Care Transformation Collaborative of RI
News & Updates | May 2022

As we recognize May as Mental Health Awareness Month, CTC-RI is highlighting our impactful, targeted program that has been engaging pediatric practices over the last 3 years to pilot an integrated behavioral health model to help address the mental and behavioral health needs of children and families.

“The CTC-RI led project, supported through the Rhode Island Foundation’s Behavioral Health Fund, which focused on early identification and intervention of behavioral health issues affecting children, could not have come at a more crucial time,” said Zach Nieder, Senior Strategic Initiative Officer for Health at the Rhode Island Foundation. “While the need for more focus and resources on children's mental healthcare predates the COVID-19 pandemic, the last 2 years have only deepened and reinforced the need for supporting and expanding such an integrative approach to health promotion, prevention, and treatment.”

Funded by the Rhode Island Foundation, Tufts Health Plan, and UnitedHealthcare, practices were given resources to fully integrate a behavioral health clinician. Read more.

For many children, adolescents, young adults — it's a stressful world. Rates of adolescents reporting thoughts of sadness, symptoms of depression, suicidal ideation, and suicide attempts have been rising, with the pandemic exacerbated these trends.

After piloting our CTC-RI Pediatric IBH program, our new evaluation results are overwhelmingly clear. In-practice screenings find behavioral health issues before they develop into full blown problems, or even find adolescents who said they "felt fine" but scores indicated suicidal thoughts or intent. Screening and handoffs to clinicians helped patients and families normalize mental health care, and importantly, IBH services helped patients deal with depression, anxiety, bullying, suicidal ideation, and school anxiety. Read more.

This Mental Health Awareness Month, we’re spotlighting one of the pediatric practices that recently wrapped up their participation in our Pediatric Integrated Behavioral Health (IBH) pilot program: Tri-County Community Action Agency. We interviewed Jennifer Caffrey, MSW, LICSW, IBH Director and Daniella Pierre, MPH, HCM, Health Center Chief Quality Officer to talk about Tri-County’s participation and advice for other practices.

How did your participation in the Pediatric IBH project impact the team and patients at Tri-County? 
Participating in the Pediatric IBH project created an opportunity for our multi-disciplinary team to closely collaborate, identify gaps in services and work together to create a streamlined approach to screening and delivery of services. Our monthly meetings with CTC-RI were crucial in the process of continual improvement of our Pediatric IBH program.  

What new adjustments or changes have been the most surprising, challenging, or helpful in your IBH work? 
Establishing a consistent approach to screening and ensuring ongoing training of staff in all positions has been challenging but so important in ensuring that patients are appropriately screened and clinicians are available in the moment for warm hand-offs from providers. Working closely with our quality improvement team was essential to the success of our IBH program.  

What advice would you give to other pediatric practices interested in exploring/introducing IBH? 
Having the support of our agency administration and health center leadership has been instrumental in the success of our IBH program. Review of the research and evidenced-based practice supporting true integration of behavioral health is essential to a successful IBH program. Participation from all disciplines within the practice is key to a successful and truly integrated program. 

May’s Behavioral Health Technical Assistance learning session focused on Behavior Plan Basics, highlighting the core elements of effective behavior plans, common pitfalls and reasons plans fail, along with sample behavior plans, contracts, and key resources. Practices participating in the Medicaid Pediatric Healthcare Recovery Program are eligible for additional funding by having a staff member attend a BH TA learning session and complete an evaluation by May 31. Read more.

Please join us for our June 10 Quarterly Breakfast of Champions (7:30-9:00am)! Presentations will highlight important RI work being done to improve care for people with diabetes from clinical, community/clinical and patient perspectives.

We are excited to welcome the following presenters:
  • Diana Mercurio, BS, RPh, CDE, CDOE, CVDOE, RI Physicians Corporation Primary Care
  • Michael Poshkus, MD and Jessica Ryan, PharmD, BCACP, Thundermist Health Center 
  • Jean Taylor, RN, BSN, CDOE, CCM, Director Clinical Programs Population Health, Care New England Integra ACO
  • Erin DiBacco, Director of Strategic Growth and Business Development, Community Servings

Please register to receive access to this virtual meeting and submit questions to the panelists. CME credits are available through AAFP for physicians, PAs, RNs, and NPs.

