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