAs
• 135 diagnostic tests arranged
• Reducing follow up appointments
• 399 (3%) appointments diverted to community
provider or stopped altogether as unnecessary
• Better care at lower cost
• 75 patients through discharge management, 29 of
which under post discharge care
• Reducing delayed discharge and preventing
readmissions
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
The TCCC Solution:
Impact so far?
Patient Outcomes
‘90 year old patient who was medically fit for
discharge but their new care package was not
available until after a weekend, meaning an
additional 3 days in hospital. The TCCC team
worked with other agencies including the
Community Enhanced Care Team (CEC) to
discharge the patient 2 days sooner than she
would have done before the TCCC existed.
The patient is now followed up regularly by the
nursing team to ensure the risk of readmission is
greatly reduced.’
Patient outcomes
‘An older female patient with no care support at home.
Recently discharged from hospital on to our 28-day post
discharge support where the team established the
patient was not managing at home. Initially the team
involved Age UK to put in some smaller support
measures and reassessed a period of time later. At the
next assessment the patient was still not managing at
home and was a high risk of calling an ambulance and
being readmitted. The TCCC team then established
there were no life threatening symptoms and
referred to the SAMs service who arranged rapid
assessments within a number of hours to help the
patient remain well at home and avoid another
prolonged hospital admission.’
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
Patient Scenario Age UK:
Patient Scenario
Mr H diagnosed Alzheimer's Disease, recently widowed and lives alone. Mr H had been visited by
Age UK at the request of his son to solve the problems he was facing around his loneliness
following his wife's death and also the fact he was becoming more forgetful.
Mr H arrived at TGH on his bicycle, disorientated and confused looking for his wife. TGH staff tried
to support Mr H back home and called a number of services including social services to try and
enable this to happen.
TGH staff finally called Age UK and luckily as Mr H was known to them, a Dementia Advisor was
able to support getting Mr H back home, ensuring he was safe and advised Mr H’s family to call his
GP where it was identified he had a water infection.
Without this intervention Mr H would almost certainly have been admitted to hospital, likely
remained there for some time and potentially discharged to a residential home and not back to his
own home.
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
TCCC Partnership Solution:
Current Position
TCCC Solution
Patient Presents at TGH
Contact made to several
agencies
Patient Presents at TGH
Delay in treatment
/ care increasing
anxiety for the
patient
Patient Assessed and treated
Patient Admitted
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
Age UK
The TCCC Solution:
Why is it different?
•
•
•
•
•
•
The TCCC has access to a clinical portal which holds all health, social care and (hopefully) voluntary
and community services information for all residents in Trafford
The TCCC has dedicated clinical and admin teams that can support multiple agencies, patients and
carers and signpost them to services to ensure the best outcome for patients
Full Directory of Service for all health, social, voluntary and community services in Trafford
Significantly, the TCCC solution has been developed to grow and build out to other services such as
police, fire and housing services
The TCCC will use its experience to re-direct commissioning… leading to intelligent commissioning
And finally and perhaps most crucially, the TCCC is live and is delivering real positive outcomes for
patients now in Trafford
A real, live and working population health management solution in the birthplace of the NHS
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group
The TCCC Solution:
What next?
• Invitation to a workshop to identify how we can work in partnership
• Map services and capacity
• Include all services in the Directory of Services held at the TCCC
• Develop a partnership agreement between the TCCC and each service
This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group