On October 31, CTC-RI held our annual conference, “Investing in Primary Care and Health Equity," which brought together over 300 attendees from across the healthcare landscape.

The event featured 13 engaging sessions on a range of critical topics, including LGBTQIA+ health, innovations in integrated behavioral health, and building trusted relationships within healthcare. These discussions fostered valuable learning, collaboration, and innovation, reinforcing our collective commitment to improving health equity and access to high-quality primary care for all. This year's conference was further strengthened by the support of 36 exhibition tables, showcasing a diverse range of partners and resources. We were proud to welcome representatives from the U.S. Department of Health and Human Services Region 1, the Rhode Island Department of Health (RIDOH), and many community-based organizations. 

The day was filled with inspiring conversations as attendees explored fresh solutions, shared best practices, and gained insights into the future of primary care in Rhode Island and beyond. We would like to extend our deepest gratitude to all our speakers, exhibitors, sponsors, and attendees for making this conference a truly memorable experience. Check out the presentations, resources, and programs here. We look forward to continuing these important conversations and collaborations.

The October CTC-RI Board of Directors annual meeting marked a change in officers and confirmation of our stellar 2024-25 slate of Directors. CTC-RI recognizes the important work and impact made by Board members who are continuing again this year with their expert direction and leadership in this capacity. During the meeting, time was dedicated to recognizing Past President, Peter Hollmann, MD, Brown Medicine, who will remain on the Board as an Ex-Officio member. 

Peter Hollmann, MD

CTC-RI Past President & Ex-Officio

Brown Medicine

The Board also welcomed in our new President, Elizabeth Lange, MD, FAAP, Coastal Medical / Waterman Pediatrics. Join us in welcoming the distinguished Board Officers as we feel fortunate to have such talented leadership in RI!

Elizabeth Lange, MD, FAAP

CTC-RI President

Coastal Medical /

Waterman Pediatrics

Noah Benedict, MHL

CTC-RI Treasurer RI

Primary Care Physician Corp.

Larry Warner, DrPH, MPH

CTC-RI Secretary

United Way of Rhode Island

Kristin David, PsyD

CTC-RI Practice Facilitator Executive Director, Foundation or Integrated Care Rhode Island

Diabetes/Chronic Kidney Disease Learning Collaborative  

The goals for the quality improvement project “Implementing Primary Care and Pharmacy Strategies to Improve Care for Patients with Diabetes” are to help primary care practices improve the screening and treatment of patients with diabetes, and to detect diabetes-related eye and kidney disease earlier in patients.  

The October Diabetes Learning Collaborative meeting opened with a presentation, "Diabetic Eye Disease: Identifying and Closing Care Gaps," by Jad Osmanski, OD, and Stephen M. Montaquila, OD, FAAO. Practices participating in the pharmacy-led diabetic initiative reported on their overall plans to improve screening rates for diabetic eye care, chronic kidney disease, and glycemic control for patients with diabetes. They shared what they learned from their chart review exercise and next steps. Aggregated baseline and Q1 eye exams, kidney health evaluation, and glycemic control data results were shared. Steve Kogut, PhD, MBA, RPh shared care team survey results and preliminary analysis of APCD eye exams for patients with diabetes with the group. The seven practices participating in this project are off to a great start. 

Funding for this project is provided by United Healthcare and RI Department of Health. 

In partnership with RIDOH, CTC-RI is excited to kick off the project, "Improving Care for Perinatal Patients and Patients with Diabetes Quality Improvement Adult Immunization". Practices already participating in the MomsPRN Quality Improvement Program and “Implementing Primary Care and Pharmacy Strategies to Improve Care for Patients with Diabetes” were offered this optional Adult Immunization Quality Improvement funding opportunity.  

People with diabetes are at higher risk for serious complications from certain vaccine-preventable diseases including COVID-19, influenza, and pneumonia. Pregnant people and their babies and at increased risk for COVID-19 and Influenza. Pertussis is on the rise and outbreaks are happening across the United States. 

