Care Transformation Collaborative of RI

News & Updates | December 2023

New OHIC report: Primary Care in Rhode Island: Current Status and Policy Recommendations

The resiliency of primary care in RI is a top priority of the Office of the Health Insurance Commissioner (OHIC). Since OHIC's inception and the creation of its first affordability standards in 2010, OHIC has sought to ensure that primary care has a place high on the state's policy agenda. These efforts include the creation of a first-in-the nation primary care expenditure target for commercial health insurers over a decade ago, mandated investments in the patient-centered medical home (PCMH) model, and co-convening our multi-payer initiative (CTC-RI) to support care transformation and the adoption of best practices in primary care delivery. This new report reviews national and local trends in primary care and focuses on priority action steps that should be taken at the local level, with emphasis on actions that are within the authority of OHIC to undertake independently, or in partnership with other local entities. Thank you, OHIC, for keeping a spotlight on the important needs of the primary care community, and our current and future workforce. Read the report.

NCQA weighs in on importance of health equity

Quality health care has been historically unequal, often depending on a population’s race, culture, religion, class, gender identity, sexual orientation, geography or language. Health equity is a commitment to provide high-level care to all populations and to remove obstacles and disparities in the health care system. RI continues to prioritize health equity, as evidenced by OHIC's recent changes to its Affordability Standards, requiring health insurers to receive NCQA Health Equity Accreditation and follow guidelines for the use of demographic data. NCQA is committed to ongoing and evolving equity in health care. Following a popular training at our annual conference led by NCQA, we recently connected with NCQA's Amelia Bedri, MHSA, Senior Program Content Engineer, Product Development around their work to prioritize and support health equity.

Why is it important for health care organizations to recognize and address health equity?

There is no quality without equity, and health care organizations must understand that investing in equity is more than just a business decision—it is a moral imperative. Understanding the comprehensive needs of a patient allows them to be seen as a whole person, rather than a condition or illness. Each organization plays a unique role in addressing health equity, whether as an anchor institution, educator or health care provider. Organizations must therefore understand how they contribute to societal and structural barriers that prohibit patients from achieving optimal health outcomes.

How can training our RI primary care workforce in health equity better support patients? 

Quality health care begins by ensuring that the health care workforce understands the path to attaining an equitable health care system for all, which includes education on the past, current and future state of health care. When health care workers are aligned on the same goal, everyone will work as if they or their loved ones are on the receiving end of care. The importance of training and embedding compassion, empathy and cultural humility is key to sustaining health equity work, and allows health care professionals to place themselves in the patient’s position.

What opportunities or successes are emerging because of intentional Health Equity training and understanding by primary care teams? 

Intentional health equity work is not done in silos. Operating as a collective health care ecosystem allows all stakeholders to understand their strengths and create opportunities for cross-collaboration. Health care workers in care teams have stronger partnerships, and understand patients’ health, social, cultural and linguistic needs. By letting patients drive their goals and by taking a supportive role, care teams can strengthen trust and relationships with patients.

UnitedHealthcare Community Plan of RI weighs in on NCQA Health Equity Accreditation

As we continue to spotlight the importance of health equity in primary care, we recognize the important contributions that our health plans make in advancing and supporting this work. UnitedHealthcare Community Plan of Rhode Island was recently awarded Health Equity Accreditation by NCQA. We connected with Stacey Aguiar, MPH, CPHQ, CHES, Senior Director of Clinical Quality UnitedHealthcare Community Plan, Rhode Island about this recognition.

Why is health equity important for organizations to recognize?

Health equity is important because eliminating health inequities results in better health outcomes for all and creates an environment where all have an opportunity for optimal care.


How can patients benefit from our RI primary care workforce being trained in Health Equity?

Training primary care providers on health equity can help eliminate historical bias and make them aware of the needs of different patient populations. Also, when there is more diverse representation reflected in primary care workforce, providers are better able to relate with their patients, which builds trust and patients feel comfortable openly discussing their healthcare concerns.


Through intentional Health Equity training and understanding by primary care teams, what successes or opportunities or successes are emerging?

