UTP Phase One

 

To start with a shared understanding: The objective of the UTP project is to enable the exchange of essential information between long-term support service (LTSS) providers, patients and their immediate caregiver, and other health care service providers.  This project will develop an initial set of standardized data elements for exchange between providers and receivers of services as well as a method for continuously refining and enlarging that data set.

 

Our methodology is an iterative one.  We develop a set of data elements with one group and bring that set to another group to modify.  In this way, we continually evolve one set of data elements until they are as complete as possible.  Our plan is to include providers, and patients and their family caregivers in the development of the data set.  There are several activities necessary to build the data set:

 

1. Collaborate with leaders of existing efforts to assess potential participants and timing of our efforts.  Ensure that a wide range of provider types are represented.
2. Reach out to potential UTP provider participants to introduce them to our project and clarify the expectations for their participation.
3. Conduct more in depth interviews with those who are interested.
4. Analyze that data and use it as the basis for material for group roundtable sessions with providers.
5. Conduct up to three roundtable sessions with providers.
6. On a parallel track, launch the same set of activities with patients and their family caregiver.
7. Hold a joint meeting that includes providers, patients, and caregivers.
8. Analyze the results of all sessions.
9. From those results, develop an  initial set of standardized data elements.
10. Corroborate and modify that data set with another group of providers who were not involved in the initial roundtables

 

Bennington

The Bennington area and the work that Heather Johnson has done provide an excellent, even serendipitous, starting point.  The timing is such that her group of potential UTP participants are at a point where their next step is to begin working on data and transfers of care.  She is currently informing her contacts of our work and requesting their involvement.  We plan on participating in her already scheduled 10/21 group meeting.

 

We have discussed with BBL avenues for engaging patients and caregivers.   Some of these include reaching out to: Legal Aid, SASH, Long Term Care Ombudsman, VCCI, hospital social workers and care managers, disease associations, and others.

 

Georgia raised the concern that there is not a broad enough range of providers in the Bennington ADRC project.  We can control for this risk by inviting provider types to participate in the UTP work who may not be currently involved in the ADRC initiative.  We will also mitigate this risk by conducting interviews with providers from other geographies.

 

In addition, we will need to reach out to providers from other regions, who are not involved in the Bennington roundtables, to enlist them in reviewing and modifying the initial data sets we develop in Bennington.  Their objective input is essential in order to insure that the data sets are comprehensive.

 

ACO LEARNING COLLABORATIVES

We have been in discussion with Erin Flynn about ways to integrate UTP work with the work she and her team already have underway with the ACO Learning Collaboratives.  Erin has invited us to participate in their regularly scheduled phone meetings with planners and providers.  In addition she has invited us to design one of the upcoming LC sessions.

 

Through this collaboration with the LC efforts, we will identify providers whom we can interview.  And we will be able to use the LC session as a UTP roundtable to have that group of ACO providers validate and modify the data elements we will have developed.

 

In this way we will be able to reach beyond Bennington to obtain input from a broader range of providers.  And, very importantly, we will have an objective group of providers with whom we can validate data sets.

 

Below are examples of some of the ways the ACO Learning Collaboratives might inform the UTP work include:

1. Provide im21 connections to stakeholder groups (ACO collaboratives, Sash) that are already organized and working on patient care transfers
2. Ask these groups to review the list of participants in Bennington and identify important participants who are not represented
3. Recommend new participants to fill those gaps
4. Review the data sets produced by the Bennington group
5. Edit the data sets produced by the Bennington group
6. Suggest modifications to the data sets
7. Help schedule interviews/work sessions with additional Learning Collaborative participants
8. Inform the next iteration of the UTP data set