With our second cohort of practices wrapping up last month, 21 practice sites have now officially completed our 12-month technology-focused learning collaborative to improve care for patients with chronic conditions. High-level results show improved access to care, patient satisfaction, and reduction in ED/hospitalizations. Read more.

As we move into the second year of the UnitedHealthcare-funded Integrated Behavioral Health (IBH) Learning Collaborative, CTC-RI would like to recognize the 11 practices graduating and 5 new practices joining. Graduating practices recently showcased their work, from developing workflows around anxiety or other BH screening, to piloting groups for stress management, to piloting tools to use during virtual BH appointments.

CTC-RI is helping practices achieve NCQA BH Distinction as a gold standard of IBH delivery. Read more.

The Rhode to Equity project kicked off in July 2021 and will move into its 2nd year this summer. This month, the 6 participating teams came together to learn about change management using the SWITCH framework, which includes three steps: (1) direct the rider; (2) motivate the elephant; and (3) shape the path. Teams practiced applying these principles to their work in addressing health inequities within their communities. Read more.
Rhode Island COVID-19 Updates

COVID-19 Cases
COVID-19 cases have been on the rise over the last month. This week (May 14), there are 527 new cases per 100,000, compared to 445 (May 7), 338 (April 30), and 235 (April 23).

COVID-19 Vaccines
As of May 18, 431,091 Rhode Islanders have received a booster vaccine (40.8%), 873,702 have completed their primary vaccine series (82.7%), and 1,036,341 are at least partially vaccinated (98.1%).
In the News
Providence Business News 
April 15, 2022
Kristin Pono Sousa, Rhode Island’s interim Medicaid program director since December of 2021, has been appointed to fill the position permanently.

“Having worked in Medicaid for over 10 years, I am committed to ensuring that the program provides access to high-quality services, fosters partnerships with all stakeholders, improves health outcomes and reduces cost growth, with a particular focus on health equity and strengthening the continuum of care for Rhode Islanders,” Sousa said. Read more.
Practice Resources
Brown Alpert Medical School: Screening and Moderated Discussion of "Cured" Film
More than 2 million elderly people in the U.S. identify as LGBTQ+ -- with many exposed to social stigma and discrimination that has led to social and health disparities. Currently, medical training does not address sex and gender medicine comprehensively. As a consequence, providers report lack of knowledge and LGBTQ+ patients report experiencing bias that discourages them from seeking care. Register for this live in-person event on June 1.

Upcoming Brown On-Demand CME Courses for Mental Health Awareness Month:
Upcoming CTC-RI Committee Meetings and Workgroups
  • May 25, 08:00-09:30AM – Practice Reporting/Practice Transformation Committee Meeting
  • May 27, 07:30-08:45AM – Board of Directors
  • June 16, 07:30-09:00AM – Quarterly Integrated Behavioral Health Committee Meeting
  • June 21, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • June 17, 07:30-09:00AM – Clinical Strategy Committee
  • June 24, 07:30-08:45AM – Board of Directors
Upcoming Learning Collaboratives and Professional Development
  • May 26, 07:30-09:00AM – Pharmacy Quarterly Learning Collaborative: Reducing Preventable Hospitalizations and ED Usage
  • June 06, 07:30-08:00AM – Virtual Coffee Breaks with Dr. Pat Flanagan & Dr. Beth Lange
  • June 10, 07:30-09:00AM – Quarterly CTC-RI Breakfast of Champions
  • June 16, 10:30-12:00PM – Rhode to Equity Momentum Session
  • June 28, 07:30-09:00AM – RI MomsPRN Cohort 3 Kickoff Meeting
  • June 28, 02:00-03:00PM – R2E CHWs Monthly Training and Networking
  • June 29, 07:30-09:00AM – Health Transition of Care Orientation Kickoff Meeting for New Practices
Care Transformation Collaborative of RI | [email protected] | ctc-ri.org