Wishing you a happy and healthy holiday season ✨

As we celebrate this season, we extend our heartfelt gratitude to all of you for your dedication and partnership this year. Your unwavering commitment helped us elevate the impact of our work, and together, we made important progress during such a pivotal time for primary care.

This year, we witnessed bold leadership from our legislators, who recognized the pressing primary care crisis and have started to take decisive action through key legislation. We’d like to thank the members of our CTC-RI Task Force for their leadership on targeted legislation impacting the primary care work force—we are deeply grateful for their vision and expertise. A special thank you to our primary care community who helped advocate and support this work. We look forward to the important ways we can continue addressing the needs of primary care together. 

Looking ahead to 2025, we remain steadfast in our mission to support practices, care teams, and patients across our state. Through our many programs and initiatives, we will continue to address care challenges, innovate, and build on the momentum we've collectively created.

Wishing you and your loved ones a joyful and healthy holiday season. We're excited to work alongside you in the new year to advance our shared goals and create a stronger, healthier Rhode Island.

Warm regards,

Your team at the Care Transformation Collaborative of RI

Debra Hurwitz receives RI Public Health Association (RIPHA) 2024 Lifetime Achievement Award

Last month, our executive director, Debra Hurwitz, was awarded RIPHA’s 2024 Lifetime Achievement Award! Debra was honored among other champion leaders and programs making outstanding contributions to public health.

“These award recipients represent the best of Rhode Island’s public health community - advancing equity, fostering collaboration, and improving lives," said Dr. Kerri Warren, RIPHA's immediate past president. "Their work inspires us all to continue striving for a healthier, more equitable state.”

"I am deeply honored to receive the RIPHA 2024 Lifetime Achievement Award, and I am incredibly grateful to the RI Public Health Association for this recognition," said Debra Hurwitz, MBA, BSN, RN. "Reflecting on my 46 years in this field, I feel fortunate to have had the support of many remarkable mentors, colleagues, and, most recently, our extraordinary Board and team at CTC-RI. Their dedication, professionalism, and passion for improving primary care and supporting patients across Rhode Island have been the driving force behind our shared success. This award is a celebration of our collective efforts to advance system transformation and achieve national recognition for Rhode Island’s health care innovation. As I prepare for my retirement next year, I carry immense pride and gratitude for what we have accomplished together, and I am confident that CTC-RI will continue to lead the charge for meaningful change." Read more.

Recruiting our next executive director as we thank Debra Hurwitz for her years of service!

Debra Hurwitz, MBA, BSN, RN, our esteemed Executive Director, will be retiring after 14 years of extraordinary service and dedication to CTC-RI since our inception. Debra has led our organization through tremendous growth and accomplishments for which we are grateful. On behalf of our organization, we want to take a moment to thank Deb for her unwavering commitment and the impactful legacy she leaves behind. We look forward to the ways that we will celebrate her in the months ahead!

A search committee has been convened to find our next great executive director. This is a unique opportunity to lead a dynamic, mission-driven organization that is shaping the future of primary care in Rhode Island and beyond. CTC-RI offers a collaborative work environment and the chance to make a meaningful impact through leadership and innovation. Learn more here.

Recap: Healthy Tomorrows Learning Collaborative meeting 

In November, primary care practices and family visiting agencies participating in the Healthy Tomorrows initiative shared progress and heartwarming success stories of collaboration supporting their shared patient population. Highlights included strategies for gathering family input and metrics from Sara Remington (RIDOH), showing higher performance among participating agencies compared to state averages. This impactful program, funded by Point32Health and RIDOH, wraps up in February. Thank you to all involved in this important effort to improve well-child healthcare and family support!

Update: RI MomsPRN Quality Improvement Initiative

Practices participating in the RI MomsPRN Quality Improvement Initiative convened in November for their midpoint learning collaborative meeting. Practices shared progress on their practice-identified quality improvement projects related to perinatal behavioral health:  



• VICTA: Partnering with community resources to provide patients with support services, and the opening of a new Harm Reduction Center.
• Tri-County: Successes and challenges on screening for safety and intimate partner violence, and work to improve screening rates of undocumented patients and handing-off all positive screens to behavioral health. 
• Brown Health OBGYN: Increasing staff and provider competency and comfort in handling patients with behavioral health concerns. A team survey identified areas of strength and need, and is informing their ongoing training programs. The practice is also working to improve depression and anxiety screening rates in the 2nd and 3rd trimesters of pregnancy.
• The Family Care Center: Increasing support services to postpartum parents by partnering with other community resources, and working to improve depression, anxiety, and substance use disorder screenings in the 1st and 3rd trimesters and postpartum. 

