Care Transformation Collaborative of Rhode Island News & Updates | August 2021
Spotlight: Emma Romey, LMSW, Associate Director of Customer Success at Unite Us
This month, CTC-RI interviewed Emma B. Romey, LMSW, Associate Director of Customer Success at Unite Us, a technology platform used by a growing number of primary care practices, community-based organizations, and community health teams. United Us, highlighted during our recent Clinical Strategy Meeting and Nurse Care Manager/Care Coordinator Best Practice Sharing meetings, is helping care teams continue to advance and coordinate primary care through use of increased digital technology.

Can you tell us about the work you are doing here in RI to help primary care practices, community-based organizations, and community health teams?
Unite Rhode Island is a coordinated care network of health and social service providers. Partners in the network are connected through Unite Us’ shared technology platform, which enables them to send and receive electronic referrals, address people’s social needs and improve health across communities. Unite Rhode Island is sponsored by Prospect Health Services RI, Inc., Rhode Island Office of Veterans Services, Lifespan Health System, Coastal Medical, and the Rhode Island Executive Office of Health and Human Services. United Way of Rhode Island serves as a key convener and their 2-1-1 is a coordination center for the network. The network is supported by a RI-based Unite Us team focused on community engagement, network health and optimization, and customer success. Joining the network is at no cost for community-based organizations and many organizations that are considered part of the safety net, such as community health centers, tribal clinics, and mental health centers.

How is Unite Us helping transform primary care, and the way practices and organizations can better support RI patients?
Rhode Island partners with various primary care practices, specifically through our work with the Accountable Entities. The Unite Us customer success and community engagement teams support clinical teams in building out workflows, training staff and assisting with following up on electronic referrals that are made to community-based organizations. Unite Us Platform enables primary care staff to search and filter for best-fit organizations, confirm eligibility criteria, send referrals, confirm acceptance of those referrals, and ultimately see the documented outcome. This closed loop referral process provides clinical staff visibility into their patients’ care as social needs are being met throughout the community.

What's a misconception or a surprising fact about Unite Us that our primary care community may not know?
There are often concerns that community-based organizations face many barriers that would prevent them from joining a coordinated care network like this. The Unite Rhode Island network currently has 190+ unique organization locations active in the platform, with 1,000+ trained users and 300+ programs offering a variety of services that cover our 200+ services types. These numbers continue to grow each week as more organizations join, and if an organization is not yet live in the platform, or "in-network", a primary care user can still document where the referral was sent so that all data points are captured in the same place.  
Meet Dr. Judith Blazar Westrick, MD, of Anchor Pediatrics in Lincoln. Her pediatric practice recently completed the first Cohort of the PCMH Kids Integrated Behavioral Health (IBH) program. Dr. Judith Blazar Westrick shares her insight and experience on introducing an integrated behavioral health program into her practice.

Why did your practice join the first Cohort of the PCMH Kids IBH program?
Our practice joined the first PCMH Kids IBH program for 2 main reasons. The first is that we saw the need for IBH services to support our patients’ mental health issues. The second is that we knew none of us had the experience to start an IBH practice and we wanted/needed assistance. CTC-RI has been very helpful supporting us through getting our IBH practice going. Their ongoing support has been indispensable. 

Why is IBH an important part of your pediatric practice today, particularly during a global pandemic?
Our patients have had mental health needs which have always been difficult to assist, especially given how overwhelmed the pediatric mental health system in RI and elsewhere seems to be. Having an IBH clinician working with our office has been extremely helpful for continuity. Not only can we provide services, but we are able to prioritize the schedule - saving room for emergent issues and making room for warm handoffs. Being able to introduce the patient/family to the IBH clinician in an easy and rapid fashion has helped overcome many of the barriers to starting mental health care for our patients/families. Having been stuck at home, away from the supports of school and their friends, and dealing with the fallout of the pandemic, our patients have suffered emotionally. IBH support has been invaluable during this time. 

