Commissioner King shares insight on RI joining CMS AHEAD Model

The Centers for Medicare & Medicaid Services (CMS) has launched the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, a bold initiative to curb health care cost growth, improve population health, and reduce disparities in health outcomes. This voluntary, state total cost of care model supports participating states with funding and resources to enhance primary care investment, stabilize hospital finances, and connect beneficiaries to community resources. Rhode Island was recently announced as part of Cohort 3 and will receive up to $12 million in cooperative agreements to implement the model over the next 5-6 years. We recently connected with Health Insurance Commissioner Cory King for more insight into this exciting commitment to health system transformation and equitable care delivery.

1. CMS announced this fall that RI was successfully selected to participate in the AHEAD Model, with some early work starting this month. Tell us more about your goals for participation. What do you hope to achieve throughout the initiative?

My expectation is that participation in AHEAD will help us achieve more affordable and equitable health care for Rhode Island residents. AHEAD offers some very appealing strategies to get us there. Foremost among these strategies is a core focus on primary care across all-payers and new Medicare investments in primary care practices. Read more.

2. What challenges may this work address?

AHEAD is a state total cost of care model intended to produce savings over time for consumers, employers, and taxpayers while improving quality and health equity. AHEAD emphasizes that these savings should not come at the expense of primary care providers. In fact, increased resourcing for primary care is a core component of the model. Read more.

3. What ways may primary care teams notice, or be impacted by, the state's participation in the AHEAD Model?

AHEAD will bring new Medicare dollars to support practices that participate in Primary Care AHEAD. These prospective monthly payments will be paid in addition to Medicare fee-for-service billing, including the new HCPCS codes for advanced primary care management that were introduced in the 2025 Medicare Physician Fee Schedule. Medicare’s goal through AHEAD is to increase the percentage of the Medicare dollar that is dedicated to primary care and to work with the State to achieve a Medicare primary care investment target. Read more.

Welcome Dr. Nelly Burdette as CTC-RI’s New Chief Clinical Officer!

We are excited to announce that Nelly Burdette, PsyD, has stepped into a new full-time role as Chief Clinical Officer at CTC-RI! For the past 10 years, Dr. Burdette has been an invaluable consultant to CTC-RI, bringing her expertise as a clinical health psychologist and leader in integrated behavioral health (IBH) to transform primary care delivery in RI. Her innovative work has shaped policy, improved systems of care, and empowered healthcare teams to embrace evidence-based practices that promote collaboration, psychological safety, and health equity. 

As Chief Clinical Officer, Dr. Burdette will continue to lead groundbreaking initiatives to enhance IBH and expand CTC-RI’s mission of improving care across the lifespan. With over 15 years of experience developing and implementing integrated care models in settings ranging from federally-qualified health centers to academic health systems, Dr. Burdette’s leadership promises to drive even greater impact in this new capacity.

Please join us in congratulating Dr. Burdette as she embarks on this exciting new chapter with CTC-RI!

New ECHO® series supports families after developmental delay screening

In January, 57 attendees joined the kickoff session of our new ECHO® series, “Screened for Developmental Delay, Now What?” Jennifer Sanchez, M.Ed., IMH-E®, shared insights from "Learn the Signs, Act Early," highlighting the importance of early identification and intervention for developmental delays. Parent speaker Sue Rivera emphasized how access to these tools empowers families to advocate for their children and support skill development. The session fostered valuable discussions on best practices and collaboration. Access the presentation, recording and evaluation. 

Don’t miss our next session on February 12: “Team-based Approach to an Inclusive Office Environment for People with Neurodiversity” with Ariana DeAngelis from The Autism Project. Funding for this series is provided by RIDOH and UnitedHealthcare. For details or to join, email mmooney@ctc-ri.org.

January Improving Child Health in RI meeting highlights

The first Improving Child Health in RI quarterly meeting of 2025 featured an Early Childhood Café with presentations from early childhood programs:  

• Reach Out and Read RI with Smithfield Pediatrics
• Know the Signs. Act Early.
• Prescription 4 Play with Providence Community Health Centers
• Greatest 8 with Tri-County

Blythe Berger, PhD, of RIDOH, reflected on the strong collaboration with pediatric practices, while Drs. Flanagan and Lange previewed new 2025 initiatives, including the PediPRN Intensive Program. Access the recording and presentation here.

Register by Jan. 17! 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.

Recap: December’s Sleep ECHO® Session

December’s Sleep ECHO® session, led by Julie Boergers, PhD, focused on improving sleep in middle schoolers and featured updates from practices on their quality improvement projects:

• Blackstone Pediatrics: Improving sleep in 6–9-year-olds using BISQ-S assessments.
• Partners in Pediatrics: Addressing sleep issues in 2–5-year-olds, emphasizing snoring and sleep apnea.
• Atlantic Pediatrics: Streamlining processes for addressing sleep concerns in children aged 6–12.
• Anchor Pediatrics: Focusing on teen sleep improvement using BEARS self-assessments for ages 13–18.