At the October kickoff meeting, we introduced the planning team and participating practice members and reviewed the goals and expectations of the program. Janet Limoges concluded the meeting with an overview of RICAIR, RIDOH’s Child and Adult Immunization Registry. Congratulations to the participating practices:  

• Clinica Esperanza / Hope Clinic 
• Brown Health – Hillside Family Medicine and Warren Avenue locations 
• Medical Associates of Rhode Island – Bristol and East Providence locations 
• Tri-County Community Action Agency 
• VICTA 

Congratulations to the nine primary care practices (Cohort 3) who recently concluded their twelve-month participation in the Health Transitions of Care learning collaborative.

Four teams of pediatric and adult practices used the “Got Transitions” framework and worked together to create and refine an efficient and sustainable workflow to assist youth and young adults as they transferred from pediatric to adult care. Transfer activities were considered for youth/young adults with and without special healthcare needs. One pediatric practice tested the system of care referral hub as an alternative way of transitioning youth to adult care.  

Participating practices reported on their successes, challenges, and ideas for sustainability at the October final learning collaborative meeting. A common challenge highlighted in this collaboration was the lack of access to adult and pediatric primary care providers based on retirement. CTC-RI presented the practices’ pre- and post-assessment results and patient feedback survey results. Overall, 90% of the young adults felt that they had been sufficiently prepared to move to an adult provider. RIPIN concluded the meeting with an overview of its Self-Direction program. 

This learning collaborative was supported by RIDOH and UnitedHealthcare. 

CTC-RI, with funding and support from RIDOH and RI EOHHS, hosted the first RI MomsPRN ECHO session on "Understanding the needs of birth people with substance use disorders." View a recording of the meeting here.

This was the first session of our eight-session series that focuses on strategies to promote recommended screening tools and resources to address maternal behavioral health and provides a renewed focus on respectful, culturally responsive, and linguistically appropriate care.

Building upon the success of past RI MomsPRN professional education efforts, we will expand offerings to promote recommended screening tools for maternal behavioral health, and screening tool resources and provide a renewed focus on respectful, culturally responsive, and linguistically appropriate care. Participants will collaborate and engage in ongoing learning. Those interested can view the didactic portion of the ECHO® sessions and earn 0.5 CME credits by completing the evaluation. Available CME credits end September 17, 2025, for this ECHO® series.

Access meeting recordings, presentations, and CME credits here.

A team attended the annual American Public Health Association conference in Minneapolis in October to present on the work of the RI Community Health Worker (CHW) Strategy Team. Linda Cabral, CTC-RI Senior Program Manager, was part of the team that included Swanette Salazar (FSRI), James Day and Mitchelle Abuna (RIDOH), and Geraldine McPhee and Nancy Silva (RIPIN). This team supports the implementation of the state CHW Roadmap, which seeks to elevate, expand, and sustain the CHW workforce in RI. 

02905/02907 Health Equity Zone Design Day: Advancing Food Access and Social Connectedness in South Providence

The second session of the Addressing Alcohol Use Disorder (AUD) in Primary Care Think Tank was held last month. This session presented an extensive overview of the services and treatment options at Addiction Care Today (ACT) and Brown University Health Recovery Center. These resources provide same-day access to substance use treatment, including medication-assisted treatment, as well as longer-term treatment and support. The session also highlighted community resources and the role Community Health Workers (CHWs) can play in the emergency department (ED) to refer individuals to these services. Slides from this session can be accessed here. We thank our expert panelists from Addiction Care Today (ACT): Cherilyn Freitas, MSN, APRN, FNP-C, CARN-AP, Nurse Practitioner, and Samuel Kaplan, Patient Transition Coordinator, for speaking about their services and experiences.

The third session of this series was held this month and focused on interventions and treatments available via the RI Certified Community Behavioral Health Clinics (CCBHCs). We thank Beth Matthews from RI BHDDH for serving as our subject matter expert.

Join us for our next meeting on December 16 when VT officials will present on their state’s approach to alcohol use treatment and the role of primary care. Sign up for our series here or email CTC-RI program coordinator, Phos Ivestei, at pivestei@ctc-ri.org.

Funded by RIDOH, CTC-RI supported the October kickoff of the RI Cardiovascular Disease Learning Collaborative: Best Practice Sharing Meeting. It was held with participation from the two participating sites, Rhode Island Free Clinic (RIFC) and Clínica Esperanza / Hope Clinic (CEHC). The session highlighted several key programs including a discussion on Unite RI’s coordinated care services, an overview of the WISEWOMAN program's screening and evaluation of social determinants of health, and an informational session on the Community Health Network.