What advice would you give to other practices interested in or considering implementing IBH?
I would encourage other pediatric practices to incorporate IBH if they are able. Both our clinicians and our patients have been very pleased with how well our program has gone. I would strongly advise getting help from someone who understands the intricacies of setting up an IBH practice for support (i.e. the facilitators at CTC-RI).
Primary Care Pediatric Practices Respond to Mental Health Needs by Providing Integrated Behavioral Health Services
Anchor Pediatrics, Comprehensive Community Action Program and Hasbro Pediatric Primary Care have successfully completed the 2-year Pediatric IBH program. At the July meeting, the Cohort 1 practices shared successes, challenges, and lessons learned. The enormous value of having an Integrated Behavioral Health (IBH) Clinician on staff was a common theme among practices, especially with the increased incidence of behavioral health needs of youth and families during COVID-19. Practices also shared stories of patients benefiting from their IBH Clinician’s care. The meeting concluded with Christina Tortolani, PhD presenting on Eating Disorders.

The Cohort 1 IBH practices will continue to participate and share their sustainability efforts at the quarterly best practice sharing meetings. Practices in Cohort 2 (Coastal Bald Hill Pediatrics, Coastal Waterman Pediatrics, Hasbro Medicine Pediatrics, Northern RI Pediatrics, and Tri-County) will complete the 2-year program in April 2022. The Pediatric Primary Care IBH program is made possible through the generous support of the Rhode Island Foundation/Blue Cross & Blue Shield of RI, Tufts Health Plan, and UnitedHealthcare.
At the August Quarterly IBH Committee meeting, Debra Hurwitz, CTC-RI Executive Director, facilitated a strategic planning discussion using Google’s online collaborative whiteboard technology, Jamboard. We want to continue to capture as many great ideas as possible and over the next couple of weeks, you can continue to add comments to the Jamboard session by clicking on this link. Click here for more information on how to use Jamboard and please feel free to share this link with your colleagues. In addition, Angela Sherwin from Faulkner Consulting Group and Marti Rosenberg, EOHHS, presented findings on a behavioral health study conducted by the Faulkner Consulting Group for Rhode Island.

The NCQA Behavioral Health Distinction and Tele-IBH Learning Collaborative will meet on September 9, 7:30-9:00am.
At the July CTC-RI / PCMH Kids Practice Reporting / Transformation meeting, Mark Olson from DataStat reviewed the process and timeline for fielding the CAHPS Survey. The following CAHPS information is available:

In addition, practices shared their latest Quality Improvement plans. Plans included improving Adolescent Well-Child visits, Lead Screenings, Asthma, transitioning Adolescents to Adult Care, Mental Health and Huddles.

Next Practice Reporting / Transformation meeting is scheduled for November 24, 2021, 8:00-9:30AM.
American Academy of Pediatrics RI Recommends Universal Masking In Schools
The American Academy of Pediatrics - RI Chapter is advocating for a universal school mask mandate throughout Rhode Island as students get ready to return to school.

The organization recently sent a letter to all Rhode Island school districts, as well as Governor Dan McKee, recommending universal masking in schools, regardless of vaccination status.

"Rhode Island successfully completed last school year with low COVID-19 transmission rates in schools thanks to a layering of several mitigation strategies which included masking, social distancing, improving ventilation, a robust K-12 testing system, and a vaccine distribution program that prioritized educators and students as soon was feasible in the statewide rollout. As rewards for this collective hard work we all had hopes that the pandemic would be in the rear view mirror by now. However, given the exponential rise in COVID-19 infection rates across our state and nation, both the American Academy of Pediatrics and Centers for Disease Control released statements recommending universal masking in school settings for everyone age 2 and up, in addition to other noted infection control measures, as the best policy to ensure that in-person return to school can be as safe as possible for all children," AAPRI states. Read the full letter here.
At the July Nurse Care Manager / Care Coordinator Best Practice Sharing meeting, Nwando OFokansi, project officer with RIDOH’s Health Equity Zones Initiative, guided the group through an interactive discussion on useful strategies to effectively communicate with others about COVID-19 vaccines. Some resources that Nwando shared with the group are:

