Join the Care Transformation Collaborative of RI for our Annual Conference on Thursday, October 31st, at the Crowne Plaza in Warwick. This year's theme is "Investing in Primary Care & Health Equity."

This year, we're excited to feature Atin Jindal, MD, MS, as the keynote speaker at our Annual Meeting. Dr. Jindal will discuss the role of artificial intelligence (AI) in healthcare and its potential impacts on the field.

Q: What inspired your interest in AI and its applications in healthcare?

Dr. Jindal: I’ve been in the software engineering world for 15 years, and large language models have recently brought AI into the spotlight. We've been using machine learning in medicine for over a decade. We use it to describe data, make predictions, and help prioritize patient care. In my work as a hospitalist, I use AI to improve administrative burden, allowing providers to spend more time with patients, as well as to diagnose and predict decompensation.

Q: How is AI currently being used in the medical research field?

Dr. Jindal: On the research side, we use AI to recognize patterns in vast amounts of data, patterns that are difficult for humans to see. AI is being used in increasingly broad research fields, especially with disease diagnosis using image analysis, drug discovery, clinical trial optimization, and genomic research. But with these new tools come ethical challenges. Most AI techniques rely on massive data sets. Every model has inherent biases because they rely on how data is provided, labeled, and interpreted. Models are a reflection of the biases in our world. For example, using race data to predict kidney failure was recognized as biased only recently.

Q: What ethical challenges do you see with AI in healthcare?

Dr. Jindal: One major concern is bias. Each step in AI—from data collection to application—can perpetuate biases without us realizing it. These biases can be especially difficult to detect due to a significant lack of external, clinical validation. There is a widening gap in the power of private industry over research and government groups. There is very little in terms of legal precedent on how to deal with inaccurate or incomplete responses, privacy, copyright, and accountability. There is also potential for widening of the "digital divide” in healthcare. We need checks to ensure AI tools are ethical and effective.

Q: How can AI affect administrative tasks in healthcare?

Dr. Jindal: AI has the potential to relieve administrative burdens significantly. A lot of provider burnout stems from excessive documentation. I've seen cases where physicians spend up to 80% of their time documenting rather than interacting with patients. Generative AI shows promise in freeing up more time for direct patient care, allowing providers to focus on what they do best.

Q: How do you see the future of AI in healthcare?

Dr. Jindal: Technology is evolving rapidly, and it's hard to predict where we'll end up. Current developments focus on diagnosis, treatment, and communication. AI is a tool that can enhance clinician performance. We know that AI plus clinician is better than clinician alone or AI alone. If we use it thoughtfully, it can change the way healthcare is delivered for the better.

We are thrilled to announce the lineup of exhibitors for this year’s CTC-RI Annual Conference. Plan to come to the event and learn from these incredible organizations who are leading the way in healthcare, community support, and patient advocacy.

• ADVANCE RI-CTR at Brown University
• American Addiction Centers
• American Lung Association in Rhode Island
• Bayer Pharmaceuticals
• Community Health Worker Association of Rhode Island
• Connecting Children and Families
• Conexion Latina
• Docs for Health
• East Bay Community Action Program
• Equip Health
• Family Services of Rhode Island
• Green and Healthy Homes Rhode Island
• Healthcentric Advisors

• Health Helper
• Intend Health
• MLPB
• Ocean State Center for Independent Living 
• Open Door Health
• Parent Support Network of RI (PSNRI)
• Pediatric Psychiatry Resource Network
• RI Department of Health
• RI Parent Information Network
• Sojourner House
• The Autism Project
• UnitedHealthcare
• RI Primary Care Physicians Corporation
• University of Rhode Island RI Geriatric Education Center 

A reminder to healthcare providers applying for Patient-Centered Medical Home (PCMH) recognition: reports are due by Wednesday, October 18th. Practices affiliated with an Accountable Care Organization (ACO) or Accountable Entity (AE) do not need to submit quality measure data or cost management details but must provide basic practice information, NCQA designation, and complete the behavioral health survey. For more details, refer to the email from Health Insurance Commissioner Cory King, sent on August 27th. Additional documentation, including survey links and Excel templates, is available on the OHIC website.

