January 2016 
Care Transformation Collaborative of Rhode Island
CTC in the News 
Upcoming Events: 
Saturday, January 30, 2016
Learn more and register
Upcoming Meetings:
February 2, 2016 7:30-9:00AM
CTC-RI Data and Evaluation Committee (Memorial Hospital Center)
February 9, 2016 8:00-9:30AM
CTC-RI NCM Best Practice Sharing (RIQI)
February 11, 2016 7:30-9:00AM (RIQI)
Integrated Behavioral Health Committee (RIQI)
February 12, 2016 9:30-10:30AM
CTC-RI Community Health Team Planning Call (HealthCentric Advisors)
February 18, 2016 7:30-9:00AM
CTC-RI Practice Transformation (RIQI)
February 19, 2016 7:30-9:30AM
CTC-RI Clinical Strategy and Cost Committee (Thundermist-Warwick)
February 22, 2016 9:00-10:30AM
CTC-RI Program Evaluation Committee (RIQI)
February 23, 2016 7:30-9:00AM
CTC-RI Contracting Committee (RIQI)
February 23, 2016 8:00-9:00AM
CTC-RI Practice Reporting (RIQI)

February 24, 2016 8:00 AM-4:00 PM, 
(Rhode Island Shriner's Imperial Room, 1 Rhodes Place, Cranston)
February 26, 2016 7:30-9:00AM
CTC-RI Board of Directors (HealthCentric Advisors)
February 26, 2016 7:00-8:30AM
CTC-RI Community Health Team Planning (HealthCentric Advisors)

Save the Date:
March 11, 2016 7:30-9:00AM
Clinical Practice Champion Quarterly Learning
(Rhode Island Shriners Imperial Room, 1 Rhodes Place-Cranston, RI)

For meeting details or to receive a calendar invite please contact:
Michele Brown
Welcome to the Care Transformation Collaborative of Rhode Island Newsletter, where CTC shares exciting updates, news, milestones, meeting information and more.
CTC Launches the Integrated Behavioral Health Pilot Program
CTC is excited to announce the official launch of the Integrated Behavioral Health Pilot Program. This pilot program, made possible through funding from the Rhode Island Foundation and Tufts Health Plan, will work to improve patient screening for depression, anxiety and substance use disorder  (SUD), access to on-site behavioral health care, and improve care coordination for  patients with high emergency department usage and severe mental illness. 

Practices that will lead the way in Cohort 1 are: 
  • Associates in Primary Care
  • East Bay Community Action Program (Newport and East Providence)
  • Providence Community Health Center-Chafee
  • Tri-Town Community Action
  •  Women's Medicine Collaborate. 
Practices that will join the pilot program in November 2016 as Cohort 2 are: 
  • Affinity-Family Medicine at Women's Care
  • Coastal Medical-Hillside Family Medicine
  • Memorial Hospital of RI- Family Care Center
  • Providence Community Health Center (Capitol Hill and Prairie Avenue Sites)
  • University Medicine-Governor Street 
  • Wood River Health Services
Throughout the pilot program, CTC  will work with RI health plans and evaluation team to evaluate results which are anticipated to  build a case for a sustainable primary care integrated behavioral health care delivery system.  A recent report released by the RI Department of Health "2015 Statewide Health Inventory Utilization and Capacity Study"  highlights the need for action. The report  concludes that there is presently limited integration between primary care and behavioral  health. A key priority in this report is to increase health parity through improving access to psychiatry and psychology care for Medicare  and Medicaid patients.  
Best Practice Sharing: Southcoast Health's Transition in Care Program
Janice Romagnolo, VP Post-Acute Care Services at Southcoast Health,  presented  at the January Nurse Care Manager meeting about the key features of Southcoast Health's care  manager system. Her presentation highlighted best practices including the use of PING for alert notification, identification of high risk patients using a  modified Cambridge Alliance Risk Identification tool, standardization of work flow and care conference  rounding to assist with problem solving difficult cases and panel review. 

Working with post-acute and skilled nursing facilities (SNF) when patients are transitioning back home is a key function under the draft OHIC guidelines. CTC recently shared tools that primary  care practices can use when working with post-acute and SNF, including a draft compact, a  General Assessment of Preparedness (GAP) , and the patient PASS
Rhode Island Achieves Top Ranked Status In Commonwealth Fund Scorecard
The Commonwealth Fund recently released the 2015 " Aiming Higher: Results from a Scorecard on State Health System Performance ." In this report states are measured on 42 indicators  grouped into 5 dimensions: access and affordability, prevention and treatment, avoidable  hospital use and cost, and healthy lives. 

RI ranked 5th in overall performance ratings (moving up from 9th in 2014) demonstrating improvement in 14 indicators and decreased performance in 3 indicators. RI  was highlighted for greatest improvement in the  ability to get and afford health care when you need it. Check out the Common Wealth Fund's Scorecard to see more highlights and how RI ranked in the other 4 dimensions 
Practice Transformation Committee Kicks Off Joint PCMH-Kids and CTC Practice Meeting
On January 1, 2016, nine primary care practices engaged in a common contract with the health plans of Rhode Island to extend the transformation of primary care to practices serving children. Until this time, the efforts of transformation within CTC-RI have been focused on the adult population. These nine practices, as PCMH-Kids pilot sites, will transform into high-quality patient centered homes through strategies specific to a pediatric population. PCMH-Kids will be integrated into the existing CTC-RI committee structure to take a lifespan approach to learning and best practice sharing across practice settings. January 21st, marked the first of such integrated meetings in the Practice Transformation Committee. Attendees walked through the PCMH-Kids Common Contract, highlighting similarities and differences between the CTC-RI Developmental Contract, as well as the OHIC Care Transformation Plan definition of a PCMH. Practices discussed struggles with and shared tips and tools for how to begin the work of transformation. While, PCMH-Kids has defined many key differences in implementing PCMH for a pediatric population, there are also many common themes which they hope to be able to share and learn with CTC practices.