Jim Berson from Fio Partners facilitated the strategic planning discussion using Google’s online collaborative whiteboard technology, Jamboard. We want to continue to capture as many great ideas as possible and over the next couple of weeks, you can continue to add comments to the Jamboard session by clicking on this link. Click here for more information on how to use Jamboard. Please feel free to share this link with your colleagues.
State Policy Updates:

Governor Mandates Vaccines for Healthcare Workers
COVID-19 transmission continues to climb back up in Rhode Island, with the state being labeled as "high transmission" according to the CDC's latest transmission measures. Governor McKee has announced that all health-care workers in all state-licensed health facilities will be required to be vaccinated by Oct. 1 (including hospitals, nursing homes, group homes, congregate-care entities and other centers and programs). Until Oct. 1, all heath-care workers at public and private facilities who are not fully vaccinated will be required to wear surgical masks at work, and will have to be tested at least twice a week. Read more here.

Governor Signs Law to Boost Use of Electronic Medical Records
Legislation sponsored by Rep. Susan R. Donovan and Senate Health and Human Services Committee Chairman Joshua Miller was signed into law on August 17 by Governor McKee to better protect patients’ health by making the electronic sharing of health records more effective. The legislation (2021-H 6210A2021-S 0495A) makes the state’s health information exchange (CurrentCare) an “opt-out” system rather than one that requires every patient to take action in order to participate. Until now, Rhode Islanders have had to opt in to CurrentCare to have their medical records made available electronically and accessible by all their health care providers, and only about half of Rhode Islanders have done so. Among the advantages of participation in the health information exchange are the availability of medical records in emergencies, the ability of prescribers to check medications prescribed by others to protect against dangerous interactions, the swift availability of test results to all providers involved in a patient’s care, and the ability to look back at patient’s medical history without the patient or provider having to make requests to other offices for information.
Photo courtesy Legislative Press & Public Information Bureau: Sen. Miller, left with bill, and Rep. Donovan, right with bill, join Gov. Daniel McKee after signature. Other advocates included Noah Benedict, RIPCPC (CTC-RI board member), Andrew Saal, PCPC (CTC-RI Clinical Strategy Committee co-chair), Neil Sarkar, RIQI (CTC-RI Clinical Strategy Committee member), along with other legislators and RIQI members.
COVID-19 State Transmission and Vaccination Update
COVID-19 transmission continues to climb back up in Rhode Island, with the state being labeled as "high transmission" according to the CDC's latest transmission measures. Access the most recent transmission and vaccine data here.
Please register to join us for the September 10 Breakfast of Champions with the following agenda:

Improving Maternal Child Care: Addressing Health Disparities in Prenatal Care
Moderator: Patricia Flanagan, MD, Hasbro Children’s Hospital, & Brown Univ. Pediatrics Professor

.......Addressing Prenatal Health Disparities - State Updates:
  • RI Data: Rhode Island Department of Health
  • Doula Services: Quatia "Q" Osorio, BSBA CCHW, CLC, MCHS CPE MCHW, Doula, Founder of Our Journ3i, and past member of the Women’s Health Council Planning Committee
  • RI MomsPRN: Jim Beasley, MPA, RIDOH Program Manager, RI Maternal Psychiatry Resource Network Program

.......Addressing Prenatal Health Disparities - Health Plan Initiatives:
  • Blue Cross & Blue Shield of Rhode Island: Matthew Collins, MD, MBA, Executive Vice President, Clinical Affairs and Chief Medical Officer
  • Neighborhood Health Plan of Rhode Island: Christopher Ottiano, MD, Interim Medical Director and Yvonne Heredia, PhD, MS, Senior Manager
  • Tufts Health Plan: Claire Levesque, MD, Chief Medical Officer, Commercial Products and Michelle Wolfsberg, MPH, BSN, Director Clinical Strategic Initiatives
  • UnitedHealthcare: Barry Fabius, MD, CMO and Sarah Coutu, BSN, RN, CCM, MNN, Health Services Director

