Care Transformation Collaborative of Rhode Island News & Updates | April 2021
RIDOH, Tufts Health Plan, CTC-RI and PCMH Kids are pleased to offer pediatric and adult practices the opportunity to apply for funding to participate in the primary care “Health Care Transfer of Care" Quality Improvement Initiative. Family medicine practices willing to partner and accept referrals from a pediatric practice are also welcome to apply. Pediatric and adult primary care practice teams are invited to submit joint applications (due April 30, 2021). This initiative will provide a shared learning opportunity for pediatric and adult practices to work together to create an efficient and sustainable approach to assist youth and young adults transfer from pediatric to adult care. Learn more.
The Rhode to Equity is an innovative funding opportunity made available through EOHHS Health Systems Transformation Project, RIDOH, and CTC-RI. This 12-month learning and action collaborative will provide up to 6 cross-sector teams with the opportunity to test and evaluate strategies that will build leadership and operational capacity for clinical-community linkages, resulting in place-based communities that improve both health and social outcomes. The Rhode to Equity will bring together teams from Health Equity Zones, Accountable Entities, Community Health Teams, and persons with lived experiences of inequity. Applications are due May 21.
With a spotlight on improving health and social outcomes in communities as "Rhode to Equity" applications stay open until May 21, we recently interviewed Carla Wahnon, Manager of Integrated Health Community Health Team at East Bay Community Action Program (EBCAP), one of two teams participating in the Rhode Island Diabetes Health Equity Challenge. Her team worked with Well-being and Equity in the World coaches to improve health equity in East Providence. Her team, “Produce to People: Green Beans and Healthy-in-Between” has a long-term goal of reducing the number of community members experiencing food insecurity through policy changes and a short-term goal of expanding fresh produce at EBCAP food pantries. 

What motivated EBCAP to “take the Health Equity Challenge” and participate during COVID-19?
This is the work I have always wanted to do and this work is what EBCAP is all about: we provide clinical care and our CHT supports people at highest risk of poor outcomes. Our HEZ supports building community solutions. We are fortunate to also be a Community Action Program (CAP) with access to a wealth of resources and knowledge from our social service program including our director of social services who manages our food pantries and family advocates.

One of the foundational principles of the Pathway to Population Health (P2PH) tools is that it is informed by a team member who has "lived experience." How has having a person with lived experience made a difference in your work?
Jamie has been so important to our work. She is the person on the team that could help us understand the challenges of using the SNAP program, of being able to pay for, access and use healthy foods and why she wanted to help her family not develop diabetes. She keeps us on target.

How have the P2PH framework, tools and coaching been helpful to you?
As one of our team members would say, improving health equity is a “big, audacious goal” and where do you start? It can be overwhelming. The tools helped us get started. Our team also had to make the commitment to meet weekly, assign responsibilities and do the work. We also needed the support of leadership who understood that this work was important and that we would have the time to meet as a team.

What advice do you have for teams that might be considering applying for “Rhode to Equity”?
Even though our team members are all from the same agency, we still needed the time to get to know each other, to understand what each of us did and could bring to the table and learn how to work together. Getting to know each other, and building relationships takes patience and is an important part of the process. It is also worth it.
On March 12, the East Bay Community Action Program and Pawtucket/Central Falls teams reported on the progress they are making with using the Pathway to Population Health Compass tool to advance the work of understanding the patient population, identifying patients at highest risk that need additional assistance, increasing the impact of people with lived experience and implementing community solutions. Read more.
Rhode Island COVID-19 Vaccination Update
As of April 13, following federal action, RIDOH has temporarily paused use of the J&J vaccine as further information is gathered following federal reports of patient reactions. Pfizer and Moderna vaccines will continue to be made available to eligible Rhode Islanders through state-run vaccination sites, local pharmacies (CVS, Walgreens, Walmart, Stop & Shop, and independent pharmacies), and local municipality clinics.

