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Final UTP Phase 1 Update – 2015

Sal,

“I feel that we are making progress towards creating a central location for shared information and updates throughout the community that will include all of the agencies and organizations that are central to the success of our peers. With the help of the UTP this is now looking like a reality rather than an abstract idea of what an ideal process would look like.

In this central location if we could include information that would provide the reader with a look at the person and their life, including barriers to independent living, and not just vitals and statistics this would be optimal.

The medical aspect and social aspect of each peer’s lives have been separated in terms of information in the past and I believe that bringing this information together is key in coordination of care and full enjoyment of independent living.

I feel like we have come so far and hope this forward momentum continues”.

Colleen Arcodia

Peer Advocate

VCIL Bennington

“And I want to echo Colleen’s comments, and thank her for putting this out there.  

We have a real desire to test out a UTP very soon. The concerns we have are the vehicles/methods by which we will be able to accomplish this task knowing that some of the real infrastructure and technological advances may not be realized until next year”.

Heather Johnson, MSW, MPH

Consultant

Vermont Aging and Disabilities Resource Connection Project Manager

 

Team Member Blue Print for Health

I would look to UTP to provide:

– Electronic document sharing between organization

More broadly

– Identify initial protocols to assign a lead care coordinator

Blue Print is working closely with three communities Care Management Collaboratives

The Collaboratives are focused on cross organization care coordination

UTP should tell us:

– What info is shared?

– What frequency and to whom?

– What is that persons role and responsibilities?

– Burlington Diabetes is an example of shared information going well

A1Cs entered and when and by whom

– BP is assertive about Social Factors and having patients, families, and caregivers taking responsibility to commit to care plans and care coordination.

– Shared personal goals

– Shared Treatment Goals

– Different communities of need and populations require specific information and specific information delivery

– Opiate Treatment for example, requires a Shared Care Plan

In the Broader Program Sense:

– Identify lead care coordinators

– Enable communication between complex care like mental health issues

– Identify Key Roles and the frequency of information shared to establish goal   setting for the patient

– UTP should provide a comprehensive list of providers, medications and conditions to clarify and align treatment goals and patient goals

– Lay out what the patient and family have to agree to

– Discharge plans

MD has continuity of care in terms of ongoing continuity

What’s missing?

– Electronic information sharing and the process to use mass technologies to transfer information and communication

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UTP Regular Updates Week Ending January 30, 2015

January 30, UTP Regular Updates

  • No access to medical or social Information that has been causing poor health.
  • No access to other organizations that the peer is currently working with.
  • Contact information such as phone number are not easily available
  • No status updates when things change in the peers life.
  • Each organization does not know what the other organizations are working on with the peer and when that goal has been successfully completed. – Colleen Arcodia Peer Advocate VCIL

“When the care managers are not involved in planning a transition from a hospital to a residential facility it affects where the next patient will go to the next available bed. If the care managers are not involved the bed they intended to use can cause a ripple affect for the impact it can have on the clinical status of the individual who is impacted. And the costs. Our Case Managers are UTP. The system is not”.

– Mourning Fox, LCMHC Clinical and Operations Director, Dept. of Mental Health

Inspiring Words From Dr. Jacob Reider, Departing Deputy National Coordinator of ONC

Author: Bertina Yen, MD, MPH  Nov. 14, 2014

http://www.zynxhealth.com/Blog/2014/November/Inspiring-Words-From-the-Departing-Deputy-National

Reider provided inspiration by:

Focusing on an altruistic mission. He kicked off his presentation by saying that he wanted to concentrate on what’s next on the health IT horizon, what we can do to anticipate what’s ahead – and ultimately “make the world a better place.”

Redefining what “meaningful” really means. For the past few years, the healthcare IT industry has gotten lost in the details (and sometimes lack of details) around the rules and exceptions that make up the Meaningful Use program. Reider, however, took a step back and defined “meaningful” as the ultimate point on a six-phased information technology maturity scale. He emphasized that meaningful technology – in healthcare and in other realms – is not just functional, reliable, usable, convenient, and pleasurable but also has the potential to result in a high level of “personal significance” for users.

Explaining how we can change behavior for the better. Reider made a simple comparison that illuminated how CDS could more easily influence provider behavior. He pointed out that when law enforcement officers use radar guns to measure how fast cars are moving and then punish drivers with speeding tickets, the impact on future driver behavior is minimal. However, when technology is used to measure and then display traveling speeds in real time (eg, on signs that show you are currently traveling at a speed of, for example, 39 miles per hour), drivers will typically use the information to immediately lower their speed (especially if they are driving in a 25-mile-per-hour school zone). Similarly, if healthcare organizations could better leverage technology to offer CDS in the appropriate context (ie, the 5 rights [right information, right person, right intervention format, right channel, right time in workflow]), then clinicians would be more likely to use the information to do the right thing.

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