TCC update January 2017
Nina, Dianne, Tina, Lisa, Sue
Care Co-ordination
Care Co-ordination
referral criteria
Referrals for Care Coordination can come from
general practices, acute
hospitals and community
health and social care
services for patients with:
The Trafford Co-ordination Centre (TCC) is a key partner for
Primary Care in delivering New Models of Care. The Care Coordination team enables practices with the wider interface of
services in the community by helping patients in co-ordinating a
‘circle of care’ that includes navigating health, social and voluntary
care services in support with daily living and community
socialisation.

indications of frailty

long term
conditions

young adults in
service transition
The Care Co-ordination team

The Care Co-ordination team currently comprises of a GP and 14
nurses with a variety of backgrounds which includes: general
practice, renal nursing, intensive care, mental health, intermediate
care, complex care, A&E, neuro intensive care, theatre recovery,
district nursing, respiratory care, haematology and general medical.
The team is supported by a Care Co-ordination admin assistant.
They are assigned to work within each of the four neighbourhoods
and they will be introducing themselves to you over the next few
weeks. They are keen to develop a good working relationship with
the practices and discuss how you and your patients can benefit
from the service.
Sue Guilfoyle, the clinical team lead, manages the team and is
happy to be contacted with any queries.
mental health
conditions who
would benefit with
support in
managing their
physical health

learning difficulties
who would benefit
from support in
managing their
physical health

recovering from a
fall, stroke or brain
injury.
Recently a Care Co-ordination patient told one of the nurses on the
phone:
“I didn't know where to turn or how to get the help I needed but I
knew the TCC could help”
Referral Management update
Conditions identified for
Referral Management
The initial 22 conditions
were identified after
consultation with Dr Sangha
based on activity volumes:
 atrial fibrillation
 chest pain/angina
 tachyarrhythmia
 heart failure
 acne
 eczema
 psoriasis
 warts
 diabetes
 hearing loss
 rhinitis
 tonsillitis
 diarrhoea – adults
 dyspepsia
 carpal tunnel
 hip pain
 knee pain
 shoulder pain
 neck pain
 COPD
 childhood asthma
13 new conditions being
reviewed:
 headache
 vasectomy
 ear care/de-wax
 minor surgery –
excisions
 minor surgery –
joint/soft tissue
injections
 irritable bowel
syndrome
 benign eyelid lesions
 dysmenorrhea
 menorrhagia
 thrush
 irregular vaginal
bleeding
 LUTS – male
 basal cell carcinoma
A further 13 conditions have now had pathways developed through the
TCC GP advisers (Dr Phil Stratford-Smith, Dr Yvonne Burke, Dr Manish
Prasad, Dr Sapna Tandon and Dr Catherine Allen) with planned
implementation from January 2017. The original 22 condition pathways
are being reviewed to see if any of these can be developed further
alongside secondary care consultants or retired.
The TCC will also commence monitoring our high volume Effective Use of
Resources (EUR) policies, not covered in other pathways, in January.
These are:

bunions

dupuytren’s contracture

ganglions

carpal tunnel syndrome

hyaluronic acid injections

hyperhidrosis

varicose veins

tonsillectomy

breast surgery

cataracts

eyelid ptosis
New referral form
We have been working on a pilot with Washway Road and West
Timperley practices to create a generic primary care form for all referrals.
This was extended to Davyhulme and Derbyshire Road, prior to its formal
launch at the GP Education event on 25th January 2017.
Following the launch, Becky Flynn will be it touch to confirm dates for
uploading the primary care referral form to your system, training on how to
utilise the tools and an overview of the benefits for your practice.
The Primary Care referral form will standardise referrals, reduce variation,
increase quality and auto-populate with the patient’s data. This form will
also be used for MSK referrals and will enable easy access to the STarT
Back tool which will be uploaded for lower back pain within Emis Web.
The tool will calculate the STarT Back score instantly and input into your
referral.
Becky will also upload all Effective Use of Resources Policy summary
documents to ensure you have the most up-to-date policies and forms
available when making Individual Funding Requests (IFR).
MSK service developments
The TCC now has access to Community EMIS which enables them to
manage all requests for information from GPs. They are able to track MSK
patients on the pathway allowing them to be your one point of contact for
any enquiries. For all MSK referrals please:

