The Trafford Co-ordination Centre (TCC) was commissioned by the Trafford Clinical Commissioning Group (CCG) in 2015. We went live in January 2016 processing hospital referrals on behalf of Trafford GP's and arranging hospital transport for Trafford patients, and in January 2017 our Care Co-ordination service went live. As 2018 draws to a close we would like to share this year’s achievements with you.
2018 began with 1688 people registered on our Care Co-ordination service. Over the course of the year this has grown to over 2,300 patients receiving this nurse-led telephone support service. All our patients have been receiving regular wellness calls based on a frequency agreed by the patient and our nurses or driven by emergency alerts.
From these calls we made approximately 4,000 interventions which resulted in; avoiding unplanned admissions to hospital, preventing patients missing appointments, onward referrals to community services, requesting specialist equipment, engaging Fire Services ‘Safe and Well’ team, and signposting to voluntary support services.
The TCC processed approximately 41,000 referrals for hospital appointments, redirected almost 1000 referrals and helped to triage over 7000 referrals for MSK services to ensure that patients received the most appropriate service at first appointment.
Recently we have begun monitoring cataract referrals to ensure compliance with the Effective Use of Resources policy. This ensures all appointments are valid, and that the patient’s time and hospital appointments aren’t wasted.
We are also supporting the CCG’s pilot diabetes strategy by ensuring referrals follow the approved procedure for enhanced diabetic care. It is hoped that this new strategy will lead to improved outcomes for Trafford patients with, or at risk of, developing diabetes.
This year saw the introduction of our first condition based clinical pathway. The “Falls” pathway is currently allowing our nurses to manage and support over 300 high risk patients using a range of measures specifically targeted to supporting patients following a fall and reducing risk of further falls.
North West Ambulance Service (NWAS)
November saw us begin a unique collaboration with NWAS. When ambulance crews attend patients who have fallen, or who may be frail and at risk of falling, the TCC are alerted and begin the process of supporting through the TCC Falls pathway. This reduces the risk of further calls to NWAS as our nurses provide the necessary support, interventions, and advice to help patients better manage their condition.
TCC are now receiving ‘real-time’ system alerts that advise our nurses if a care co-ordination patient is admitted to, and when is discharged from, hospital and/or A&E. We are also alerted if our patients call an ‘out of hours’ GP. TCC nurses will then contact our patients within 48 hours of the ‘call out’ or hospital discharge to ensure that they remain safe and well at home, by securing any immediate support and increase the frequency of the wellness calls.
October saw the TCC begin our ‘Winter Wellness’ programme. Our nurses have been calling those of our care co-ordination patients most at risk with advice on keeping safe and well at home during the winter months.
Our nurses offer advice of both a clinical and wellbeing nature and remind our patients we are available every day including over the Christmas and New Year period should they wish to contact us. We will also be calling our most socially isolated patients on Xmas Day, Boxing Day and New Year’s Day.
In May the TCC sent out a patient survey to our Care Co-ordination patients to find out what they thought of the service. From a 45% response rate 86% of respondents said the help the nurse gave has been of benefit and making a difference, and 73% of respondents said they would recommend the service to friends or family.
Patients occasionally take the time to write to us with their thoughts and experiences of the TCC. Here is a letter recently received from a patient in October this year:
“Since you contacted us, we have been so grateful and amazed at how we’ve been treated. Thank you one and all. When you are dealing with cancer it turns your whole world upside down. The telephone calls we receive from your office are so caring, helpful and most of all what you say will happen DOES!! Yesterday the Occupational Therapy lady called. In this day and age it is so nice to write and say a very big thank you to one and all. Please keep up your wonderful work and service.
It is appreciated”
Stay Well This Winter
We would like to remind everyone to ‘Stay Well This Winter’. If you have not already received a winter wellness call from our nursing team you will soon. Remember you can call our team every day of the year between 8am and 8pm if you need any help or support, particularly over the Christmas holiday period.
Throughout the year we received a number of invitations from local organisations to engage with us. This provided the TCC team with some great opportunities to meet directly with members of the public and talk to them about the work that we do, how we do it and the benefits from Care Co-ordination. Some of the organisations that we met included Age UK, Home Instead Senior Care and Home being there.
In addition to our website, www.traffordcoordinationcentre.nhs.uk we have utilised Facebook and Twitter to keep everyone across Trafford up to date with our work. We’ve found this is a great way to share our achievements and connect on a more personal level with the people and partners that we help and support.
Visits to the Centre
Throughout 2018 we received a number of requests from members of professional organisations who would like to visit the centre and find out more about the TCC and how we operate. This year we have enjoyed visits from Betsi Cadwaladr University Health Board (North wales), Walsall Borough Council, NWAS Community & Engagement team, Marie Curie Care & Support and GMFRS Safe & Well team.
As we ease into the New Year the TCC team are looking forward to:
• Extending our condition-based clinical pathways to enable more people to benefit from TCC
• Extend our alerts to include all carer hospital admissions
• Continuing our support of Trafford’s new diabetes strategy
• Enhancing our collaboration with Trafford’s Community Care Navigator service, a non-clinical team working to connect patients following discharge from hospital with appropriate community and voluntary services
• Enhancing our collaboration with Trafford Council’s One Trafford Response service to assist them in providing the right coordinated support for residents
• Supporting the Trafford Enhanced Care Home Team by alerting them when any care home residents are admitted to and discharged from hospital
• Supporting the CCG on wider health campaigns such as the smoking cessation programme by contacting smokers who are committed to quitting smoking but require regular structured support to achieve this.
All the TCC staff would like to take this opportunity to wish all our patients and carers, and all our partners working hard for better outcomes for Trafford residents, a very happy and safe Christmas and New Year.