As of April 13, Rhode Island has expanded its vaccine eligibility to ages 40 and older, one week ahead of when the state will open vaccines to everyone 16 and older.
Spring 2021 Breakfast of Champions a Success! Save the Date for June 11
On March 12, almost 80 clinical practice champions and practice site clinical and administrative leaders gathered virtually to get a deeper understanding of how to practically improve population health and health equity in RI at the CTC-RI/PCMH Kids Breakfast of Champions. From an interactive session with brainstorming around strengthening primary care and community linkages to highlights from a pharmacy-led quality improvement initiative, this spring meeting was a great success! Read more, and don't miss the next Breakfast of Champions on June 11 on the changing role of PCP and clinical team in capitation, and potentially avoidable ED visits.
CMS announced the CPC+ model will end in all states, regardless of start date, on December 31, 2021. Participants will receive a formal notification of this action in the coming weeks. CMS remains committed to strengthening primary care. Impacted practices and payers can apply for Cohort 2 of the Primary Care First (PCF) Model, which builds on CPC+ principles, as is an opportunity for practices to assume greater independence, prioritize the clinician-patient relationship, and increase revenue through performance-based payments. To accommodate impacted CPC+ participants, the deadline for PCF practice applications has been extended to May 21, 2021 and the deadline for payer applications has been extended to June 18, 2021. Learn more.
CTC-RI hosted the February 25 closing session for the 12-month learning collaborative, “Empowering the Safe, Effective and Efficient (S.E.E.) Use of Medications in Older Adults.” The 7 practices presented on their successes with pharmacy-led quality improvement strategies including patient engagement and plans for sustainability and spread. Read more.
Success Spotlight: Helping Patients with COPD/Asthma Medication Management
Through the CTC-RI Pharmacy Quality Improvement Initiative, practices identify and implement a data-driven performance improvement action plan to address a particular medication area of concern among adults ages 50 and older. The goal is to help patients improve medication management through pharmacy practice facilitation support, peer learning opportunities, and team-based performance improvement. One participating practice site, CNEMG-Pawtucket (Integra), focused their pharmacy-led quality improvement project on supporting patients with COPD/Asthma. The pharmacist leading this work was Ronald Tutalo, Pharm.D., BCACP, CDCES, who recently shared his experience on this important work.

What was the greatest challenge of your involvement in the pharmacy-led quality improvement initiative?
The greatest challenge was adjusting our workflow to meet the needs of our patients during the COVID-19 pandemic. Optimizing inhaler use in patients with COPD and asthma during the time when we were primarily offering virtual visits required workflow adjustments since our intent was to continue using the In Check Dial Training device. We adapted by incorporating more inhaler demonstration videos and ensured use of the teach-back method.

What success did you find in your efforts to support patients with COPD/Asthma?
We found that this pharmacy initiative resulted in an improvement in patient symptoms related to COPD and asthma. Patients felt better and this resulted in fewer exacerbations. This is because patients were supported in an effort to ensure inhaler regimens were affordable and evidence-based. Also, we worked with patients to make sure individual inhaler regimens could be adhered to and that patients were comfortable administering selected devices.

