December 2, 2015  
Care Transformation Collaborative of Rhode Island
CTC in the News 

NCQA Corner: Performance Improvement and Lean Training 
Patient Centered Medical Home practices, as identified in NCQA Standard 6, use performance data to identify opportunities for improvement and act to improve clinical quality, efficiency and patient 
experience. CTC practices recently participated in Lean Training Workshops and were introduced to a set of
performance  improvement tools to help practices think about how to: 

 - Improve what we do so it is      better for our patients and        better for our colleagues; 

 - Lead, enable and develop        people to continue to improve    care for patients now and in      the future and; 

 - Develop a culture of                  continuous improvement. 


Practices participating in the Lean Training Workshops have been asked to apply what they learned in the workshop to their practice setting and work with the practice improvement team to select, develop and

implement an A-3 plan with a recommended focus of emergency room reduction improvement. 

Bryan Liese, BA, will be offering two webinars to assist practices with project c ompletion. The first webinar is scheduled for Wednesday 12/9/15 from 12:00 to 1:00 pm (call in 508- 856 8222 participant code 4614).
RIQI Launches CurrentCare Knowledge Center  For Practices Using CurrentCare - and Those Who Want to Get Started!
The Rhode Island Quality 
Institute has created a great ne w resource called the CurrentCare  Knowledge Center for practices  who are using CurrentCare services. Please take a look to learn how to integrate CurrentCare patient Enrollment, Hospital Alerts and Viewer into your workflows and maximize value for your patients and staff.   Click here to visit the Knowledge Center. 

Meaningful Use got you down? 
Join RIQI for a peer-to-peer education session for Medicaid Practices
RIQI's Regional Extension Center experts, Sue Dettling and Suzette Santos, will provide an overview at this in-person event about Meaningful Use changes for 2016 and what it means for your practice. You'll have an opportunity to discuss how to incorporate these measures into your workflow and how to calculate patient volume. You may also ask questions about registration for the RI EHR Incentive Program.
Wednesday, December 9, 2015
50 Holden St., Suite 300, Providence, RI 02908
5:30 - 5:45 pm - Enjoy networking and light snacks
5:45 - 7 pm - Program
Space is limited! Please register on or before 12/7.
CTC Quarterly Practice
Champion Learning Session
CTC will be hosting the
second quarterly Practice Champion Learning Session
on December 11, 2015 from 7:30am to 9:30 am at the Shriners Imperial Room One Rhodes Place Cranston Rhode Island.

Provider champions are required to attend. Learn more and register here
Upcoming Meetings:
December 8, 2015 
8:00 -11:30AM
Nurse Care Manager Best Practice Sharing and Practice Reporting (RIQI)
*Practice Reporting on 12/22/15 is cancelled

December 9, 2015 
12:00 -1:00pm
Lean Training Webinar-Follow up for Lean Training Participants
(Conference Call 508-856-8666 Passcode: 4614)
December 11, 2015 
7:30 - 9:30AM
Mandatory Clinical Practice Champion Quarterly Learning Session (RI Shriners Imperial Room)
December 14, 2015
2:30 - 5:30PM
CTC Strategic Planning Meeting for Board of Directors (TBD) 
December 17, 2015 
7:30 - 9:00AM 
Practice Transformation (HealthCentric Advisors)
December 18, 2015 
7:30 - 9:30AM
CTC Clinical Strategy and Cost Committee (Thundermist, Warwick) 
December 21, 2015 
7:00 - 8:30AM 
South County Steering Committee (South County Hospital) 
December 22, 2015 
7:30 - 9:00AM
Contracting Committee (RIQI)
December 28, 2015 
9:00 - 10:30AM
CTC Program Evaluation Committee (RIQI) 

For meeting details or to receive a calendar invite please contact:
Michele Brown
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.
Care Transformation Collaborative of Rhode Island Wins $600,000 Grant to Integrate Behavioral Health into R.I. Primary Care
CTC is excited to announce the receipt of a $600,000 grant from the Rhode Island Foundation's Fund for a Healthy Rhode Island to expand efforts to integrate behavioral health into the primary care setting.
The grant will fund a pilot program that places a behavioral health clinician onto the primary care teams in up to 16 CTC practices throughout the state. Through this effort, CTC will work to identify more patients with behavioral health and substance-use disorders, increasing services to patients with moderate depression, anxiety, substance-use disorders and co-occurring chronic conditions; and reducing emergency room visits by providing care coordination and intervention for high-risk patients.

