August 2015  
Care Transformation Collaborative of Rhode Island
Mandatory Clinical Practice Champion Quarterly Learning Session
Friday September 11, 2015, 7:30am-9:30am
Crowne Plaza Hotel Warwick
ALL physician champions from all CTC practice sites are required to attend.

T opics will include: 
- Current direction for primary      care and what it means for you  and CTC
- Advanced learning on high risk    identification and engagement
- Additional highlights from the    Advanced Collaborative work in  the Clinical Strategy and  Cost  Committee
NCQA Corner: Getting Ready for 2014 PCMH Recognition
A number of CTC primary care practices are in the process or have submitted NCQA patient centered medical home applications under the 2014 standards. 

Kathryn Amalfitano (University Medicine)  and Ruth Lorenzo (RIPCPC) shared  their knowledge and experiences with preparing their practices for becoming patient centered medical homes under the 2014 standards at the August Practice Transformation Committee. I n addition to sharing their preparation tools, they  emphasized the need for team involvement, quality improvement and clinical leadership. 

Kathryn  (who is submitting a multi-site application) and Ruth (who has submitted single site applications) have  both offered to speak with practices that want to learn more about getting ready for 2014 NCQA PMCH  recognition. Also, practices may want to look into Bizmed as this website offers 2014 NCQA  resources and tools at no cost.
Save the Date for the CTC Learning Collaborative
The CTC Learning Collaborative "Primary  Care Plus: Paving the Way" will be held on 11/12/15 from 7:30am to 12:30pm at the Renaissance Hotel, Providence RI. 

The Learning Collaborative will feature national and regional speakers  as well as local experts who will focus on key topic areas to assist primary care practices with functioning  successfully in the patient centered medical home and ACO environments. 
Register for the CTC Integrated Behavioral Health Webinar: "Skills Not Pills" September 17, 2015
Plan to register and attend the third Integrated Behavioral Health Webinar: "Skills Not Pills" presented by Nelly Burdette PsyD.  The webinar will be held at Healthcentric Advisors (235 Promenade St., Suite 500, 5th floor) from 7:30 - 9:00am on September 17, in place of the September Practice Transformation Committee. Practices can also participate remotely through Go to Meeting, details to follow. 

CTC would like to extend a special thanks to Tufts Health Plan who provided funding for this learning  opportunity.
Lifespan Healthy Rewards Program 
The Lifespan Healthy Rewards  program for 2015 is coming to a close on Saturday, October 31.  Learn more about how practice staff can assist patients by participating in Lifespan Healthy Rewards, earn up to $300 in incentives, and how  practices  can receive fees for completing patients' forms as well as a follow-up visit fee: Lifespan Healthy Rewards benefits Lifespan employees and their providers!
Webinar Learning Opportunity: Understanding Your Patients Cultural Needs
Blue Cross and Blue Shield of Rhode Island is offering CTC practices the opportunity to complete the  webinar training "Understanding Your Patients' Cultural Needs."  Clinical staff (physicians, nurses, mid- level providers) who complete the learning modules by October 1, 2015 will receive 3 free CME/CEU  credits.

CTC in the News 

ConvergenceRI: "Dr. Fine joins Blackstone Valley Community Health Center" - 8/24/2015

Practice Resources
" Guide for Caregivers" - Rhode Island Executive Office of Health and Human Service 
Upcoming Meetings:
September 1, 2015 7:30-9:00AM 
D ata and Evaluation Committee ( Memorial Hospital Center for Primary Care)

September 8, 2015 8:00-9:00AM
CTC-RI Nurse Care Manager Best Practice Sharing ( RIQI)

September 11, 2015 
CTC-RI Community Health Team Planning Committee  ( RIQI)

September 17, 2015 3:00-4:30PM

September 18, 2015 7:30-9:30AM
CTC-RI Clinical Strategy and Cost Committee (Thundermist, Warwick)

September 21, 2015 7:00-8:30AM
SC Steering (SC Hospital)

September 22, 2015 7:30-9:00AM
CTC-RI Contracting Committee (RIQI)

September 22, 2015 8:00-9:30AM
Practice Reporting  ( RIQI)

September 25, 2015 7:30-9:00AM
Board of Directors Meeting ( BVCHC)

September 25, 2015 9:30-10:30AM
CTC-RI Community Health Team Planning Committee  ( BVCHC)

September 28, 2015 9:00-10:30AM
CTC-RI Program Evaluation Committee ( RIQI) 

For meeting details or to receive a calendar invite please contact:
Nicole Mossey
CTC of Rhode Island

235 Promenade Street

Suite 500, Box 18

Providence, RI 02908

Welcome to the Care Transformation Collaborative of Rhode Island Newsletter, where CTC shares exciting updates, news, milestones, meeting information and more.
CTC Practice Reporting on High Risk Patients: Reports Due 10/15/15
In line with CTC's 2014-2015 strategic priority focused on targeting and effectively treating high-risk patients, practices must report on Nurse Care Manager (NCM activity). 

This past year, a CTC NCM measurement group has been meeting to test a NCM reporting system using a common definition of high risk patients. (Learn more about the accomplishments of the Phase 1 NCM measurement group here.)

Many thanks to the practices and to the Health Plans that have worked together to address barriers and pave the way for other CTC practices to report on NCM activity with high risk patients. 
CTC, together with the health plans, have created a  document  to assist practices with understanding how to access high risk patient lists from the health plan portals. 

CTC  practices that are presently in Transition, Performance Year 1, Performance Year 2 and Advanced Collaborative status will start reporting on NCM activity with high risk patients by 10/15/15.  High risk patient measurement specifications and the reporting template can be found here

The Nurse Care Manager Committee provided input into a revised Nurse Care Manager Job Description that better identifies nurse care manager responsibilities for care coordination with high risk patients. 

