Attendees engage in an activity lead by Valerie Tutson, Executive Director, RI Black Storytellers

Best Practices in Team-Based Care: Improving Lead Screening

Dr. Beata Nelken led the November Best Practices in Team-Based Care meeting with best practice strategies used at Jenks Park Pediatrics to improve lead screening. These included purchasing a van to assist patients with transportation needs to their appointments, setting up an in-office lead screening workflow, and partnering with Lifespan labs. Michelle Almeida, Health Program Administrator for the Rhode Island Department of Health (RIDOH) Center for Healthy Homes and Environments, also provided an overview of RIDOH's Lead Prevention Program and the new CDC lead guidelines. Cynthia Ali shared best practice strategies used at Children’s Medical Group to improve lead screening and Janet Limoges, Provider Relations Manager at RIDOH KIDSNET, reviewed lead reports available in KIDSNET to help practices target patients with missing lead screens.

The January and February Best Practices in Team-Based Care meetings will include capstone project presentations from nurse care managers and care coordinators enrolled in the NCM Core Curriculum program. Read more.

CTC-RI Hosts Health Transitions of Care November Quarterly Learning Collaborative Meeting

Sixteen participants joined the November Health Transitions of Care learning collaborative to share patient and family experiences, available resources, and best practices around improving care coordination for youth transitioning from pediatric to adult care.

Stephanie Trafka, RIPIN Family Voices, kicked off the meeting speaking about family experiences and the difficulties families face throughout the transition process. Kathleen Kuiper, RIDOH, introduced the Medical Home Portal with a website demonstration and resources available for families and clinicians.



Several practices shared updates on increasing transitions of care knowledge within their system of care, while new participating practices discussed their experiences with patient transitions. Read more.

Pharmacy QI Learning Collaborative Meeting Focuses on Professional Use of Continuous Glucose Monitoring (Pro CGM) in Primary Care

Primary care practices that are part of systems of care and participate in the Pharmacy QI Learning Collaborative met in December to share their progress on identifying patients who might benefit from professional use of continuous glucose monitoring interventions. Goals and team-based workflows were presented. Leslie High of Abbott Diabetes Care provided a tutorial on Libreview and how it can be used to customize practice reports. Billing options for Pro CGM services were also discussed. Special thanks to UnitedHealthcare and the Rhode Island Department of Health (RIDOH) for providing funding for this important quality improvement initiative. Learn more and access helpful resources.

Upcoming CTC-RI Committee Meetings and Workgroups

• Dec. 20, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
• January 17, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
• January 20, 07:30-09:00AM – Clinical Strategy Committee 
• January 27, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

• December 22, 02:00-03:00PM – Monthly Healthy Tomorrows meeting
• January 11, 07:30-08:30AM – Asthma Essentials ECHO
• January 11, 07:30-09:00AM – RI MomsPRN Learning Collaborative - Cohort 3
• January 19, 07:30-08:30AM – Pediatric Weight Management ECHO
• January 26, 07:30-08:30AM – Medicaid Recovery Program Behavioral Health ECHO - Difficult Conversations
• January 26, 08:00-09:30AM – Community Health Teams Expansion Best Practice Sharing