The Rhode Island Quality Institute (RIQI) was recently awarded a four-year, $8.3M grant -
Transforming Clinical Practices Initiative (TCPI) - to provide technical assistance to help equip clinicians in Rhode Island  with tools, information, and network support needed to improve quality of care, increase patients'  access to information, and spend health care dollars more wisely. As a Practice Transformation  Network, RIQI will support 1,500 clinicians to expand their quality improvement capacity, learn from one  another, and achieve common goals of improved care, better health, and reduced cost. The TCPI  program is open to all providers, including specialists, as long as they are not already participating in a  federal Shared Savings Program (MSSP, MAPCP, CPCI, Pioneer ACO), or with another Practice  Transformation Network. If practices are interested in learning more about receiving free service and support 
through the TCPI initiative, please email us at [email protected] and we will contact you shortly. 

Read the press release  here.

Changes with Cedar Family Centers and Medicaid Direct Services for Children
The Executive Office of Health and Human Services (EOHHS) certified five Cedar Family Centers certification effective on Jan 1, 2016: 
Cedar Family Centers are the state designated Health Home for children and youth with special health care needs. Cedar Family Centers employ a multidisciplinary team including licensed clinicians and parent resource specialists to coordinate care for children and their families, including an assessment of current needs and connection to resources and services. Cedar Family Centers and PCMH-Kids Pilot Practices are making concerted efforts to improve collaboration and comanagement of shared patients, exploring options such as colocation and regular case conferencing models. 
Additionally, several Medicaid direct services have moved into the RIte Care plans through Neighborhood Health Plan and United Community Health Plan.  Home Based Therapeutic Services (HBTS), Personal Assistance Services and Supports (PASS), and Respite can now be accessed directly or by calling the health plan. A link to information on these services so that providers may make an informed referral can be found here. If a family is unsure of what services will meet their needs, they can be directed to a Cedar Family Center for assistance with care coordination.
Rhode Island Office of the Health Insurance Commission Paves the Way for Implementing Updated Rhode Island Affordability Standards 
Rhode Island's Office of the Health Insurance Commissioner (OHIC) has led a variety of  initiatives to reform the health care delivery and payment system. As part of its mission to  improve the affordability of health insurance for consumers and employers.  O HIC first  implemented its Affordability Standards in 2010, which focused on increasing primary care  spending, accelerating patient-centered medical home efforts and reducing the rate of hospital cost increase s

In February 2015, after an intensive stakeholder process to solicit recommendations  and comments, OHIC updated its Affordability Standards in order to recognize current  developments in the health care sector. The revised Affordability Standards focus on the practice  transformation (including Patient-Centered Medical Home adoption) and driving health care  payment practices toward value-based models. OHIC continues to work with stakeholders and  other health care reform efforts in the state. Through these collaborations, which include the  State Innovation Model Grant and Reinventing Medicaid, OHIC aims to drive the system toward  value, composed of efficiency and quality, inclusive of clinical-best practices, safety, and patient  satisfaction. 

To assist in this work, OHIC has convened two committees: Care Transformation Advisory Committee and the Alternative Payment Methodology Advisory Committee. These two Committees have been convened twice, once in Spring 2015 to develop the 2016 Care Transformation and Alternative Payment Methodology Plans and once in Fall 2015 to develop the 2017 plans. Currently, the  2017 plans, along with stakeholder feedback, are being reviewed by the Commissioner. OHIC  anticipates working with committee members on implementation of the plans throughout 2016  and will reconvene the two committees in the Fall to discuss activities and targets for 2018.
Rhode Island Business Group on Health Receives $50,000 Grant from the Rhode Island Foundation To Launch Choosing Wisely - RI
The  Rhode Island Business Group on Health (RIBGH) has received a $50,000 grant from the Rhode Island Foundation to roll-out the Choosing Wisely - RI campaign to reduce waste in the state's healthcare delivery system.  The Choosing Wisely campaign will encourage physicians, patients and other health care stakeholders to think and talk about the overuse of health care resources in the United States.The campaign was created by the American Board of Internal Medicine Foundation (ABIMF)  and Consumer Reports

Through Choosing Wisely, RIBGH will give consumers, providers, and employers in Rhode Island access to a national learning network of communities and organizations that are launching campaigns to reduce waste. Plans call for the creation of a free micro-website for Rhode Island organizations. 

Nationally, the program partners with over 70 physician specialty societies and is endorsed by many organizations ranging from AARP to the Institute for Clinical Systems Improvement. Locally, 
Amica Insurance and Brown University have already adopted Choosing Wisely for their employees and families.
CTC of Rhode Island
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Providence, RI 02908