Thank you to our participating practices and Blue Cross Blue Shield of RI for funding this work.

Join us for the next session on January 23, featuring Richard Millman, MD, discussing sleep medication for high schoolers (ages 14–18).

Final Learning Collaborative: 2024 Improving Demographic Data Collection in Primary Care to Address Health Disparities Quality Improvement Initiative

In December, 15 primary care practices participating in CTC-RI's 2024 Quality Improvement Initiative on Demographic Data Collection convened for the final learning collaborative.

The session featured Katelyn Ferreira, Health Equity Program Manager at Southcoast Health, who shared lessons from their project “Southcoast Cares About My Diabetes: A Community Collaboration to Advance Equity in Diabetes Management.” Following the presentation, participating practices had the opportunity to review their achievements from the past year and reflect on data trends in their Race, Ethnicity, and Language (REL) and Sexual Orientation and Gender Identity (SOGI) measures. Practices shared insights from their best practice assessments, lessons learned, and impactful takeaways from the initiative. 

CTC-RI celebrates the initiative's impact and thanks funders UnitedHealthcare and Rhode Island Foundation, and our participating practices, for their dedication to advancing health equity. View the recording and materials here.

Upcoming Best Practices in Team-Based Care Webinar: Nurse Care Managers in Action

CTC-RI invites you to an insightful webinar exploring the impact of the Nurse Care Manager (NCM) / GLearn training program on patient care and team-based practices in primary care settings on Tuesday, January 21 (8–9am). Register now! This session will delve into: 

• How NCMs are applying GLearn training to enhance patient care and demonstrate NCM value
• The ways online training modules and peer learning equipped NCMs with patient-centered skills for working with patients with complex needs
• The importance of team-based care and NCM contributions in driving better patient outcomes

Featured speakers: 

• Kerri Walsh, RN, Care New England Family Care Center 
• Margaret Mellor, RN, BSN, MSN, RIPCPC 
• Cydney Gregory, RN, Wood River Health 
• Jamie Ferris, BSN, RN, CLC, Aquidneck Pediatrics 

Think Tank Series: Addressing Alcohol Use Disorder in Primary Care

The December session of the Addressing Alcohol Use Disorder in Primary Care Think Tank featured Central Vermont Medical Center’s ROAD program, showcasing insights on state model origins, data trends, emergency department guides, primary care integration, and recovery coaches' impact.



Thank you to our expert panel and moderator, Dr. Nelly Burdette. Access slides here and recordings here.

Join us for the final session on January 27, where recommendations for alcohol use treatment in primary care will be presented. Sign up by emailing pivestei@ctc-ri.org or using this SurveyMonkey link.

January is Birth Defects Awareness Month

January marks National Birth Defects Awareness Month, a time to raise awareness about birth defects, prevention, and the importance of early intervention and care. Affecting one in every 33 babies born in the United States, birth defects are a leading cause of infant mortality and long-term disability. 

Primary care plays a critical role in identifying risk factors, providing education, and ensuring timely screenings for pregnant patients and newborns. While not all preventable, steps such as preconception planning, proper maternal nutrition, avoidance of harmful substances, and managing chronic conditions can reduce birth defect risks. Key actions for primary care providers: 

• Educate patients about the importance of folic acid before and during pregnancy
• Encourage routine screenings and vaccinations for expectant mothers
• Identify lifestyle risks such as smoking, alcohol use, and medication safety during pregnancy
• Support early intervention for infants born with birth defects to improve outcomes. 

By working together, we can improve health outcomes for families and ensure all children have the best start in life. For additional resources, visit the CDC’s Birth Defects Awareness page. 

January Clinical Strategy Committee to focus on clinical care and policy

The upcoming meeting on January 17 at 7:30am will address two key topics aimed at enhancing both clinical care and policy:

• Postpartum hypertension home monitoring program utilizing Community Health Workers, with a discussion on improving patient connection to primary care providers to enhance continuity of care and health outcomes. Presentation will be led by Adam Lewkowitz, MD, MPHS, Assistant Professor, Department of Obstetrics & Gynecology.

• Updates on the OHIC Affordability Standards, focusing on efforts to improve health insurance affordability and its implications for healthcare delivery in the state. Presentation will be led by Charlie Estabrook, Director of Policy, OHIC.

To join this meeting, email mmooney@ctc-ri.org.