Additionally, participants received updates on epidemiological data from contributing practices as well as the latest advancements in electronic health records, data collection efforts, and challenges faced by the practices themselves. We thank our guest speakers: Laudine Koster, Lifespan; Justan Baker, Evaluator and Epidemiologist, RIDOH; Cindy Ariza, MPA, RIDOH WISEWOMAN Program Manager; Adrian Bishop, EHR Consultant, AHP; Jayne Daylor, QI Consultant, and; Erica Hanson, RIDOH Community Health Network Manager.

The next quarterly Learning Collaborative will be on January 29.

The November Clinical Strategy Committee had 44 attendees join for a discussion of the State Health Care System Planning (HCSP) Cabinet Primary Care Workgroup and sustainable payments for Advanced Primary Care.

Jerome Larkin, MD, Director of Health, RIDOH, and Elena Nicolella, MPH, President & CEO, RIHCA, who serve as co-chairs of the HCSP Primary Care Workgroup were joined by Debra Hurwitz, MBA, BSN, RN, Executive Director, CTC-RI, to provide updates and recommendations from CTC-RI's Task Force for Primary Care Provider Workforce Development.

Dr. Patricia Flanagan, Medical Director, CTC-RI, discussed work on core competencies and staffing models for successful primary care capitation. Michael Bailit, MBA, Bailit Health, reviewed staffing costs for advanced primary care practices. The session was moderated by Pano Yeracaris, MD, MPH, Chief Clinical Strategist, CTC-RI, who led the discussion and summarized key takeaways.

Erica Hardy, MD, MMSc

Associate Professor of Medicine and Obstetrics & Gynecology, Division of Obstetric Medicine and Infectious Disease, Warren Alpert Medical School, Brown University

In October, CTC-RI held the second of six ECHO® learning sessions in its Best Practices in Sexually Transmitted Infections (STI) in Primary Care ECHO® Learning Series generously funded by UnitedHealthcare.

Erica Hardy, MD, MMSc presented to 33 participants on “Diagnosis and Management of Syphilis: A Clinical Review.” Participants learned about the epidemiology of syphilis and congenital syphilis, risk factors, screening recommendations, and guideline recommendations for treatment and follow-up of syphilis. The presentation also included several useful clinical guidance resources for providers and care teams. A recording of the session is available here. Click here to claim CME/CEU Credits.

The next session in the ECHO® learning series on HIV and PrEP will be presented by Dr. Philip Chan on November 20, 7:30 – 8:30 AM

In this session, we’ll explore technologies designed to enhance the efficiency, accuracy, and accessibility of primary care. The presentation will feature speakers who will showcase their work with AI, patient communication tools, prior authorization systems, and behavioral health apps to improve both clinician workflows and patient outcomes. 

Presenters include:

• Using AI for Progress Note Documentation - Paul Larson, MD, MBA, Medical Director, Brown University Health
• Using Health Helpers to Reduce Gaps in Care - Stephanie Grenier, Director of Quality & Performance, Rhode Island Primary Care Physicians Corporation
• DME with Parachute - Krystal Bevilacqua, PharmD, CDCES, CDOE, CVDOE, Diabetes Program Manager, Brown University Health
• Behavioral Apps for PCPs: Assessing Evidence and Evaluating Options - Julian Herpertz, MD, Department of Psychiatry and Psychotherapy, University of Jena in Germany

CTC-RI's upcoming ECHO® Learning Series will enhance care coordination and support for children aged 0-5 with neurodevelopmental challenges. Participants will gain practical skills, share best practices, and access resources, with options for full or flexible participation.

For details, contact Carolyn Karner at ckarner@ctc-ri.org.

CBO Spotlight: Family Service of Rhode Island

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 spoke with Family Service of Rhode Island CEO Margaret Holland McDuff.

How does your organization uniquely support Rhode Islanders?

