1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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