Learn more about what Phase 2 for reporting on high risk patients will focus on here.
Assisting Patients with Making Behavior Change: CTC Tests Use of Pro-Change Behavioral Systems, Inc.
Pro-Change Behavior Systems, Inc. is an internationally recognized behavior change company that partners with wellness companies and health care systems to produce award winning programs designed to reduce multiple health risk behaviors and enhance well-being while lowering health care costs and increasing productivity.

CTC is partnering with the Rhode Island Department of Health and Pro-Change Behavioral Systems, Inc. to pilot the use of Pro-Change tools within Community Health Teams, associated CHT primary care practices and selected practices that are part of the RI Chronic Care Collaborative. The project goal is to improve patient engagement and treatment through use of an interactive website application. T he  Pro-Change system provides reporting tools that will be used to assist with evaluating program effectiveness in assisting patients with making behavior change. 

CTC offered the first Pro-Change training session on 8/14/15 for Community Health Team staff and will schedule a second training for primary care practices this fall. Funding for this program has been made available through the RI Department of Health and Tufts Health Plan.
CTC Practice Support Systems: Practice Facilitators and RIQI Relationship Managers
One of the benefits of being part of CTC is having on site support from the practice facilitators and RIQI Relationship Managers who can assist practices with quality improvement, workflows, change management (practice facilitators) using Current Care and reporting (RIQI).

CTC would like to thank Anne Pushee and Aimee Schayer who have worked on the CTC practice facilitation team since 2013 and welcome Chrystal Boza as the new Blue Cross and Blue Shield of RI practice facilitator. Practices can find the current resource assignments  here.
Practice Spotlight: University Internal Medicine
The CTC Committee structure has been used to share "best practices" around developing practice work flows and using the electronic health record system to report on nurse care manager activity with high risk patients. Team members from University Internal Medicine (Yvette Chartier, NCM and Raquel de Cardenas,  Practice IT specialist) presented  at the July Practice Reporting Committee on the work they have done to develop and implement a nurse care manager process and reporting system. 

The practice "flags" high risk patients in the electronic health record so that all team members are now aware when a high risk
patient is interacting with a team member. They believe that this identification and focus on high risk patients has assisted the practice with providing higher quality care and better customer service. UIM is one of the CTC practices that achieved all CTC customer experience targets.
In a step aligned with Governor Gina M. Raimondo's efforts to strengthen the health care system for all Rhode Islanders, Health Insurance Commissioner Kathleen C. Hittner, MD, adopted standards to significantly align health care payment methods with efficiency and quality by setting targets for commercial health care payment reform and for continued investments in the patient centered medical home model. These standards stem from the Affordability Standards implemented in 2010 by the Office of the Health Insurance Commissioner ( OHIC ) to support the agency's mission of improvi ng the affordability of health insurance for consumers and employers. 

Read the full press release and learn more about the new standards here
Call for Participation for the Rhode Island Health Policy Learning Collaborative
Health care is one of the fastest growing and complicated career sectors in Rhode Island.  Changes are taking place every day, sparked by the private sector and government. Where do  you fit in to the health care system in Rhode Island? What would you like to learn, to  make your work more effective, to advance your position in your current organization, or to  take the next step in your career? 

ProvPlan's Health Initiative and nriAHEC are pleased to issue this Call for Participation (CFP) for the first Rhode Island Health Policy Learning Collaborative, focused on recruiting, training, and retaining the next generation of community health leaders. 

At the end of the 9-month program:
  • You will have increased your confidence and skills in 5 or more content areas,
  • You will be a stronger leader,
  • You will have learned more about RI's advocacy community, and had the ability to strengthen personal commitment to community health work, and
  • You'll have a network of peers and experts from whom you can continue to learn and interact

For more information and to apply, please visit the ProvPlan website.

RIQI Receives $2.7 Million Federal Grant to  Improve Care Coordination and Transitions for Long-Term Care Patients  and Caregivers
The Rhode Island Quality Institute (RIQI) has been awarded the Advance Interoperable Health  Information Technology Services to Support Health Information Exchange grant from the Office of the  National Coordinator for Health IT (ONC). The two-year, $2.7 million grant will support the Sharing  Health Information for Transitions in Care (SHIFT in Care) project which will leverage the existing  capabilities of RIQI's CurrentCare and Regional Extension Center (RIREC) to expand the capacity for  statewide exchange of health information. Click here to read the complete article.
CurrentCare Quick Bites 
Top 5 Viewer Tips - Register
Wednesday, September 9, 2015 - 12:15 - 12:30 pm 

If you missed some of the Current Care Quick Bites sessions, tune in to learn about the top 5  favorite Viewer features most often used by practices. You'll learn how these  tips and shortcuts can help you get the information you need without chasing down  results, reordering tests, or waiting for faxes from other providers.

We know you and your staff work really hard - how about a free lunch at Panera?
Contact RIQI to help your practice set up an online enrollment campaign. 

CurrentCare is the No. 1 way to share patient health information quickly and  accurately. And it can save you time and money. It's that simple -- and RIQI is  offering an incentive for you to enroll patients online!

Here's what you need to do:
  • Contact RIQI to learn how to securely submit a patient panel
  • Receive back a list of patients who are not enrolled in CurrentCare
  • Use RIQI's email template, that includes a link to the enrollment form
  • Email the message to your patients who have not enrolled. That's it!
And as a thank-you for your hard work, RIQI will send you a $100 gift card to  Panera Bread so you can treat your staff to a great lunch!

To get started, contact Brian Miller at 401-276-9141 x 286, or drop him an email  at [email protected].