refer all MSK conditions, with the exception of red-flags, using the
referral form and e-mail to the TCC

use the standard format for email subject heading: *condition*
(identify if the referral is for physio or a specialist community clinic - pain
management; trauma and orthopaedics; or rheumatology) *patient
surname* *NHS number*

for lower back pain complete the STarT Back Tool. This stratifies
patients into appropriate pathways. Patients scoring low only require
support within primary care to enable self-management.

note any diagnostics will be ordered by the MSK service.
The new service will clinically triage all MSK referrals. Initially, the
outcome of this triage could be that the patient requires secondary care
treatment (as these patients may have already received some
management in primary care.) In this case the referral will be passed
back to the TCC to book the appointment. Once patients are accepted
into the new service, any future referral to secondary care for surgery will
follow on from relevant diagnostics and shared decision making with the
patient. Again, this will be arranged by the TCC.
Information governance
General practices are ‘data controllers’ and it is a requirement of the
data protection act to process personal data fairly and lawfully.
Being transparent by providing a privacy notice is an important part of
fair processing as this informs the patient about how and why you use
and process their personal information and who you share it with the
Trafford Clinical Commissioning Group (CCG)/TCC Fair Processing
Notice will be shared with your practice and if you do not already have a
notice published, it should be added to your website regarding data
sharing for the purpose of the TCC service and risk stratification.
This can also be found on the TCC website.
NB Patient records on EMIS must note that patients have given consent
to have their information shared in order for the TCC to access their
record to enrol them for Care Co-ordination.
Information for patients and clinicians
For patients
You recently received a poster to display in the waiting room and patient
information. If you need more of these please contact Helen Tester,
[email protected]
The TCC has a dedicated website with further information about the
service, tips on wellbeing, an introduction to the teams and news items.
You may find relevant to add a link to from your website:
www.traffordcoordinationcentre.nhs.uk
Clinicians
There are a number of documents that the practice will have previously
received that support the referral process. These have been updated
and will be sent to you in an information pack.
The TCC Care Co-ordination as an integrated service
A patient’s experience
The team at the TCC have been busy registering and supporting patients
with Care Co-ordination. Before Christmas they received a referral from the
Mastercall Pathfinder service. The gentleman had complex needs including
cancer and anxiety and often missed taking his medication. He was also a
frequent caller to the out-of-hours service and 999.
Following his welcome call the TCC nurse referred to the SAMS team for
twice daily visits to help him keep on top of his medication. During the first
visit SAMS were concerned about his personal safety because of his
cluttered living conditions so the
TCC made a referral to the Fire Service's Safe & Well service, who they
have a partnership agreement with to help improve his living arrangements.
The TCC made twice weekly wellness calls to the gentleman to monitor his
condition and provide him with some extra support and re-assurance.
Since the intervention from the TCC the gentleman hasn’t made any calls to
the out-of-hours service or to 999, he has got on top of his medication, the
visits from the SAMS team have been reduced and he is feeling much more
secure, knowing that he can call the TCC whenever he is worried.
Contact
information
The TCC email
addresses have been
updated to the following:
Referral Management
enquiries/referrals:
[email protected]
MSK referrals:
[email protected]
Care Co-ordination
requests/referrals:
Tcc.carecoordadmin@nhs.
net
Key contacts
Sue Guilfoyle
TCC Clinical Team Lead
0161 976 2555
[email protected]
Carolyn Eadie
Trafford CCG Information
Governance Manager
[email protected]
Helen Tester
TCC Communications and
Engagement Lead
07841 860480
[email protected]
General enquiries
Trafford Co-ordination
Centre
Ground Floor
Crossgate House
Cross Street
Sale
M33 7FT
0161 976 2555 (prefix
18001 for text relay)
[email protected]
TCC website
www.traffordcoordinationc
entre.nhs.uk