What lessons learned or advice can you share with other practices?
We found that using a collaborative approach with pharmacists as part of an interdisciplinary team to manage patients with asthma and COPD resulted in improved patient symptoms and less frequent exacerbations. When prescribing an inhaler device, it is crucial that the patient can use the device appropriately, adhere to the device, and afford the device. We would encourage practice sites to utilize pharmacists when possible to ensure optimal inhaler use.
On March 26, guest speaker Allen Dobson, MD, former CEO of Community Care of North Carolina and former Assistant Secretary and Medicaid Director for the North Carolina DHHS presented at the CTC-RI Board of Directors and CHT Oversight Committee meeting. Dr. Dobson touched on how North Carolina has structured their community health model and how it could be applied to Rhode Island. CTC-RI continues CHT planning efforts with national consultants for recommended design and payment components. Read more.
With almost 50 attendees, the March 19 CTC-RI Clinical Strategy Committee (CSC) meeting had several engaging presentations and discussions. CTC-RI’s Susanne Campbell, RN, MS, PCMH CCE, Senior Program Director and Susan Dettling, BS, Practice Facilitator presented the results of the Patient and Practice Telehealth Survey and an update on the ongoing webinar series and Telehealth Learning Collaborative. March's CSC meeting also welcomed Michael Cropp, MD MBA, President and CEO, Independent Health Association of WNY who presented Advances in Community – Clinical Linkage, including leveraging community-clinical partnerships to reduce COVID-19 health outcome disparities in the Black population in Buffalo, NY. A CSC Primary Care Specialist Collaboration proposal to plan an e-consult collaborative was also discussed and a smaller planning subgroup will be convened. The April 16 CSC meeting will focus on data to support successful CPCC snd the changing role of the primary care provider and expanded clinical care team under capitation. Read more.
CTC-RI Continues Telehealth Webinar Series on April 27
CTC-RI/PCMH Kids' next telehealth webinar, made possible by authorized CARES Act and UnitedHealthcare funding, is on Tuesday, April 27 from 12:00-1:00pm. The webinar, “Advancing Team-Based Care in RI Webinar: Remote Patient Monitoring” will include representatives from UnitedHealthcare, BCBSRI, and practices from RI Primary Care Physician Corporation and Providence Community Health Center to get an overview of some of the common RPM platforms being used by practices, payers and vendors.
On March 5, 11 practices met to kick off a new year-long IBH learning collaborative funded by UnitedHealthcare and the Rhode Island Foundation. Nelly Burdette, PsyD is leading the project, and Kristin David, PhD and Liz Cantor, PhD, will be serving as practice facilitators. The learning collaborative will focus on best practices for tele-IBH and NCQA BH Distinction. Learn more.
Debra Hurwitz, MBA, BSN, RN, CTC-RI Executive Director and Pano Yeracaris MD MPH, Chief Clinical Strategist teamed up to recently present to the Health Systems Science II course of the Warren Alpert School of Medicine at Brown University. They shared CTC-RI’s impact across the state, including patient-centered medical home model, integrated behavioral health, and community health teams. Empowering future clinicians with CTC-RI’s experience in improving health in RI and beyond was both exciting and gratifying by offering such hope through science, technology, compassion and collaboration. Read more.
In Case You Missed It: News and Publications
Lowering A1c Through Integrated Behavioral Health Group Visits
By Dr. Markin Kerzer, Dr. Siddharth Marthi, Jamie Handy, Kristin David, PsyD
Rhode Island Medical Journal (February 2021)
Read this month's published article in the Rhode Island Medical Journal highlighting the work of Associates in Primary Care Medicine and their pilot study aimed to evaluate the effect that group visits, conducted using an integrated behavioral health model at a primary care practice, had on A1c and distress levels in diabetic adults. Read about their success here.
Northeast Telehealth Resource Center featured CTC-RI in its January Field Report, “Sample Stakeholder Challenges, Solutions and Lessons Learned.” The report highlighted our collaborative work in the 3 phases of our UnitedHealthcare and CARES Act funded Telehealth project: 1. Fielding the practice/patient needs assessment, 2. Developing a RI webinar series based on telehealth primary care / patient needs assessment findings, and 3. Planning our 12-month Telehealth Learning Collaborative. Read more.
CTC-RI/PCMH Kids hosted its quarterly Pediatric Integrated Behavioral Health Learning Collaborative meeting on April 8, with pediatric practices reporting on progress made with screening for behavioral health needs during COVID-19 and their performance improvement plans. Celeste Corcoran, MD, FAAP, Diplomate in Obesity Medicine, Assistant Professor at the Warren Alpert Medical School of Brown University and clinical educator presented on Childhood Obesity and Mental Health, the impact that COVID-19 has had on children, and medical and behavioral health interventions that can be helpful. Read more.
CTC-RI/PCMH Kids hosted a quarterly PCMH Kids stakeholder meeting on April 1. The discussion started with reflections on the Alternative Payment Models learning session from the night before and addressing questions. Drs. Flanagan and Lange provided an update on how PCMH Kids Cohort 3 performed in Year 2 of in the program, while managing through the demands of a pandemic. All Cohort 3 practices met their incentive targets and program deliverables. Read more.
In partnership with RIDOH, CTC-RI/PCMH Kids successfully applied for a 5-year HRSA “Healthy Tomorrows” grant to improve communication and care coordination between the Family Visiting Program and pediatric primary care practices with a specific focus on improving well-child care. On March 29 we launched the 1-year pilot learning collaborative with 2 practices (Hasbro Pediatric Primary Care and Providence Community Health Center – Central) and 2 Family Visiting Programs (Meeting Street and Blackstone Valley Community Action Program). Read more.
Update: Pediatric Alternative Payment Model Learning Session
CTC-RI/PCMH Kids recently hosted a virtual learning session on Alternative Payment Models (APMs), specifically focused on special considerations related to pediatric care. Speakers included Cory King, OHIC Chief of Staff, and John Freedman and Mary Jo Condon, both of Freedman Healthcare. Many of RI’s pediatric community gathered virtually for this late-night learning session where presenters provided background information on OHIC’s primary care APM targets and timeline, defined key terminology, supplied some history on Capitation, and suggested areas to consider when negotiating on behalf of pediatric practices. Read more.
CTC-RI Presents to a National Audience at Milbank Seminar
On April 12, CTC-RI Executive Director Debra Hurwitz, MBA, BSN, RN, and Senior IBH Program Director Nelly Burdette, PsyD, presented to a national audience on CTC-RI’s IBH program at the Milbank Multipayer Primary Care Network Virtual Seminar. The full seminar, “Behavioral Health Integration - Sustainable Solutions,” also included presentations from organizations supporting IBH initiatives in Arkansas and New Jersey. 
Primary Care National Survey Results
Results are now available from February and March national surveys of primary care practices fielded by the Larry A. Green Center and Primary Care Collaborative. Thank you to all practices and clinicians in Rhode Island who provided input!
Practice Resources
Focus Group Recruitment: Clinicians, Doctors, Direct Support Professionals, and Patients Needed
RIPIN is coordinating health care listening sessions on the experiences of adults (ages 22-59) with intellectual and/or developmental disabilities (I/DD) who are eligible for both Medicare and Medicaid. Participants will receive a $200.00 gift card for their time. RIPIN will also be coordinating input sessions for the clinicians, doctors, direct support professionals who provide services to this population. Click here for patient recruitment and here for providers.