Thank you to RIDOH and EOHHS for your continued support and funding for this opportunity. 

Register now! 2025 CHW/MA Asthma Training Program

In partnership with RIDOH, CTC-RI is excited to offer up to 15 community health workers (CHWs) and medical assistants (MAs) the opportunity to participate in the Asthma Basics Training Program. This two-day, in-person training in February is designed to enhance skills in asthma education, better support patients, and reduce emergency department and hospital visits. Completion of this training is a prerequisite for the Asthma Home Visiting Training coming in spring 2025. 

Funded by RIDOH, this program aims to ensure CHWs and MAs receive a consistent, high-quality curriculum by using an effective, nationally recognized asthma training program, and facilitate communication with clinical mentors for professional development. Read more and apply here.

December is HIV/AIDS Awareness Month

While great strides have been made in reducing HIV transmission, more than 1.2 million people live with HIV in the US, and approximately 13% remain unaware of their status. December marks HIV/AIDS Awareness Month, a critical time to highlight the role primary care plays in addressing this epidemic:

• Routine Testing: CDC guidelines recommend HIV screening for all individuals aged 13-64 at least once and more frequent testing for high-risk populations. 
• PrEP and Prevention: Educating eligible patients about Pre-Exposure Prophylaxis (PrEP) and safe practices can significantly reduce transmission rates. 
• Early Intervention: Prompt diagnosis and linkage to antiretroviral therapy (ART) are essential for improving outcomes and preventing the spread of HIV. 

This December, let’s commit to enhancing awareness, reducing stigma, and strengthening our efforts to end the HIV epidemic. More information and CDC resources. Schedule a refresher for your team on HIV screening protocols and have open conversations with your patients about risk factors and prevention options. 

STI Best Practices ECHO Learning Series: HIV and PrEP

In November, CTC-RI held the third session of its “Best Practices in Sexually Transmitted Infections (STI) in Primary Care ECHO® Learning Series."

Part of a larger six-session series funded by UnitedHealthcare, 34 participants heard Dr. Philip Chan provide a clinical update on HIV prevention. Dr. Chan is Brown University Associate Professor in the Department of Medicine and School of Public Health and is Open Door Health Chief Medical Officer, the state’s only community-based LGBTQ+ clinic. Dr. Chan also serves as RIDOH Consultant Medical Director. Participants learned about HIV epidemiology and recommendations for treatment and prevention including guidance for providing PrEP (Pre-Exposure Prophylaxis). A clinical case was presented by Dr. Carol O’Shea, of P.R.I.M.A. Pediatrics, followed by an engaging discussion facilitated by Dr. Patricia Flanagan. The presentation also included several useful clinical guidance resources for providers and care teams. Access the recording or claim CME/CEU credits.  

Community Health Worker Roadmap Summit

CTC-RI supported a RIDOH summit in Providence this month to celebrate progress on the RI Community Health Worker (CHW) Roadmap project. Since the Roadmap's completion in October 2023, RIDOH teams have been advancing its four key priorities: CHW leadership, sustainable payment models, person-centered care coordination, and workforce development.

The summit brought together 78 attendees to hear updates on these efforts, with opening remarks by RIDOH leaders Jerome Larkin, MD, and Deborah Garneau, MA, highlighting the critical role of CHWs and the project's four Roadmap teams. Discussions included sustaining CHWs in times of change, led by Sherri Ohly (University of Wisconsin), and a civic engagement session co-led by Rep. Arthur Handy (FSRI) and Cristy Romero, CHW (FSRI, Jenks Park Pediatrics).

The day concluded with a world café session fostering collaboration and strategies to propel this work forward. Closing remarks were provided by Kristine Campagna and James Day from RIDOH.

Learn more about the CHW strategy meetings and view the full roadmap.

DULCE Learning Collaborative celebrates accomplishments and looks at sustainability

This month’s DULCE Learning Collaborative meeting highlighted progress in improving family and child health outcomes. Participants shared progress on enrolling new families, celebrating six-month graduations, and boosting screening rates for health-related social needs and well-child visits.

Key discussions focused on successes and challenges in implementing community health worker billing, including barriers to accessing Medicaid numbers for babies.

Practices also explored innovative workflows, reviewed performance data against national DULCE goals, and discussed new funding opportunities to sustain this critical work.