This month, CTC-RI held our quarterly DULCE Learning Collaborative with 31 participants. The four practices—Blackstone Valley Community Health Center, Tri-County, Care New England Family Care Center, and Hasbro—shared their progress. See the slides from this meeting here. 

Michelle Hirst from Children’s Friend discussed how family visiting supports families by providing parenting guidance, health insurance, childcare, and more. She highlighted the partnership between Children’s Friend and Care New England Family Care Center, noting how group sessions help new parents.

CHW/family specialists shared how they support families at the six-month graduation, offering checklists, gift cards, and certificates. Thank you to our funders including Congressional Direct Spend, UnitedHealthcare, RIDOH, EOHHS, and Tufts Health Plan!

CTC-RI Launches Two Workforce Development Efforts: Nurse Care Manager Glearn Core Curriculum Training Program and University of Rhode Island Nursing (URI) Student Primary Care Pilot Program

Care Transformation Collaborative of Rhode Island (CTC-RI) is excited to have accepted five nurse care managers (NCM) into its fall 2024 cohort of Nurse Care Manager/GLearn Training. Throughout the training, the NCMs will complete online modules that were developed by Geisinger Healthcare System to train their nurses in primary care to assume the role of nurse care manager in the patient-centered medical home practice setting. Nurse Care Managers will also meet with Kateri Buerman, RN, BSN, NCM faculty to discuss the course content and apply the modules to their roles as NCMs in adult and pediatric primary care.

Additionally, CTC-RI kicked off its second cohort of URI senior nursing students who are assigned to NCM primary care preceptors and who will participate in Nurse Care Manager/GLearn Training Program with the aim of introducing nursing students to the nurse care manager role in primary care. As part of their clinical experience, nursing students will complete an abbreviated set of GLearn modules and meet bi-weekly with Jayne Daylor RN MS, a CTC-RI NCM faculty. The discussions are focused on helping the students apply the content to their primary care community clinical experience. As part of this experience, students are tasked with completing a home visit and a capstone project.

This pilot was developed with support from Christine McGrane, PhD, RN, CNE, Clinical Assistant Professor, College of Nursing, URI, Dahianna López, PhD, MSN, MPH, RN, Assistant Professor, College of Nursing, and Ginette G. Ferszt PhD, RN, PMHCNS-BC, FAAN, Consultant and Pilot Evaluator and CTC-RI project management staff. Many thanks to our placement sites and preceptors at Aquidneck Pediatrics, The Miriam Hospital and Coastal Medical including Chelsea Sylvaria, Meghan Wood, RN, Jennifer Nappi, and Jamie Ferris RN, CLC.



Funding for this pilot was provided by UnitedHealthcare.

CTC-RI launched the "Delivering Age-Friendly Care" learning collaborative to help practices implement the 4M Model and improve care for older adults and people with dementia. Six practices are joining this six-month quality improvement journey, funded by CTC-RI, RIDOH, and the RI Geriatric Education Center.

The practices will work on achieving Level 1 or 2 Recognition from the Institute for Healthcare Improvement (IHI) while also supporting care partners for patients with dementia. Special thanks to Jenny Knecht-Fredo from Penn State College of Nursing for presenting "What Does Age-Friendly Mean to You?" and to our participating practices:

• Brown Medicine
• University Internal Medicine
• Breakwater Primary Care (Dr. Yamada & Dr. Steinmetz)
• CNE Family Care Center
• PACE-RI

A big thank you to our participating practices, practice facilitators, subject matter experts, and our funders, UnitedHealthcare, RIDOH, and RI Geriatric Education Center, for making the collaboration such a success. We’re excited to see their progress!

