Trafford Care Co-ordination Centre

Descriptions

NHS Trafford Clinical Commissioning Group is looking to commission a service which will help support the delivery of integrated care for Trafford patients.In an integrated care system the patient will be seen by the appropriate team/clinician at the right place. This is about taking the service to the patient; treatment may be in the patient's home which may for many be a nursing or residential home, a GP surgery, at a hospital or in the community. This new way of coordinating care in Trafford will be through a patient Care Coordination Centre. The Principles, Infrastructure, Core Services/Deliverables, and Benefits/Outcomes are described below.Principles— A Health and Social Care 'proactive system';— Patients should always get the right care at the right place at the right time, through an effortless journey;— A focus on complexity and vulnerability regardless of age.Infrastructure— Single phone point / one point of contact;— Single 'live' directory;— Supported by IT infrastructure - explore use of technology i.e. mobile messaging reminders;— IT infrastructure to capture and translate data;— Access to all records i.e. patient care plans feeding in to enable proactive planning;— Alignment to 111 and out of hours;— 7 days a week service. Night - probably continue with data/info service rather than a manned service;— Virtual or physical centre? To be explored via competitive dialogue process.Core Services/Deliverables— Tracking of patient journey;— Close monitoring of vulnerable patients i.e. expected discharge date from acute following through to community services/primary care;— Links to transport services;— Meaningful links between transport and appointments (relationship);— 'Auto pick up' patients as they go through the system. Patient is in the system from the point of admission onwards;—- Clinical triage to support monitoring of patient and appropriateness of care delivered to need;— Brokerage - Give Options I.e. Care Planning/personal Budgets. Trigger/criteria To Access This?Benefits/Outcomes— Coordinated care seamlessly around the patient;— Delivery of the right care in the right time at the right place;— Can equate an appropriate level of care to care site;— Best possible patient experience;— Greater focus on local issues i.e. health appointments and transport in Partington;— Proactive care planning.