Health equity accreditation provides an actionable framework for improving health equity goals, delivering culturally and linguistically appropriate services and reducing health inequities. Opportunities continue to include obtaining more data on race, ethnicity, language, sexual orientation, and gender identity to better inform interventions, supports and services.  

Breakfast of Champions focuses on gender-affirming care

CTC-RI hosted its quarterly Breakfast of Champions Meeting this month focused on the crucial topic of gender-affirming care with distinguished speakers Dr. Jason Rafferty and Dr. Amy Nunn, with over 60 attendees.  

Dr. Jason Rafferty, MD, MPH, EdM is a renowned pediatrician and child psychiatrist practicing at the Gender and Sexuality Clinic and the Adolescent Healthcare Center at Hasbro Children's Hospital. With an impressive background and extensive experience, Dr. Rafferty shared his insights into the importance of gender-affirming care, and the landscape of healthcare for transgender and gender-diverse individuals.

Dr. Amy Nunn, ScD, MS, Professor of Behavioral and Social Sciences at the Brown University School of Public Health and Executive Director at Open Door Health, brought her expertise to the discussion. Dr. Nunn explored how discrimination can act as a barrier, preventing people from accessing the healthcare they need and deserve. View the recording and claim CME credits here. Review the presentation here.

Pediatric/Adult Primary Care Health Care Transfer of Care Quality Improvement Initiative

CTC-RI and PCMH Kids, in collaboration with UnitedHealthcare and RIDOH, is pleased to announce that the following practices have been invited to join the 2023/2024 Pediatric/Adult Primary Care Health Care Transfer of Care Quality Improvement Initiative:

  • Anchor Pediatrics and Adult Medical--Lincoln
  • Children First and Dr. Matt Rocheleau
  • Concilio Pediatrics
  • East Greenwich Pediatrics and University Family Medicine
  • Dr. Richard Ohnmacht and Dr. Chad Lamendola

These practices include new and continuation teams that will participate in a year-long learning collaborative. They will work on creating and refining an efficient and sustainable approach to assisting youth and young adults as they transfer from pediatric to adult care. Congratulations to all selected practices! Read more.

Healthy Tomorrows Cohort 3 Quarterly Learning Collaborative

Healthy Tomorrows Cohort 3 Quarterly Learning Collaborative is supporting family access to well-child health care and family supports through a primary care and family visiting partnership. Practices and Family Visiting programs participating in the third cohort of Healthy Tomorrows met again in November to share their progress in referring patients and improving care coordination. In addition, each team shared success stories on how partnerships and joint care coordination have benefited patients and their families. Tiffaine Cataldo, a member of the Healthy Tomorrows planning team, representing the family voice, shared her personal story on how her family got involved and benefited from Family Visiting. Sara Remington, RIDOH shared that Family Visting programs participating in this initiative are achieving 90% or greater of enrolled children who had their most recent well-child visit. In the next three months, practices and family visiting agencies will be wrapping up the program with the final learning collaborative meeting in February. Special thanks to Tufts Health Plan and RIDOH who are providing the funding for this important quality improvement initiative.

Monthly CBO Spotlight: Genesis Center

Our primary care transformation efforts often include the support and partnership of community-based organizations (CBOs) statewide. CTC-RI is spotlighting a different CBO each month to recognize and appreciate their work in our communities. This month, we're spotlighting Genesis Center. A multi-service organization offering a full range of services to immigrants, refugees and low-income families, Genesis Center provides the highest quality education, job training and support services to people of diverse cultures so that they may achieve economic independence and participate fully in society.

In which ways does your organization uniquely support Rhode Islanders?

We provide free job training to low-income adults for several in-demand jobs, including Medical Assistant, Dental Assistant, Nursing Assistant (CNA) and Pharmacy Technician. These programs serve the dual purpose of getting Rhode Islanders into better-paying jobs with clear career paths and helping RI employers fill vacancies.


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

Primary care providers provide feedback and suggestions that help us improve our classes. They host our students for internships, which are a critical part of their training. Finally, they frequently offer our students paid employment opportunities, especially at the conclusion of internships.