In September, CTC-RI held a session of the "Best Practices in Team-Based Care" series focused on "Improved Communication between School Nurses and Pediatrics for Better Management of Students' Medical Conditions." This meeting shared tools to boost collaboration between pediatric practices and school nurses, with an emphasis on care for students with chronic conditions like asthma. Speakers included Dr. Maureen Crotty from Blackstone Valley Pediatrics and Dr. John Butler from Barrington Pediatric Associates. Key topics covered included care coordination, managing chronic conditions, and educational tools and supplies to enhance care coordination, communication, and missed days of school.

Our next Best Practices in Team Based Care session is scheduled for October 15, 8:00-9:00 AM.

Welcome Our New CTC-RI Program Coordinator!

EOHHS announced the release of the Grant Application for the new Ladders to Licensure program. Ladders to Licensure will help to increase the capacity and diversity of the health professional workforce by funding partnerships between healthcare providers, institutions of higher education, and others to support employees in paraprofessional roles to pursue higher education leading to health professional licensure.

CBO Spotlight: Parent Support Network

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're spotlighting the Parent Support Network of Rhode Island (PSNRI), a statewide, family, and peer-run nonprofit serving the behavioral health community since 1993. PSNRI partners with the state, families, individuals, and communities to reduce health disparities and address social factors that affect health. We spoke with Assistant Director Danielle Boucher at PSNRI about their work.

How does your organization uniquely support Rhode Islanders?

PSNRI offers services in community health, and peer recovery, and helps with accessing healthcare, food, housing, trauma treatment, education, employment, and a healthy environment. Our team has over 50 diverse, dual-certified community health worker-peer recovery specialists who provide direct support to children, youth, adults, and their families.

Our staff understand these challenges firsthand and work with individuals and families to identify their strengths and needs, creating personalized care plans to meet their goals. We also assist with transportation, coaching, supervised visitation, and home wellness visits. For adults, we offer ongoing recovery life skills classes and individualized support.

How can partnering with primary care providers strengthen your work?

PSNRI is ready to expand partnerships with primary care providers across Rhode Island. This partnership would help the people we serve gain better access to healthcare. It would also strengthen our referral network, making healthcare more accessible for the children, youth, and families we support.

What would you like the primary care community to know about your organization?

We know primary care providers are at the frontline of healthcare. We can support you by taking referrals to provide home and community-based health education, care coordination, and family and peer support. This includes helping children in early intervention, special education, behavioral health treatment, child welfare, and the justice system. We also work with pregnant women with substance exposure and offer rapid response peer support for emergencies, including behavioral health and housing crises. We prioritize serving the Medicaid population.

Please contact our warm line at 401-467-6855 or visit us at www.psnri.org.

Upcoming CTC-RI Committee Meetings and Workgroups

• September 20, 07:30-09:00AM – Clinical Strategy Committee
• September 27, 07:30-08:45AM – Board of Directors
• October 09, 08:00-09:00AM – Primary Care Workforce Taskforce
• October 18, 07:30-09:00AM – Clinical Strategy Committee
• October 25, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

• September 20, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
• September 25, 07:30-08:30AM – ECHO: Best Practices in Addressing Sexually Transmitted Infections in Primary Care
• September 26, 07:30-08:30AM – Pediatric Sleep ECHO series
• October 02, 07:30-08:30AM – PCP/Specialist Monthly Oversight Meeting
• October 15, 08:00-09:00AM – Best Practices in Team-Based Care
• October 15, 12:00-01:00PM – MomsPRN ECHO Series
• October 18, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
• October 22, 07:30-08:30AM – Transition of Care Learning Collaborative
• October 23, 07:30-08:30AM – ECHO: Best Practices in Addressing Sexually Transmitted Infections in Primary Care
• October 24, 07:30-08:30AM – Pediatric Sleep ECHO series
• October 29, 07:30-09:00AM – Diabetes/CKD Pharmacy project Learning Collaborative
• October 31, 07:00-03:30PM – CTC-RI Annual Conference: "Investing in Primary Care & Health Equity"