Read more here
Neil Steinberg, President and CEO of the Rhode Island Foundation,  announcing the Fund for a Healthy Rhode Island Grant recipients on December 1, 2015. 
CTC Hosts 2015 Learning Collaborative 
On November 12,  CTC brought together national and local health care experts at the 2015 Annual Learning Collaborative, "Primary Care: Paving the Way." Discussions revolved around patient engagement and empowerment , high risk patient identification and shared decision making.  A patient-focused approach to care, an integral component of CTC's practices, can improve patient adherence to treatment recommendations, and emerging evidence shows it can improve health outcomes.

View the presentations and resource materials from the 2015 Learning Collaborative here
Nilay Shah, PhD Consultant Division of Health Care, Policy and Research, Mayo Clinic presents at the 2015 Learning Collaborative. 
Best Practice Sharing Corner: Care Coordination
The CTC Annual Learning Collaborative on November 12, featured two "best practice" speakers that presented on work being done to improve care coordination for complex patients. Eleni Carr, MBA,
LICSW, Director of Care Integration at Cambridge Health Alliance (CHA) discussed work that CHA has done over the last four years to build a complex care management program. Her  presentation
provided a framework for the identification of high risk patients 
(Triage Tool), and  performing patient assessment  and care plan development ( Humbolt tool) .

Hannah Rosenberg,  MSc, Program Coordinator Boston Children's Hospital, provided insight into the framework used for engaging children/adolescents/families in care plan development . CTC practices providing care for children, adolescents and adults are striving to strengthen  our care coordination programs and benefited from learning about "best practices" in other areas of the  region.
CTC Welcomes Two New Board Members
The CTC Board of Directors elected and welcomed two new board members at the October 23, 2015 Board meeting. 

Tina Spears is the Government Relations Director for Rhode Island Parent Information Network and has previously worked at RIPIN as the Public Policy Manager. Tina has been actively involved in the PCMH-Kids initiative. Having Tina Spears on the Board of Directors is an important addition as she will help represent the consumer voice.

Puneet Sud MD is the President and owner of Internal Medicine Partners, Inc. and Medical Director of IPA Prospect Medical Group. He has additionally been a Clinical Instructor of Medicine at Boston University School of Medicine from 2005-2014. Internal Medicine Partners joined CTC in 2013 and is presently at Performance Year 1 in the CTC developmental contract. Having Dr. Sud on the Board of Directors is an important addition as he will help to represent the voice of the smaller practice.
Health Plan Proposal on Final Performance Reconciliation Payment for Current Performance Year 2 Sites
There are currently 23 CTC practice sites that are in Performance Year 2 (PY2), the final year of the CTC  Developmental Contract. In July 2015, based on performance in PY 1, practices in PY 2 received performance incentives per the 2014-2015 Performance Standards. As of 06/30/2016, contracts between the health plans and the PY 2 practices will end. CTC Contract Committee has determined that practices in PY 2 will have the option of obtaining additional incentive payment if the practice did not receive the maximum incentive for quality, customer experience and/or utilization in July 2015 based on meeting performance improvement targets set for 2015-2016. This will be a one-time payment of 12-months' worth of these PMPM performance incentives, based upon the most recent attribution for a practices panel.

  • In July, 2015 Practice A moves into PY 2 and achieved success for meeting clinical quality measure as it met 4 out of 6 quality measures in contract year ending 6/30/15 but did not receive the full payment for which it was eligible because it did not meet 6 out of 6 of the quality measures. Practice A then achieves success in meeting 6 out of 6 quality measures based on 2015-2016 targets in the contract year ending 06/30/16. Practice A will be paid a final one time performance reconciliation PMPM payment ($0.25) based on attribution times twelve months.
  • Practice B achieves top level of success for payment on clinical quality measures (6 of 6 thresholds) in contract year ending 06/30/15. Practice B then achieves success for payment on clinical quality measures in contract year ending 06/30/16. Practice B will not be paid final performance reconciliation payment.
  • Practice C is in the Performance Year II measurement cohort, which did not achieve success for utilization metrics in contract year ending 06/30/15. The Performance year II cohort then achieves success for Inpatient or ED use metrics, during the 06/30/16 contract year. Practice D (in addition to the rest of the cohort) will then be paid final performance reconciliation payment for the PMPM incentive associated with these metrics.
Practice Reporting Committee Refines Quality Measurement Specifications
The Data and Evaluation Committee has approved the Quality Measurement Specification document to clarify the reporting timeframes and definition of active patient. The document will be updated again to reflect ICD-10 codes when HEDIS updates (that incorporate ICD-10 codes) are released.
Sue Dettling, Relationship Manager with Rhode Island Quality Institute, developed a project management tool on the clinical quality measures to assist practices with implementing and interpreting these measures.
OHIC Update on RI 2016 Care Transformation Plan
The RI Office of Health Insurance Commissioner (OHIC) has recently issued draft documents that provide additional detail to the Rhode Island 2016 Care Transformation Plan . Under the definition of  a Rhode Island Patient Centered Medical Home, a primary care practice will be considered a PCMH as  long as the practice is participating in a formal transformation initiative and/or has attained NCQA recognition  (level 3). In addition, by the end of the first year, the practice must meet the cost containment strategy 
implementation  requirements , and  by the end of the second year, following a 6-month claim run-out, the practice demonstrates meaningful  performance improvement (definition is under consideration). 

OHIC has outlined a crosswalk of Rhode Island PCMH Cost Containment Strategies to the NCQA PCMH Standards. This draft document provides information on which cost  containment requirements will be eligible for deemed status if the practice has obtained NCQA PCMH  Level 3 designation. 

document provides a framework for OHIC activities, OHIC requirements  and a comment section that identifies payer and practice expectations around payment

Practices are welcome to submit comments on these draft documents to Deb Hurwitz ([email protected]) or Pano Yeracaris ([email protected]) who are both members of 
the Care Transformation Advisory Committee.
Quality Behavioral Health Provider Portal and Compact Information
Quality Behavioral Health (QBH) has developed a safe and secure method for CTC members to refer patients for behavioral health services.

Conveniently located in Warwick, QBH is now positioned to receive
referrals through an easy-to-use portal located on the company
website. Each participating provider group will have its own secure
account accessible through a customized client dashboard. Upon 
registering you will receive (within 24 hours) a user name and password, enabling members of your staff to refer patients for appointments.

With a large staff of Board Certified Child, Adolescent, and Adult
Psychiatrists, two Developmental Pediatricians, prescribing Nurse
Practitioners, Clinical Psychologists, Licensed Mental Health Counselors, and Social Workers, QBH can now provide behavioral health services to your patients in an even more efficient way.

To initiate a referral simply go to the company website,, and click on Provider Portal. Instructions are available on the site. After receipt of the referral your patient will be contacted within 24 hours and you will receive notification of the contact and details of the appointment.

Quality Behavioral Health has also developed a Collaborative
Care Management Program which describes behavioral health
services available to CTC membership. The compact outlines the mutual responsibilities and expectations of each party and
establishes a protocol for the development of a plan of care and the communication of essential information.

To receive more information about QBH/CTC compacts and to enlist in the program please contact: 

Stan Galek,  Quality Behavioral Health
75 Lambert Warwick, RI 02886 
Phone:  401-681-4274