View session materials here. This work is supported by the RIDOH ECCS Grant, UnitedHealthcare, Tufts Health Plan/Point32Health, and Congressional Direct Spend.

Midpoint Learning Collaborative on Delivering Age-Friendly Care

Last month, CTC-RI hosted a midpoint Learning Collaborative for the Delivering Age-Friendly Care project, which helps primary care practices implement the 4M Model (What Matters, Medication, Mentation, Mobility) to improve care for older adults and their care partners, while achieving Level 1 or Level 2 Recognition from the Institute for Healthcare Improvement. 

The session brought together 34 attendees from five practices—Breakwater Primary Care (Lincoln, Warwick), Family Care Center, PACE RI, Brown Medicine, and University Internal Medicine—who shared updates on improving care partner education and resource access.

Guest speakers Aura Medina (The POINT Network) and Robyn Earley (CareLink) discussed long-term care services (Medicare, Medicaid, and state and federal social service programs), and innovative CareLink programs. View the session and materials here. Special thanks to UnitedHealthcare and RIDOH for their funding and support!

Addressing Alcohol Use Disorder in Primary Care Think Tank Series

In November, CTC-RI hosted the 3rd session of the Addressing Alcohol Use Disorder (AUD) in Primary Care Think Tank. BHDDH presented on Certified Community Behavioral Health Clinics (CCBHCs), covering their role in AUD treatment, care levels, and primary care integration. A panel discussion addressed gaps in ED-to-outpatient transitions, the need for peer recovery specialists, and screening tools. View slides or watch the session recording.

The 4th session held this month featured Central Vermont Medical Center’s ROAD program and included insights from Turning Point Center of Central VT, CVMC clinicians, UVM Health Network, and other key experts.

Join us for the final session on January 27, where we’ll present recommendations for AUD treatment and the role of primary care. Sign up here or email Phos Ivestei at pivestei@ctc-ri.org for more info.

Expanding Pediatric Integrated Behavioral Health Capacity

This month, in partnership with Foundation for Integrated Care (FIC), we held our final Expanding Pediatric Integrated Behavioral Health (IBH) Capacity project meeting. This meeting shared an overview and developments for FIC, pre- and post-data from participating practices, and overview of their quality improvement projects. Practices presented positive change reflections, challenges with IBH, future plans, and patient success stories. 

We thank FIC members Kristin David, PsyD, Executive Director, and Sarah Ferszt, LICSW, Director for Program Development for sharing FIC’s overview and future plans. Additionally, we thank Liz Cantor, PhD, CTC-RI Pediatric IBH Practice Facilitator, for presenting the PDSAs, and participating practices for sharing their experiences—Barrington Pediatrics, NRI Pediatrics, and P.R.I.M.A. Pediatrics. A call for applications for this project's cohort 2 will be announced in early 2025.

Clinical Strategy Committee to discuss critical healthcare initiatives

The December 20 Clinical Strategy Committee meeting will feature key updates and discussions on critical healthcare initiatives. Peter Hollmann, MD, Brown Medicine Chief Medical Officer, will provide an update on the new primary care management codes. Mary Jo Condon, MPPA, Freedman Healthcare Principal Consultant, will lead an examination of the impact of primary care on total medical expenses in Massachusetts. Additionally, Charlie Estabrook, MPH, OHIC Director of Policy, will present an update on the AHEAD Model, offering insights into the state’s evolving healthcare initiatives. To attend this meeting, email Michelle Mooney, MPA, Program Coordinator II, mmooney@ctc-ri.org.

Medicare Physician Fee Schedule - Telehealth Impacts 

On November 1, 2024, the Centers for Medicare and Medicaid Services (CMS) released the final rule for the 2025 Physician Fee Schedule (PFS). The PFS provides new policy updates for the Medicare program for the following year. There typically has been some policy proposed each year impacting telehealth. While many of the temporary federal telehealth waivers in the Medicare program are set to end this year and would require action by Congress to alter their current expiration date, CMS has made adjustments to further preserve some telehealth policies with this final rule. Please see full details in the fact sheet provided by the Center for Connected Health Policy - the National Telehealth Policy Resource Center. Topics covered include:  

• Audio-Only 
• Eligible Telehealth Services 
• Table 1. with: CMS PROPOSED CODES, DESCRIPTION & PROPOSED STATUS 
• AMA Proposed Telehealth E/M CPT Codes 
• Frequency Limitations on Inpatient Visits, Nursing Facilities, and Critical Care Consults 
• Direct Supervision Using Live Video  
• Federally Qualified Health Centers (FQHCs) & Rural Health Clinics (RHCs)  
• Opioid Treatment Programs 
• Other proposals/Discussion 