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

Genesis Center is well-regarded and trusted in the community that we serve (low-income adults, including many immigrants and refugees), partly due to our commitment to diversity and cultural sensitivity. Our students are patients of many of the primary care providers and are uniquely positioned to serve other members of the community. 

Want to get in touch?

Contact Liz Hanke, Workforce Director at [email protected] or 401-781-6110.

Pharmacy QI Learning Collaborative

CTC-RI is improving Population Health / Reducing Low-Value Care in Primary Care through Professional Use of Continuous Glucose Monitoring (Pro CGM). The final year of the Pro CGM project is focused on sustainability and spread of the program. Practices enrolled in the initiative presented their plans to spread beyond the pilot practice site and how they plan to sustain their efforts. Stephen Kogut, PhD, MBA, RPh from University of RI, presented aggregate data on the program. So far, 309 patients have received a Pro CGM device to help manage their diabetes. Preliminary results show an overall drop in patients’ A1c. A comment shared by a care team member surveyed as the most important benefits of the Pro CGM was “visualization of hyper- and/or hypoglycemia as a tool for education and pattern recognition; identification of hypoglycemia in patients with hypoglycemic unawareness who don't use personal CGM.” The meeting concluded with a discussion on billing for CGM services using the 95250 and 95251 billing codes. Special thanks to UnitedHealthcare and RIDOH who are providing the funding for this important quality improvement initiative.

Unwinding Medicaid in Rhode Island

Deputy Director Kristin Sousa made a special appearance at December’s Virtual Coffee Break with Drs. Flanagan and Lange, where she reviewed the plans for Medicaid’s renewals for households with children. As of April 1, 2023, Medicaid renewals restarted in Rhode Island with a staggered implementation. Households with children under 19 years old enrolled in Medicaid will get renewal notices sometime between December 2023 and April 2024. If the state knows the Medicaid member’s income and other information needed to decide that they’re still eligible and the information is correct, coverage will continue automatically. Roughly 80% of children currently enrolled in Medicaid meet these criteria. If the state doesn’t have enough information to determine a Medicaid member’s eligibility, they will receive a yellow-highlighted notice indicating that action is required. Deputy Director Sousa laid out all the ways these members could submit the additional documentation requested and explained the process if members are no longer eligible for Medicaid. She also responded to questions from meeting participants. Those who were unable to attend December’s Virtual Coffee Break with Drs. Flanagan and Lange, can watch the recording and view the presentation. In addition, the American Academy of Pediatrics has additional resources to share.

New project launches to expand pediatric IBH capacity

CTC-RI is excited to kick off our new project, Expanding Pediatric Integrated Behavioral Health Capacity. This is supported by funding from Blue Cross and Blue Shield of RI and Point32Health/Tufts Health Plan, and is a collaboration with CTC-RI and the Foundation for Integrated Care (FIC).

This project aims to increase the number of RI pediatric providers who work in integrated behavioral health (IBH) programs by connecting interested clinicians with practices in need. This 12-month pilot will support the integration of an early career IBH clinician, hired by FIC, at a practice that is interested in expanding their pediatric IBH services. FIC will provide supervision and support for the clinician placed in the practice. The practice staff and IBH clinician will participate in monthly practice facilitation meetings to enhance team-based efforts and IBH capacity.

We are excited to announce the three practices chosen to participate in this project. Congratulations to:

  • Barrington Pediatrics
  • Northern Rhode Island Pediatrics
  • P.R.I.M.A Inc.

