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 The bottom line on the TCC is that it acts very much in the same way as an air traffic control system that ensures planes travel safely, and the data and technology solutions are the ‘radar’ which enables the work. The CCG has estimated benefits that will be derived 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? 13% of all referrals have anomalies Variation in GP referrals Referral management Beds at UHSM / CMFT blocked by Trafford patients medically fit for discharge Discharge management 30% of patients with chronic conditions use 70% of health and social care budget and still suffer poor outcomes Complex Care Co-ordination Patient empowerment, self care and signposting to voluntary and community services Enquiry Management To identify patients for complex care management To drive intelligent commissioning Analytics This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group

The TCCC Solution: TCCC Analytics What areas will TCCC focus on, what will it do and what outcomes and benefits is it targeting ? OUTCOMES Ref Mgmt. Reduced follow up appointments Reduced DNAs Better utilisation of community services Dis Mgmt Reduce length of stay and reduced re-admission Complex Care Cord. Reduce unplanned admissions and re-admissions Reduce unplanned A&E visits ENQ Mgmt. Reduce unplanned A&E visits, GP visits Reduce unplanned admissions Quality check and re-direct referrals Co-ordinate discharge between hospital, community and social care services Co-ordinate care for frequent users (LTC, frail, elderly, MH) Signpost service users GP referrals & outpatient appointments Patient self-care A&E visits Inpatient stays and social care FOCUS AREA TCCC IMPACT BENEFITS Increased quality and safety across health and social care TCCC Analytics All 250,000 Residents Reduction in costly acute services 3,000 Patients Sustained community services 2,000 – 4,000 Patients Improved patient outcomes All 250,000 Residents Intelligent commissioning across health & social care This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group

To end May 2016: Clinical outcomes 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 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: 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 Patient Presents at TGH Delay in treatment / care increasing anxiety for the patient Contact made to several agencies Steve C Patient Assessed and treated Age UK Patient Admitted This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group

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 Steve C 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 Steve C This service is managed and provided by CSC on behalf of NHS Trafford Clinical Commissioning Group