Recap: Navigating Eating Disorders in a Pediatric Primary Care Setting

CTC-RI hosted its monthly Best Practices in Team-Based Care webinar on December 17. This session focused on “Navigating Eating Disorders in a Pediatric Primary Care Setting,” addressing the unique challenges of supporting youth and their families. Attendees gained practical tools for patient and family education, weight restoration standards, and overcoming monitoring barriers. Expert speakers included Christina Tortolani, PhD (Bryant University), Heather Pelletier, PhD (East Greenwich Pediatrics), and Brittany Vose, MA (Aquidneck Pediatrics).

These webinars are held on the third Tuesday of each month. For more information, contact Nijah Mangual at nmangual@ctc-ri.org.

CTC-RI MomsPRN ECHO® Learning Series: December recap

In December, the MomsPRN ECHO® Learning Series focused on "Perinatal Anxiety and OCD," offering valuable insights into addressing these conditions in maternal behavioral health care. Participants explored best practices for screening, treatment, and culturally responsive care. A recording of the session, presentation materials, and a CME evaluation and credit (pending NASW approval) are available for those who missed it.

Stay tuned for more impactful sessions in this series. CME credits are available until September 17, 2025.

CBO Spotlight: Progreso Latino

Our primary care transformation efforts often include the support and partnership of statewide community-based organizations (CBOs). CTC-RI is spotlighting a different CBO monthly to recognize and appreciate their work in our communities.

This month, we spoke with Cindy Montoya, Deputy Director at Progreso Latino.

1. What ways does your organization uniquely support Rhode Islanders?

Progreso Latino helps RI’s Latino and immigrant communities achieve greater self-sufficiency and socio-economic progress by providing transformational programs that support personal growth and social change. Our programs include early childcare and afterschool programs, adult education, workforce development, older adults' program, youth leadership programs, domestic violence advocacy, social services, health and wellness programs, immigration services, VITA services, financial literacy, and food pantry.

2. How can a partnership with primary care providers strengthen your work?

A partnership with primary care providers can significantly strengthen our work by improving patient outcomes and enhancing healthcare accessibility. At Progreso Latino, we can help bridge the gap between patients and their primary care providers by offering health literacy awareness campaigns that empower individuals to take charge of their health. Additionally, our social services and community health workers can directly connect residents to primary care, ensuring they receive the care they need. By working together, we can improve patient compliance, reduce missed appointments, and promote preventive care, ultimately fostering a more cohesive and effective healthcare system for the community.

3. What's something you'd like the primary care community to understand about your organization?

Progreso Latino is deeply committed to addressing the unique needs of underserved communities, particularly within the Hispanic population. Our organization provides not just services, but a holistic approach to health and wellness, including health literacy, social services, and culturally tailored support. We work closely with individuals to connect them to essential resources, including primary care, and help bridge gaps in access to care.  

Learn more at www.progresolatino.org.

Upcoming CTC-RI Committee Meetings and Workgroups

• December 20, 07:30-09:00AM – Clinical Strategy Committee
• January 17, 07:30-09:00AM – Clinical Strategy Committee
• January 24, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

• December 20, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
• January 08, 08:00-09:00AM – CTC-RI Primary Care Workforce Taskforce
• January 08, 12:00-01:00PM – ECHO Kickoff: Screened for Developmental Delay: Now What? “Learn the Signs: Act Early”
• January 09, 07:30-08:30AM – Improving Child Health in RI
• January 16, 07:30-09:00AM – Sexually Transmitted Infection Quality Improvement Learning Collaborative Kickoff
• January 17, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
• January 21, 08:00-09:00AM – Best Practices in Team-Based Care
• January 21, 12:00-01:00PM – MomsPRN ECHO Series
• January 22, 07:30-08:30AM – ECHO: Best Practices in Addressing Sexually Transmitted Infections (STI) in Primary Care
• January 23, 07:30-08:30AM – Pediatric Sleep ECHO series
• January 27, 11:00-12:30PM – CHW Advocacy Network for Leadership
• January 27, 12:00-01:00PM – Addressing Alcohol Use Disorder in Primary Care Think Tank
• January 28, 07:30-09:00AM – Diabetes/CKD Pharmacy Project Learning Collaborative