A complex system that works is invariably found to have evolved from a simple system that worked. A complex system designed from scratch never works and cannot be patched up to make it work. You have to start over, beginning with a working simple system. — John Gall, General Systemantics, 1975
We all want to get to the grand solution, the program that solves all of our problems. In LTSS,the grand solution is the coordination of all service providers Continue reading
This is a bit technical, so for this you’ll need to fasten your seatbelts; but it is a chance to get your hands dirty, and to dig through our data, and to have your say. As we have said, one of the cornerstones of the UTP project is our iterative methodology, by which we talk to LTSS providers (as well as patients and caregivers) to learn what are the important activities on which we should focus, and what are the patient/client data behind these activities that must be transmitted from one provider to another to maximize quality and efficiency of care.
After a first round of interviews we have arranged what we have heard in a series of tabs in a master UTP work-in-progress spreadsheet. Continue reading
“Dr. Scott, this is Dr. Font.” The call came from my mother’s cardiologist as I was about to see my first patient of the morning. “Your mother is worse. You’d better come as soon as you can. I don’t think she’ll survive the day.” Continue reading
Let’s say that you were working in a state, county or city with a homeless person who had bipolar disorder, type 2 diabetes and multiple incidents of hospitalization. Obviously, there’s a lot to be done for that person from a variety of agencies in order to provide housing, address mental health needs, deal with the chronic health condition and so on. Wouldn’t it be good if the various agencies and departments involved could easily share information about the client?
Consider the advantages Continue reading
“Standards and Interoperability” is a phrase that makes most of us pull the covers over our head and go back to sleep hoping it will all be gone when we wake up. We use it to describe some important characteristics of information that we use every day in our work to provide services to our clients. It is the basis of information exchange and the Universal Transfer Protocol. Continue reading
Reider provided inspiration by: Continue reading
LTSS providers routinely observe individuals in their homes. Their observations of function, behavior, medication adherence, and safety could be important to health care service providers who are required to report Medicaid Quality Measures and Meaningful Use attestation. The examples which are routinely monitored by LTSS providers are fall risk assessment, depression screening and observation of cognitive impairment without a formal diagnosis of dementia.
For a variety of reasons, these observations are not shared. Continue reading