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The VT UTP project has made much progress in directions that are aligned with the original intent when it was funded; and it has also made progress in unexpected, and valuable, directions. We share below some of the benefits that we are seeing from early work on the UTP project in VT.

The Vermont UTP effort is ahead of and will be able to inform Federal efforts to enable continuity of care and data exchange across the full spectrum of care:

The UTP work advances, is consistent with, and will be integral to the activities of the eLTSS (Electronic Long Term Services and Supports) work group within the Standards and Interoperability Framework of ONC which has been set up to provide support to SIM and TEFT grant states around issues of interoperability and information exchange standards.

The Health IT Policy Committee has started a new work group, Advanced Care Models and Meaningful Use, which is looking at “accountable care communities” which include the full range of service providers, and how they are integrated and communicate.

NQF (National Quality Forum) is about to convene a workgroup to identify quality metrics for LTSS providers and to measure person centered care.

UTP can, as a bi-product, inform other ACTT projects, and help them meet their objectives.

Data quality can be derived from the UTP data elements needed to provide safe and efficient transfers of care.  The UTP work can be leveraged to provide the data for the Quality work without adding a burdensome reporting requirement.  Instead, standardized, interoperable data, which is needed to provide appropriate services to the individual, can also be used to produce quality metrics without any additional work.

Technologies for data exchange and storage will depend on the communication abilities and requirements of the providers and agencies to be discovered through the UTP project. Any technologies must include the data needs of LTSS, LTPAC, the individual and caregivers, as well as health care providers.

The UTP project has been embraced by key Vermont LTSS agencies, existing coordination of care initiatives, and providers within acute, post acute, and ACO entities:

We are working with the SVCOA (which serves Bennington and Rutland) as a key collaborator in piloting the exchange of data elements with other LTSS, acute, and post acute providers.

We are partnering with the ADRC and the St. Johnsbury Learning Collaborative in ways that enable UTP to help drive their mission, and their coordination of care initiatives accelerate UTP’s access to provider communities.

Through our interviews with BluePrint team leaders, ACO physicians, VNA CIO and case workers, Options counselors, hospital-based nurse transition coordinators, staff from DAIL, VCIL, BIAVT, SASH, and more, we are hearing a yearning for the value UTP will bring to their care efforts.

In addition, because of UTP’s cross-boundary nature, our work is connecting initiatives and people who are now benefitting from these new collaborations — e.g. Heather Johnson and the ADRC, and Erin Flynn and the St. Johnsbury Learning Collaborative.

These Phase One discussions about UTP are generating a strong momentum for ongoing engagement and continuity:

Providers are enthused not only about UTP’s ability to systematize communication among acute, post acute, and LTSS providers, they are also enthused about the potential for including social data, which has the potential for improving outcomes.

Providers also see the value the UTP can provide in clearly defining roles and responsibilities and thereby reduce redundant care management efforts and the time spent tracking down providers who have missing data.

In addition, UTP is addressing how to involve the patient/client and family/friend caregiver in data exchanges.

You can find the UTP website here:



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