Clinical Strategy Committee Meeting: Lessons from Rhode to Equity and Community Health Worker Billing

The Clinical Strategy Committee meeting in November, attended by over 50 attendees, focused on lessons from Rhode to Equity and Community Health Worker billing. We heard from RIDOH and EOHHS on the Rhode to Equity initiative, focusing on the project framework and how teams worked together to bridge clinical and community gaps. This was followed by Roberta Goldman, PhD presenting on the findings of a qualitative evaluation focused on the CHW Medicaid billing rollout and implementation. View the recording and presentation here. Speakers included:

  • Allegra Scharff, MPH, Chief of Healthcare Equity and Olmstead Coordinator, RIDOH
  • Breanna Lemieux, Accountable Entity Program Lead, EOHHS
  • Robyn Hall, Assistant Program Officer, Local Initiatives Support Corporation
  • Kinzel Thomas, MSW, LCSW, LCDP, CCHW, Vice President of Equity & Community Development, Family Service of Rhode Island
  • Lynne Driscoll, RN, BSN, CCM, Assistant Vice President Community Health, South County Health
  • Roberta Goldman, PhD, Brown University

The next Clinical Strategy Committee meeting on December 15 will focus on a review of the work conducted throughout the year and a discussion of the CTC-RI strategic plan moving forward.

CTC-RI hosts second webinar in Demographic Data Collection Pilot Train-the-Trainer Series

The second webinar in our train-the-trainer series for the Demographic Data Collection Pilot was held in November. Focused on Demographic Data Standards, Natasha Viveiros and Jennifer Etue from PCHC delved into a discussion of the 1997 OMB standards, current state, and the future 2023 OMB-Proposed Race and Ethnicity Stratification. Their insightful presentation addressed key objectives, including understanding the intricacies of race and ethnicity demographic data collection standards, recognizing the role of race and ethnicity in shaping patient interactions, building comfort and capacity for front desk staff in addressing race and ethnicity questions, and enhancing comprehension of organizational oversight and accountability mechanisms tied to demographic data collection. The webinar series continues with our next session specifically addressing SOGI Data Collection. We look forward to continuing to work with the 15 participating practices in this initiative.

CTC-RI Hosts Midpoint Learning Collaborative “The Next Building Block: Implementing the 4M Framework for Better Care for Older Adults"

The Next Building Block QI initiative, offered in collaboration with RIDOH and URI Geriatric Education Center, and with funding from UnitedHealthcare, focuses on two components: 1) provide practices the opportunity to develop a plan and test the Institute for Healthcare Improvement (IHI) 4M approach to age-friendly care and 2) implement a performance improvement plan that measures identifying caregivers of patients with dementia, providing them with education and referrals to additional support. The five selected practices have taken a crucial step forward and by February 2024 will be submitting their plans to IHI for Level 1 Age-Friendly Recognition.

During our recent midpoint November Learning Collaborative meeting, Dr. Angela Catic, Associate Professor at Baylor College of Medicine presented on "Patient Priority Care." Her insights underscored the significance of aligning care with what matters most to older patients and their caregivers. Dr. Catic's expertise illustrated a path toward a more patient-centric approach in elder care. The experiences shared and insights gained during this meeting lay a solid foundation for the continued application and refinement of the 4M Age-Friendly Framework. Practices reported on their progress with identifying the caregiver and creating a path to address caregiver burden. To view the Midpoint Learning Collaborative, you may access the slides and recording here: PowerPoint Recording.

Best Practices in Team-Based Care: Supporting Older Adults through Grief and Loss

The CTC-RI Team-Based Care group gathered in November for a presentation from the RI Geriatric Education Center (RIGEC) when Mari Dias, Ed.D. focused on Supporting Older Adults through Grief and Loss. The 130 meeting attendees were invited to reflect on the causes of grief, cultural ideas of death and mourning, and the neurological responses to a loss. Dr Dias provided some best practices for helping older adults navigate loss and grief of all kinds. The slide deck for this presentation is available on the RIGEC’s website along with the recording.

We hope that you will join us for our next Team-Based Care meeting on December 19, featuring Margo Katz, MA, presenting on Safe Sleep Best Practices. Margo is the RIDOH Program Manager for Safe Sleep and Substance-Exposed Newborns. Register here.