We offer a range of public health services, such as integrated care, HIV testing, case management with AIDS Project Rhode Island (APRI), Early Intervention, and maternal health programs for at-risk infants. We also provide screenings through Cedar Family Centers for children with special health care needs and intellectual and developmental disabilities (IDD) and care coordination. Our Healing division offers behavioral health services, including Certified Community Behavioral Health Center (CCBHC), trauma-focused treatments, school-based mental health, Mobile Response and Stabilization Services (MRSS), and substance use disorder services. We provide same-day evaluations, and our pediatric and adult psychiatrists are accepting new clients. 

Our Hope division runs psychiatric day treatment and Mount Pleasant Academy for grades K-8. We also offer victim services through Go Teams, colocated with police in 8 departments, including the RI State Police. Additionally, Lucy's Hearth, our family shelter, supports over 30 families, and we run multiple housing support programs. Our Home division focuses on child and family well-being, offering services like family preservation, therapeutic foster care, and residential treatment.

How can partnerships with primary care providers strengthen your work?

Partnerships with primary care providers help us prevent behavioral health conditions from worsening through immediate access and seamless care coordination. For example, past collaborations with Coastal and Brown Health proved successful, although grant funding ended. These partnerships benefit both patients and practices by providing access to FSRI's 40+ programs when outpatient care isn’t enough. Our current integration at Jenks Pediatrics has been a major success, offering vital support to their patients. CCBHC offers exciting opportunities to deepen these partnerships and expand care.

What should the primary care community understand about your organization?

We can be a key resource to support patients with social determinants of health that affect their overall well-being, such as mental health, housing, substance use, food security, and sexual health services. We provide psychiatric care, early intervention, counseling, and access to basic needs. As value-based care becomes more common, our screening programs help identify issues early, connecting patients to the care they need to prevent conditions from worsening and ensure they stay healthy and safe.

Contact Family Service of Rhode Island by visitng www.familyserviceri.org/contact/, calling their intake line (401) 519-2280 (non-urgent) or contact the Crisis Support Hotline at (401) 854-6678.

November is Diabetes Awareness Month, a time to spotlight prevention, management, and support for those living with or at risk for diabetes. Community Health Network is a resource for primary care and connects people to proven chronic disease prevention and management programs across Rhode Island, including for diabetes. A schedule of classes with the Community Health Network is available online at www.ripin.org/chn or you can call 401-432-7217.

Watch the video below with two local diabetes experts, Drs. Tracey Taveira and Kelley Sanzen speak about the importance of diabetes management.

Diabetes awareness and prevention with R.I. Dept. of Health | Studio10 | November 14th 2024

Upcoming CTC-RI Committee Meetings and Workgroups

• December 06, 07:30-08:45 AM – Board of Directors   
• December 20, 07:30-09:00 AM – Clinical Strategy Committee  

Upcoming Learning Collaboratives and Professional Development

• November 21, 07:30-08:30 AM – Pediatric Sleep ECHO series  
• November 25, 11:00-12:30 PM – CHW Advocacy Network for Leadership  
• November 25, 12:00-1:00 PM – Healthy Tomorrows Quarterly Learning Collaborative meeting - Cohort 4  
• November 26, 12:00-01:00 PM – MomsPRN Mid-Point Meeting  
• December 05, 07:30-08:00 AM – Virtual Coffee Break with Drs. Pat Flanagan and Beth Lange  
• December 10, 07:30-08:30 AM – ECHO: Best Practices in Addressing Sexually Transmitted Infections in Primary Care  
• December 11, 08:00-09:00 AM – Primary Care Workforce Taskforce 
• December 12, 07:30-09:00 AM – DULCE Learning Collaborative  
• December 13, 07:30-09:00 AM – Breakfast of Champions  
• December 16, 12:00-01:00 PM – Addressing AUD in Primary Care Think Tank: 4-Part Series  
• December 17, 08:00-09:00 AM – Best Practices in Team-Based Care  
• December 17, 12:00-01:00 PM – MomsPRN ECHO Series  
• December 18, 07:30-09:00 AM – Demographic Data Collection Quality Improvement Wrap-Up Meeting  
• December 19, 07:30-08:30 AM – Pediatric Sleep ECHO series  
• December 20, 12:00-01:00 PM – Integrated Behavioral Health Meet and Eat