We’ve moved these meetings back to an Eventbrite registration, so please use this link to register.
CME credit available.
On August 18, the Telehealth Learning Collaborative, ‘Using Technology to Improve Care for Patients with Chronic Conditions’, is coming together for a 3rd learning collaborative meeting. The 21 participating practices will have the opportunity to hear a presentation from Andreina Sanabria, MHA of Tu Salud 24, a Latino-led organization working to address challenges in healthcare equity for Hispanic communities. The Tu Salud 24 presentation and discussion will focus on strategies for providing telehealth services to Spanish- and Portuguese-speaking patients.

After the presentation, some of the practices will share their progress with their learning collaborative projects. Each practice is working on a project that will improve the delivery of telehealth to their patients. A few of the highlighted projects will include: use of apps to monitor and engage children at risk for obesity and diabetes, use of RPM technology to provide real-time data on HTN and other chronic conditions, and partnerships with community organizations to address social determinants of health. Thank you to UnitedHealthcare and authorized CARES Act funds for funding this learning collaborative!
Practice Resources
Larry A. Green Center and Primary Care Collaborative Release Data from National Patient Survey Fielded May 2021
The Larry A. Green Center and Primary Care Collaborative have released national data from its COVID-19 Patient Primary Care Survey fielded May 13-26, 2021. View the executive summary here.

Dermatology for Primary Care Providers Registration is Open!
Up to two thirds of patients with a primary skin complaint present to primary care doctors. Despite this, primary care doctors receive little training in this area. Through case-based discussions, expert faculty will cover a variety of adult and pediatric dermatology related issues commonly encountered in the primary care setting. The aim of this Brown CME course on September 29 is to increase primary health care professionals' skill and confidence with the diagnosis and treatment of the most common skin disorders. Learn more.

Participants Needed: Building Socially Integrated Communities
AARP is launching a free evidence-based pilot program in Rhode Island and Connecticut with the goal of providing those who participate with an opportunity to increase their social integration for themselves and those in their community. Participants will help contribute to building a socially integrated community. Learn more.

Global Summit: Ending Physician Burnout (Live or On-Demand)
Register now for the August 24-26 Global Summit! Participants will come away with core skills needed for burnout prevention, recovery, and optimal well-being, shared by industry experts in 55 live interactive sessions. Participants will also receive an industry-tested roadmap and strategies for positive organizational change from the thought leaders in healthcare provider well-being also available to attendees after the event on-demand, and networking/connection with a community of thousands of colleagues and leaders around the world working to end burnout.
Job Opportunities
Rhode Island COVID-19 Response
There’s still work to be done to crush COVID and there are several job openings available today!
August and September CTC-RI Committee Meetings and Workgroups
  • August 20, 07:30-09:00AM – Clinical Strategy Committee
  • August 26, 03:00-04:30PM – SBIRT/CHT Executive Committee
  • August 27, 07:30-08:45AM – Board of Directors
  • September 10, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • September 16, 03:00-04:30PM – SBIRT/CHT Executive Committee
  • September 17, 07:30-09:00AM – Clinical Strategy Committee
  • September 21, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • September 24, 07:30-08:45AM – Board of Directors
September CTC-RI Program and Initiative Meetings
  • September 15, 08:30-09:30AM – RIDOH CHT Expansion Best Practice
  • September 29, 08:00-10:00AM – CCE Best Practices Sharing Meeting
Upcoming Learning Collaboratives and Professional Development
  • September 02, 07:30-08:00AM – Virtual Coffee Break with Dr Pat Flanagan & Dr Beth Lange
  • September 09, 07:30-09:00AM – CTC-RI Tele-IBH/NCQA BH Distinction Learning Collaborative Meeting
  • September 10, 07:30-08:00AM – Quarterly CTC-RI Breakfast of Champions