MLPB Phase II Action Lab: Best Practices for Strength-Based Screening, Triage and Response


MLPB hosted the fourth of its Phase II Health-Related Social Needs (HRSN) Learning and Action Lab series this month. Guest facilitator Maureen Maigret, RN, BS, MPA talked about HRSN priority setting, and the work that has been happening in different RI settings. Maureen has incredible experience and expertise on what has happened and is happening in Rhode Island for older adults. The 31 participants then reflected on all information they’ve received and discussed from the two previous sessions about how to implement anti-racist strategies in healthcare with Dr. Baraka Floyd; and best practices in strengths-based screening from Ariel Singer. The session culminated in an exciting and interactive discussion of how to work through obstacles identified for patient-centered screening of health-related social needs. The final session, “Putting It All Together” is scheduled for January 25.

CTC-RI and Providence College: perfect partners!

CTC-RI has enjoyed hosting student interns from Providence College (PC) for many years. The interns come from PC's Department of Health Sciences' Health Policy and Management (HPM) Bachelor of Science major. CTC-RI has provided learning opportunities to two students per year--one each semester. Our most recent intern, Jordan Brewster, is pictured here at PC's November intern poster fair with her mentor and PC alumnus, Sue Dettling, CTC-RI Program Manager / Practice Facilitator. Jordan assisted with the CTC-RI annual conference, conducted research, and helped analyze and display data for key projects. If you would like more information about hosting an HPM intern, please reach out to Todd Olszewski, Ph.D., Associate Professor and Department Chair, Department of Health Sciences, Providence College at: [email protected]. General inquiries regarding PC interns may be directed to Victoria Lally, Associate Director for Alumni & Employer Engagement at: [email protected]. 

Find past CTC-RI learning sessions and CME/CEUs here!

CTC-RI offers CME credits for select meetings, including asynchronous viewing of meeting recordings. Learn more and access evaluation forms here.

Practice Resources and Information

CMS: Request for Applications for the Guiding an Improved Dementia Experience Model now available

CMS is now accepting applications for the Guiding an Improved Dementia Experience (GUIDE) Model, which aims to support people living with dementia and their caregivers. The Request for Applications is now open. The application deadline is January 30, 2024. The model will launch on July 1, 2024, and run for eight years. The GUIDE Model will test whether providing an alternative payment methodology for participating dementia care programs to deliver a package of care management and coordination, caregiver education and support, and GUIDE Respite Services to Medicare beneficiaries with dementia and their caregivers reduces expenditures while preserving or enhancing quality of care.

December 19 Team-Based Care Meeting: Safe Sleep

Please join us for our December 19 Team-Based Care Meeting, focusing on Safe Sleep. Margo Katz, MA, Program Manager for Safe Sleep and Substance Exposed Newborns at the Rhode Island Department of Health will provide an overview of Sudden Unexpected Infant Death (SUID), common causes and state data, and evidence-based recommendations around having shared decision-making conversations. Register.

Dec. 19 webinar: Maximizing Autonomy for Older Adults: Guardianship and Less Restrictive Alternatives 

MLPB will help participants recognize how to obtain guardianship of a person in the limited circumstances where they are unable to make any decisions for themselves, identify less restrictive tools that can be used to preserve the autonomy of a person who needs limited assistance, and apply role-aligned caregiving problem-solving strategies in partnerships with those you serve. Details.

MLPB: December News and Resources

Read MLPB's most recent updates, including new law and policy consultants, and more.

Free live December webinars: Collaborative Gender Affirming Care with Families

This webinar is a first in a series that will help providers who work with gender diverse clients across the lifespan understand the basics of gender affirmative care using a collaborative developmental model for working with transgender, non-binary, gender expansive children, adolescents, young adults and their families that is inclusive of the many intersections of identity we all hold. The presentation will include case examples and experiential exercises.

Primary care provider survey: Managing memory concerns for older adults

Improving routine screening is the first step toward detecting Alzheimer’s disease and related dementias early, before the onset of major symptoms. The FDA has recently approved a new medication that may slow or prevent Alzheimer’s with early intervention. Understanding the experiences and needs of primary care providers is critical as we study tools to improve early disease detection. Take the survey.

Practice flyer resources: Health equity, influenza, sepsis

Please feel free to download and utilize these free practice flyer resources on health equity, sepsis, and influenza.

