● Participants are very motivated to create a UTP based on systematizing communication in order to improve workflow and continuity of care.

“We have been waiting for something like this for years.”

● Participants see that UTP has the ability to include critical social elements, ones that can improve the quality and personalization of care and have the potential to reduce readmissions and ER usage.

“We often have the clinical data or notes to refer to, but there is not enough emphasis put on the social side to help understand how to really create a care plan.”

● There is a lack of clearly defined roles and responsibilities that creates role confusion, redundant care management efforts, and much time spent tracking down the providers (options counselors, case managers, etc.) who are involved in an episode of care.

“We never know who is the lead case manager on this one?”

“I have spent weeks arranging at home equipment for example, only to discover someone else provided it”