Care Transformation Collaborative of RI

News & Updates | September 2022

Kicking off a third Pharmacy Quality Improvement Initiative to support patient health

CTC-RI and the RI Department of Health (RIDOH), in collaboration with URI College of Pharmacy, just kicked off a two-year Pharmacy Quality Improvement Initiative focused on management of hypertension and diabetes through team-based care. Using Continuous Glucose Monitoring (ProCGM), practices will aim to increase utilization over time by the number of patients, providers, and sites. Practices participating include:

  • Anchor Medical Associates
  • Coastal Medical Physicians
  • Medical Associates of RI
  • Miriam Hospital Ambulatory Clinic
  • Providence Community Health Center
  • RI Primary Care Physicians Co.

UnitedHealthcare and RI Department of Health provided financial support for this pharmacy quality improvement initiative. Read more.

Spotlight: Bradford Pease, PharmD CDOE, Medical Associates of Rhode Island on team-based pharmacy initiative

CTC-RI just launched its third Pharmacy Quality Improvement Initiative following the success of its last, which worked to reduce preventable hospitalizations and emergency department usage. Medical Associates of Rhode Island was among the practices that participated in 2021 to reduce preventable hospitalizations and ED usage through team-based care. We asked Bradford Pease, PharmD CDOE, Clinical Pharmacist, to share his experience. 

Why did you decide to participate in the Pharmacy Quality Improvement Initiative, and what did you hope to gain from it?

The Pharmacy Quality Improvement Initiative was an opportunity for us to develop a chronic disease management program that empowered the embedded pharmacist to practice at the top of their license and make individualized, data-driven therapeutic recommendations. We hoped to create a model that would be sustainable, accessible, and align with our efforts to provide high-quality, patient-centered care.

What was your team's specific focus area and why?

We elected to focus on the use of 24-hour ambulatory blood pressure monitoring (ABPM) in patients with uncontrolled hypertension at high risk for hospitalization and/or emergency department usage. Data suggests that ABPM correlates better with cardiovascular risk than in-office blood pressure readings. Patients at high risk for preventable hospitalizations or ED usage are better managed and more likely to stay out of the hospital by incorporating ABPM into the primary care setting.

What success did your team see throughout this initiative, and how will it impact your work moving forward?

Aside from the improvement in blood pressure control, I think the buy-in we received from patients and providers was one of our biggest successes. 87% of high-risk patients that were referred for ABPM during the Quality Initiative completed at least one ABPM study, resulting in at least two additional touch-points with the pharmacist. I believe that the high participation rate was due to the fact that our providers saw the value in recommending the service to their high-risk patients, and the fact that we were and are able to continue to offer the service at no cost to our patients thanks to the investment from CTC-RI.

Mark your calendar! New September virtual series on pediatrician burnout and resiliency with Dr. Nelly Burdette

Made possible by CTC-RI and in partnership with the RI Chapter of the American Academy of Pediatrics, Dr. Burdette will lead three virtual learning sessions addressing pediatrician burnout and resiliency, focused on individual, organizational, and community approaches. Sessions include:

  • Sept. 16 (4-5pm): Individual Approaches to Identifying Burnout and Building Resilience
  • Sept. 21 (8-9am): Organizational Approaches to Impact Changing Systems Around Burnout and Resilience
  • Sept. 29 (8-9am): Community Approaches to Bridge the Impact of Burnout and Grow Resiliency

Register here and access more details, including CME information, here.

Register by September 21! CTC-RI Asthma Essentials ECHO (Extension for Community Healthcare Outcomes)

Launching on October 12 (held 2nd Wednesdays of the month from 7:30-8:30am)

What is Echo?

ECHO creates a virtual learning community and encourages participants to engage in an all teach, all learn model which includes presentations from subject matter experts and presenting real, de-identified cases to specialists—and each other—for discussion and recommendations.

Why Asthma ECHO?

Asthma is one of the most common and costly conditions in the U.S. In RI, around 1 in 12 people have asthma. Even though asthma is controllable, an estimated 50% of children with asthma have uncontrolled asthma and 40% of adults who had asthma reported having one or more asthma attacks in the past year. 

Why participate?

  • Learn about best practices and evidence-based care for patients.
  • Enhance skills, competencies, and best practices in asthma care.
  • $250 stipend per org. for attending 5/6 sessions & case presentations.
  • Eligible to earn up to 6 CME/CEU.

Learn more here. Ready to join ECHO? Register by September 21!

Register Today!

Best Practices in Team-Based Care: Older Adults at Risk for Opioid-Induced Respiratory Depression

At the August Best Practices in Team-Based Care meeting, Anita Jacobson, PharmD, presented on the risks for opioid-induced respiratory depression. She explained how to identify adults at risk of an opioid-involved breaking emergency, and described the barriers to access of naloxone, buprenorphine and/or methadone in the community and long-term care settings. She also provided a resource for free, anonymous naloxone delivery

The September 20 meeting will focus on improving diabetes patient care, with CEU credit available. Register and learn more here.

CTC-RI welcomes 7 practices to Pediatric Weight Management ECHO & Quality Improvement Initiative

CTC-RI is excited to kick off our first ECHO® learning series on Pediatric Weight Management. The 12-month learning and action series will improve practices' ability to manage pediatric weight management challenges using a behavioral health approach. Practices selected to participate include:

  • Anchor Pediatrics
  • Atlantic Pediatrics
  • Coastal Waterman Pediatrics
  • Santiago Medical Group
  • St. Joseph Health Center
  • The Westerly Medical Center
  • Tri-County Community Action Program

Read more.

Join our IBH practice facilitators for a monthly lunchtime 'Meet and Eat'

CTC-RI is offering an opportunity to have a casual Zoom conversation with our Integrated Behavioral Health (IBH) practice facilitators, Dr. Liz Cantor and Dr. Kristin David. This is an opportunity for IBH clinicians (Psychologists, Therapists, Social Workers, and Nurses) to connect with other IBH professionals, discuss best practices, challenges, successes, and more!

The event will occur over Zoom, every 3rd Friday of the month at 12pm, starting September 16. To register for this recurring event, visit the registration link here.

DULCE Learning Collaborative launches

This month, CTC-RI welcomed CNEMG Family Care Center and Coastal Toll Gate Pediatrics to the 15-month Developmental Understanding and Legal Collaboration for Everyone (DULCE) learning collaborative with an orientation and kickoff meeting.

With funding from UnitedHealthcare and the RI Department of Health, these practices will implement the DULCE approach that proactively addresses social determinants of health, promotes the healthy development of infants, and provides support to their parents, all during the precious and critical first 6 months of life. An identified Community Health Worker/Family Specialist staff member will be specially trained in child development, relational practice, and concrete support problem-solving and work with an interdisciplinary team to connect families with resources and support. Read more.

August Clinical Strategy meeting focuses on community health workers

In an informative August Clinical Strategy Meeting, system of care leaders, practice leaders, provider and health plan representatives focused on “Community Health Workers: How Are Practices and Systems of Care Approaching Effective and Sustainable Deployment of CHW’s in the Expanded Primary Care Team?”Topics included embedding CHWs in primary care, personal success stories of integration, training pathways, and billing for CHW services. