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

Blue Cross & Blue Shield of Rhode Island Distributes Advanced Primary Care Program Policies
Blue Cross & Blue Shield of Rhode Island recently disseminated updated program policies to all contracted provider groups participating in Patient Centered Medical Home (PCMH) and/or System of Care (SOC) arrangements.  The policies, effective January 1, 2016,  highlight areas of practice transformation activities including, but not limited to, achievement of NCQA PCMH recognition, Nurse Care Manager (NCM) roles and responsibilities, practice reporting requirements, and access to care.

Any questions related to the program policies can be directed to your PCMH Practice Facilitator and/or 
CTC practices highlighted in the new CurrentCare Knowledge Center!
Learn how your CTC peers are integrating CurrentCare patient Enrollment, Hospital Alerts and Viewer into their workflows and maximizing value for patients and staff by visiting   the CurrentCare Knowledge Center

CurrentCare Knowledge Center highlights:

- Discharge CoCs - Have you heard about the *New* Discharge Continuity of Care (CoC) documents from Lifespan Hospitals (RIH, Hasbro, Miriam & Newport)?


- My CurrentCare Story - staff from different roles and healthcare settings have shared some great stories in their own words ... check out all the CTC practices!


PCMH Job Opening
Associates in Primary Care Medicine, Inc. is looking to hire a Nurse Care Manager. 

Learn more about this position and view the job description here
2016 CDOE Classes
The CDOE Board of Executives  is  now accepting applications  for 2016 CDOE classes. 
Webinar: Reporting CTC Quality Measures 
January 6, 2015 4:00-4:30PM
Practices are invited attend a webinar on the new process for reporting CTC quality measures online on the CTC portal. For more  information 
please contact Marie Sarrasin ( 
Upcoming Meetings:
January 5, 2016 7:30-9:00AM
CTC-RI Data and Evaluation Committee  (Memorial Hospital Center)
January 12, 2016 8:00-9:30AM
CTC-RI NCM Best Practice Sharing (RIQI)
January 12, 2016 5:00-6:30PM
Integrated Behavioral Health Pilot Program Kick Off for Accepted Practices (HealthCentric Advisors)
January 14, 2016 3:00-4:30PM
Integrated Behavioral Health Committee Meeting (RIQI)
January 15, 2016 7:30-9:30AM
CTC-RI Clinical Strategy and Cost Committee (Thundermist-Warwick)
January 18, 2016 7:00-8:30AM
CTC-RI Steering Committee Meeting (South County Hospital)
January 21, 2016 7:30-9:00AM
CTC-RI Practice Transformation
January 22, 2016 7:30-9:00AM
CTC-RI Board of Directors Monthly Meeting (Health Centric Advisors)
January 26, 2016 8:00-9:00AM
CTC-RI Practice Reporting (RIQI)

For meeting details or to receive a calendar invite please contact:
Michele Brown
CTC of Rhode Island
2 35 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 Announces Practices Selected to Participate in the Integrated Behavioral Health Pilot Project
With funds from both the Rhode Island Foundation and Tufts Health Plan CTC is happy to announce the launch of a pilot project designed to provide integrated behavioral health (IBH) services within the primary care setting. 

Project goals include: 
  • Increasing the identification of patients with behavioral health and substance use disorders
  • Increasing patient access to on-site brief behavioral health intervention and provide care coordination for patients with high emergency department utilization 

An evaluation plan is incorporated into the pilot program which will determine the effectiveness of the integrated clinical model in the primary care setting.  Evaluation results will help determine cost savings from emergency department/inpatient usage and how those savings could be incorporated to sustain future IBH efforts in the primary care setting.


The CTC Selection Committee is pleased to announce that they have selected the practices who will participate in the IBH Pilot Project: "Implementation and Evaluation of an Integrated Behavioral Health Model in Primary Care." View the list of pilot practices here.

Practices, with input from the selection committee, identified their cohort start date (Cohort 1: January 1, 2016 or Cohort 2: November 1, 2016).  All selected practices will attend an orientation kick off meeting scheduled for Tuesday 1/12/16 from 5:00 to 6:30 pm at HealthCentric Advisors (235 Promenade Street Providence RI). 

CTC extends its appreciation to the Selection Committee members,
to the Rode Island Foundation and Tufts Health Plan for their generous support of this important effort.

CTC Hosts Quarterly Leadership Training
This month, CTC held a quarterly leadership training meeting to help prepare practices for "next steps"  after they have completed the CTC developmental contract. Pano Yeracaris, Co-Director of CTC,  opened the meeting by offering an overview of CTC key strategies and initiatives . Andrea Galgay, Director of Development RIPCPC provided an  outline of OHIC's Patient Centered Medical Home Standards

Keynote speaker, John Wasson, Professor Emeritus at Dartmouth Medical School and developer of "How's Your  Health" software spoke about how practices could utilize "How's Your Health." The  presentation provided directions for how practices can start using this "no cost" self- administered patient survey and how it could be used for reimbursement for Medicare wellness visit ,
Medicare Chronic Care Management billing, risk stratification and to measure patient experience. The  tool also provides patients with opportunity to create a care plan and obtain educational resources and  motivational coaching.

View the video from this meeting here
(Note: You need a access code to view this video.  Please email Michele Brown at for the access code.)
Courtesy of John Wasson via ConvergenceRI 12/14/2015
Best Practice Spotlight: Associates in Primary Care
At a joint Practice Reporting and Nurse Care Manager meeting, Karen Sciamacco, Nurse Care Manager,  and Jamie Handy, Practice Manager discussed what Associates in Primary Care has done to assist patients who frequently use the Emergency Room .

Associates in Primary Care  holds a monthly ED reduction meeting  to discuss patient needs and practice solutions. The practice also developed patient education materials and the video  featuring Marty Kerzer MD who stressed patient benefits of seeking care first at the practice Another useful tip for practices included inviting the health plan representatives to a monthly  meeting for conducting a joint review of patients that are high risk.  Efforts have been made to increase  patient access and notifying providers of patients who are using the ED so the providers can discuss  patient needs and options during the patient visits. 

Associates in Primary Care is a great example of  what a small practice has done to creatively address issue of ED reduction.

View Karen and Jamie's presentation here
Practice Patient Specific Reporting to Each Health Plan Due February 20, 2016
CTC introduced the Phase 2: High Risk Patient Practice Reporting Specifications for Patient Specific  Reports at the 12/8/15 Nurse Care Manager/Practice Reporting meeting. The patient specific report on  Health Plan referred Complex/High Cost Patients is due to each health plan starting 2/20/16

The report will provide health plans with needed information on practice engagement with complex /high cost patients. Practices in Transition, Performance Year 1, Performance Year 2 and Advanced  Collaborative are required to provide patient specific reports on all health plan referred Complex/High Cost  Patients for all payers. Startup practices by virtue of the Blue Cross Blue Shield of Rhode Island  Program Policies are required to provide patient engagement reports on BCBSRI high risk patients  effective 2/20/16.
RI Office of the Health Insurance Commissioner Requests Comments on Revised Documents
RI Office of the Health Insurance Commissioner (OHIC), together with the Practice Transformation Advisory Council, have made some additional revisions to their working documents and are requesting feedback.  View the edited documents here  

Please send feedback to by 12/29/15. 
Performance Improvement Using Lean Training Tools
Practices that participated in Lean Training are reminded that A-3 Plans are to be submitted to Candice Brown

Practices may choose any practice process that is of concern and needs improvement but it is recommended that practices consider selecting an Emergency Room reduction improvement plan based on OHIC draft Cost Reduction requirements: "Practices use data to implement care management focus on high risk patients and interventions that impact ED and Inpatient Utilization"

Bryan Liese, will host a second webinar on 1/13/16 from 12-1pm (1 508-856-8222 participant code 4614).  During this session, practices will have a opportunity to discuss their Lean Training projects and obtain additional consultation.