Recent News

Providence Journal: 'How did this happen?' Primary care shortage keeps hitting RI hard

Rhode Island will need around 100 more primary care doctors in the next six years, one study predicts. Meanwhile, patients have lost their doctors and struggled to find new ones. Is the solution empowering more physician assistants and nurse practitioners to help fill gaps? Long waits, frustrated patients and overworked health care staff are all the symptoms of a doctor shortage that has pushed providers to the brink of burnout. It's a crisis that's been building nationally for years. In recent months, it caused the head of the American Medical Association to raise alarm over doctors saddled with college debt and stretched to exhaustion. Rhode Island is no exception, particularly when it comes to primary care. Read more.

Milbank Blog: Understanding the Impact of COVID-19 on Health Care Spending in Three States 

As the health care system rebounded in 2021 from the widespread disruption of services during the COVID-19 pandemic, states saw notable, though not unexpected, increases in health spending. Three states — Connecticut, Oregon, and Rhode Island — leveraged insights from their cost growth target programs to understand the key drivers behind the higher 2021 spending growth. A new blog post by Christopher Romero-Gutierrez and Michael Bailit of Bailit Health examines the findings from the states' analyses of commercial market data from all-payer claims databases to understand why spending grew so fast. 

Medriva: Addressing the Pressing Issue of Primary Care Physician Shortage

The national shortage of primary care physicians in the US is projected to worsen, with states like Rhode Island and Florida feeling the pinch. The Robert Graham Center projects a shortfall of about 100 primary care physicians, or 11% of the workforce by 2030, resulting in up to 200-thousand residents not having access to a regular physician. The Care Transformation Collaborative – Rhode Island is supporting legislation to incentivize medical students to go into primary care. Read more.

RINewsToday: World Diabetes Day: Nov. 14 Blue Light Awards event in Rhode Island 

Rep. Diaz will present the Grace Diaz Blue Light Award, which is given annually to an individual or organization that has made a positive difference in diabetes prevention and care in Rhode Island. In keeping with this year’s theme, “Access to Diabetes Care,” the award will be presented to those who have shown a commitment to providing access to diabetes care, including: Krystal Bevilacqua, Kenny Correia, Alex Gianfrancesco, Patricia Hoffman, Lillian Nieves, Bradford Pease and Kelley Doherty Sanzen. Read more.

Upcoming CTC-RI Committee Meetings and Workgroups

  • January 03, 07:30-08:30AM – PCP/Specialist Monthly Oversight Meeting
  • January 03, 02:30-03:30PM – Demographic Data Monthly Committee Meeting
  • January 10, 08:00-09:00AM – Task Force for Primary Care Provider Workforce Development
  • January 19, 07:30-09:00AM – CTC-RI Clinical Strategy Committee
  • January 26, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • December 19, 08:00-09:00AM – Best Practices in Team-Based Care
  • December 21, 07:30-08:30AM – ECHO: Increasing Access to Care for Children and Adolescents with Restrictive Eating Disorders by Optimizing Integrated Behavioral Health Care
  • December 21, 02:00-03:00PM – Monthly Healthy Tomorrows
  • January 04, 07:30-08:30AM – Improving Child Health in RI (formerly PCMH-Kids Stakeholder Meeting)
  • January 08, 11:00-12:00PM – CTC-RI/RIDOH HEZ Community of Practice: Bridging the Clinical Community Divide
  • January 09, 09:00-10:00AM – Demographic Data Collection Pilot Train-the-Trainer Webinar
  • January 16, 08:00-09:15AM – Best Practices in Team-Based Care
  • January 18, 07:30-08:30AM – ECHO: Increasing Access to Care for Children and Adolescents with Restrictive Eating Disorders by Optimizing Integrated Behavioral Health Care
  • January 19, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • January 25, 09:30-03:00PM – Foundational Training for Community Health Workers (CHWs) Session #4
  • January 25, 02:00-03:00PM – Monthly Healthy Tomorrows
Care Transformation Collaborative of RI | [email protected] |