STI Best Practices ECHO® Learning Series: Chlamydia and Gonorrhea

In December, CTC-RI held the fourth of six ECHO® learning sessions in its Best Practices in Sexually Transmitted Infections (STI) in Primary Care: ECHO® Learning Series funded by UnitedHealthcare. 34 participants were educated on the current recommendations and guidelines for screening and treatment of chlamydia and gonorrhea by Matthew Perry, MD, ScM, a primary care provider at Providence Community Health Centers’ Crossroads clinic that oversees their street-based medicine program. Participants learned about clinical presentation of the diseases, testing, treatment and prevention protocols. A special focus of the presentation was the health equity impact for the transsexual community, and clinical guidance resources for providers and care teams. A recording of the session is available here. Click here to claim CME/CEU Credits. The next session in the STI ECHO® learning series will feature Dr. Alan Epstein’s presentation on treatment of Hepatitis C in primary care on January 22, 7:30–8:30am. 

New CPT® and Medicare Codes for 2025

In December, over 100 providers and other healthcare professionals attended “Uncoding” New 2025 Codes for Telehealth and Advanced Primary Care Management, a webinar presented by Dr. Peter Hollmann. The session covered new 2025 CPT® codes for telemedicine and guidance for use of the new codes. Dr. Hollmann also provided information on Medicare Advanced Primary Care Management codes and the service elements associated with the codes, as well as other CMS G codes and G code rules. To access the webinar slides, please click here.

CBO Spotlight: RIPIN

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 Emily Garthee, MBA, SHRM-CP, PHR, Chief Operating Officer at RIPIN.

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

RIPIN combines lived experience with professional expertise, employing peer professional Community Health Workers (CHWs) who provide personalized, empathetic support throughout the lifespan. Most of RIPIN’s board and staff are parents or caregivers to a loved one with a disability. More than 50% of our client-facing staff are bilingual in Spanish and English, ensuring we can effectively serve a diverse population. Across special education, health care, and healthy aging, RIPIN empowers Rhode Islanders to access essential resources and support. Peer professionals are at the heart of RIPIN, offering the expertise and advocacy necessary for individuals to thrive.

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

Partnerships between RIPIN and primary care providers amplify our mutual impact by helping patients bridge gaps between clinical care and community resources. As the largest employer of certified Community Health Workers (CHWs) in the state, RIPIN offers invaluable, culturally competent support, assisting patients in navigating health care, managing chronic conditions, and accessing services.

We work both to connect vulnerable patients to consistent sources of primary care and to help primary care providers address the non-clinical challenges their patients face. For example, we receive hundreds of referrals annually from pediatricians seeking support for patients and their families navigating special education. We also provide chronic disease self-management classes and other workshops that reach more than 10,000 Rhode Islanders every year. Together, we can address clinical and non-clinical challenges to help patients thrive.

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

RIPIN is a trusted ally in supporting patients beyond the clinical setting, offering compassionate, practical guidance informed by the lived experiences of our peer professionals. We help individuals and families navigate complex systems, such as health insurance, education, and aging services, while addressing barriers like social determinants of health. Our work has helped Rhode Islanders save over $8 million in healthcare costs over the last six years, underscoring the impact of patient advocacy and support. By equipping patients with the knowledge and tools to advocate for themselves and take charge of their health, we improve outcomes for both patients and providers.

Learn more at www.ripin.org.

Upcoming CTC-RI Committee Meetings and Workgroups

• January 17, 07:30-09:00AM – Clinical Strategy Committee
• January 24, 07:30-08:45AM – Board of Directors  
• February 21, 07:30-09:00AM – Clinical Strategy Committee
• February 28, 07:30-08:45AM – Board of Directors  

Upcoming Learning Collaboratives and Professional Development

• 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 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 AUD in Primary Care Think Tank 
• January 28, 07:30-09:00AM – Diabetes/CKD Pharmacy Project Learning Collaborative
• January 29, 07:30-09:00AM – Best Practice Sharing - CVD Learning Collaborative 
• February 05, 07:30-08:30AM – PCP/Specialist Monthly Oversight
• February 05, 09:30-01:30PM – CHW Asthma Basics Training
• February 06, 07:30-08:00AM – Virtual Coffee Breaks with Dr Pat Flanagan & Dr Beth Lange
• February 06, 09:30-02:30PM – CHW Asthma Basics Training
• February 12, 08:00-09:00AM – Primary Care Workforce Task Force
• February 12, 12:00-01:00PM – ECHO Screened for Developmental Delay: Now What?
• February 18, 08:00-09:00AM – Best Practices in Team-Based Care
• February 18, 12:00-01:00PM – RI MomsPRN ECHO-Engaging with Doulas: Empowering Birthing People
• February 20, 07:30-09:00AM – 4M Framework Wrap-Up Learning Collaborative
• February 21, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat 
• February 24, 12:00-01:00PM – Healthy Tomorrows Quarterly Learning Collaborative - Cohort 4
• February 26, 07:30-08:30AM – ECHO: Best Practices in Addressing STI in Primary Care 
• February 27, 07:30-08:30AM – Pediatric Sleep ECHO Series