At the end of 2017 the Trafford Co-ordination Centre looked back over its progress and achievements for the year.
The year began with just 80 people registered for the Care Co-ordination service. Over the course of the year this has grown significantly to over 1,600 patients who receive this unique telephone service.
The service aims to keeps individuals safe and well at home through regular wellness phone calls from specially trained nurses.
During 2017 the TCC has made around 4,000 interventions for patients which includes things such as; avoiding unplanned admissions to hospital, preventing people missing appointments, referrals to community or voluntary services and requesting specialist equipment.
With the Centre being open 7 days a week, 365 days a year there is always someone on hand to give practical advice and support over the phone or answer a query about a hospital appointment and book transport for patients who are eligible for this service. Along with co-ordinating care for some of Trafford’s most complex patients the TCC has also processed nearly 60,000 referrals to hospital and community services. This includes re-directing appointments to more appropriate community services which can mean the patient receives a sooner and more convenient appointment.
The TCC works with the GP practices to identify the people who would most benefit from Care Co-ordination. Primarily this is done using a risk stratification tool which identifies patients who are at a high risk of admission into hospital, followed by any other patients the GP deemed as appropriate for the service.
In September the GP Portal was launched which is a web based application providing comprehensive information on specialist services, referral processes and administrative support to help direct patients to the right care, in the right place.
Representatives from the TCC went out to visit all the practice managers during August to November to keep them fully up-to-date with the developments in the service, share some testimonies of patients that have been helped and deliver training sessions to the staff. The general feedback from these visits was really positive and has helped the practice staff to gain a greater understanding of how the TCC can support in co-ordinating care for patients.
In May the TCC sent out a survey to 200 Care Co-ordination patients to find out what they thought of the service. There was a 42% response rate from the survey and 89% of respondents said they would recommend the service to friends or family. When asked if the service helped them stay well at home 90% of respondents agreed it did and 87% felt their care was important to the staff. On being given the opportunity to add further comment some of the responses received told us:
‘I am really grateful for all the help and support the nurse gives me and my mum. I couldn't have got through some weeks without this support.’
‘The Care Co-ordination team have been most helpful in all aspects, especially regarding hospital appointments and patient transport.’
‘When I came out of hospital I just couldn't cope at all, then the nurse rang me for a chat from the Centre. She organised so many things to make life easier for me and less stressful, but also having her number to ring if I needed help was a blessing. My health problems are long term but the service was the main thing that helped my recovery and still does.’
One patient took the time to write in to thank the nurses for the support she receives. She was 96 and living alone having outlived her friends and family. She went on to say:
‘I have been looking after other people all my adult life and it is good to know there will now be someone to look after me! I think the setting up of this new centre is the best thing Trafford has done for a very long time.’
During the summer the TCC supported the Trafford Clinical Commissioning Group (CCG) at a series of Trafford Talks Health events, held in each of the four neighbourhoods of Trafford. The events were well attended by members of the public and gave them the opportunity to understand the plans the CCG has for healthcare in Trafford, along with an update on the progress of the TCC. These events concluded with the CCG’s Annual General Meeting at Sale Waterside.
In September the TCC was invited to speak at the first Healthwatch Advisory Board meeting to report on the progress of the service and the benefits it provides to patients in the community.
Throughout the year invitations were also received from local organisations that included singing groups, lunch clubs, Age UK Trafford dementia hubs, Trafford Housing coffee mornings, VBME Wellbeing event and local over 50’s clubs. These were great opportunities for the TCC to meet directly with members of the public and talk to them about how they may benefit from Care Co-ordination.
Connecting with other organisations
Along with co-ordinating care for patients the TCC also signposts them to organisations, groups and services that they feel could be of benefit to their wellbeing. This year the TCC has made new connections with the Homeshare scheme, Be Social, Being There and Talk, Listen, Care along with keeping in touch with existing contacts.
As the TCC becomes more widely known in Trafford they receive numerous invitations from people wanting to connect with them. This has included delivering talks to service users and attending staff meeting for organisations including Age UK Trafford, Phoenix Futures and Trafford Carers Centre. These meetings give staff a more in depth knowledge of the TCC and how it can support their service users. The TCC is also working with Talk, Listen, Change over the winter months to support over 55’s who may be feeling lonely or isolated and may benefit from their counselling service.
Along with the development of the website, the TCC went live on Facebook in July. This has been a great way to get to know what’s going on in Trafford, to share some of the Centre’s achievements and show followers the human side of the service. A regular Wellbeing Wednesday post uses the 5 ways to wellbeing to help inspire people to improve their wellbeing. The page also promotes local activities, celebrates achievements and links to new features on the website.
As curiosity grows within Greater Manchester around the Trafford Co-ordination Centre many requests are received from people wanting to come and visit and find out more about how this concept works. Guests to the centre have included local councillors, Healthwatch, Health Innovation Manchester, Public Reference & Advisory Panel and neighbouring CCGs.
The staff at the TCC don’t just provide excellent service to patients as they co-ordinate their care, manage their referrals and make transport bookings, they also get involved in charity events. Some of the fundraising events the team have got involved in this year have included the Macmillan Coffee morning, Jeans for Genes day, the Great Manchester 10km and half marathon, going sober for October and Save the Children Christmas jumper day.
The team also take time out to look after their wellbeing, inspired by a weekly Wellbeing Wednesday message. In April a joint workplace wellbeing week was held in conjunction with the CCG and Trafford Leisure. During this week staff at Crossgate House clocked up an impressive 1,645,837 steps (779) in the week long pedometer challenge and attended taster classes in yoga, Pilates and body pump. At the CCG’s Annual General Meeting the TCC was one of the organisations in Trafford to receive an award in recognition of their workplace wellbeing initiatives, presented by Dr Yvonne Burke.
As we move into 2018 the TCC looks forward to developing the Care Co-ordination service to support people in the management of long term conditions and provide intensive support following a stay in hospital to help prevent them being re-admitted and to address any concerns they may have about their health. The TCC will also be at the heart of the proposed integration between Trafford Council and the CCG.