Our March webinar recording is now available from our Telehealth webinar series focused on Community Health Workers/Patient Navigators. Access it here.

Be Kind RI Launches to Connect Volunteers to Rhode Islanders In Need
Be Kind RI is a new technology platform that connects volunteers to their neighbors across Rhode Island through text alerts to coordinate food deliveries from grocery stores and food pantries for those experiencing COVID-19 risk factors including seniors 65+, anyone with underlying health conditions, those in quarantine or isolation, anyone experiencing a lack of childcare, and those who would otherwise experience difficulty in obtaining food. Be Kind is brought to you through a partnership between Age-Friendly RI, RI Community Food Bank, and Family Services of RI.

Save the Date: RI Health Center Association's Virtual Cancer Screening Summit
You are invited to learn about current cancer screening trends in Rhode Island and hear from experts on colorectal, cervical and bladder cancers at this virtual summit on Friday, June 25 (8:30-11:30am).

Job Openings: RIDOH COVID-19 Unit
From case investigators to Health Equity Leads to Lab Data Quality Specialists, RIDOH is hiring for open positions on their COVID-19 Unit. Details here.

Bradley Conference: Fostering Empathetic Relationships Within a Child's Care Team
This virtual session on May 6 (8:00-10:15am) will focus on delivering impactful care. Distrust, bias, frustration, miscommunication, cultural norms, opposing expectations, and trauma can all influence one’s approach to members of the child’s care team. These influences often lead to breakdowns in communication and can negatively impact the child as a result. This presentation addresses, from both the family and professional perspective, causes of these communication breakdowns, and strategies for repairing and preventing them.

CTC-RI COVID-19 Briefing
Please reference CTC-RI's latest COVID-19 briefing for related updates, news, and practice resources.
April and May CTC-RI Committee Meetings and Workgroups
  • April 16, 07:30-09:30AM – Clinical Strategy Committee
  • April 20, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • April 23, 07:30-08:45AM – Board of Directors Meeting
  • April 23, 09:00-10:00AM – Community Health Team Oversight Committee
  • May 13, 07:30-09:00AM – Quarterly Integrated Behavioral Health Committee
  • May 14, 09:30-11:00AM – Community Health Team Best Practice Meeting
  • May 18, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • May 20, 03:00-04:30PM – SBIRT/CHT Executive Committee
April and May CTC-RI Program and Initiative Meetings
  • April 22, 02:00-03:00PM – Healthy Tomorrows
  • April 26, 02:00-03:00PM – Healthy Tomorrows Joint Meetings
  • May 06, 07:30-08:00AM – Virtual Coffee Breaks with Dr. Pat Flanagan & Dr. Beth Lange
  • May 12, 07:30-09:00AM – Telehealth Learning Collaborative Quarterly Meeting
  • May 19, 07:30-08:00AM – Healthcare Transfer of Care Quality Improvement Kickoff
  • May 20, 07:30-08:00AM – Reducing Preventable Hospitalizations and ED Usage Pharmacy Kickoff
Spring 2021 Learning Collaboratives and Professional Development
  • April 27, 12:00-01:00PM – CTC-RI Telehealth RPM Webinar
  • May 6, 08:00-10:15AM – Bradley Conference: A Common Goal: Fostering Empathetic Relationships Within a Child's Care Team
  • June 11, 07:30-09:00AM – Quarterly CTC-RI Breakfast of Champions
  • June 25, 08:30-11:30AM – RIHCA Cancer Screening In Rhode Island
Care Transformation Collaborative of RI | c[email protected] | ctc-ri.org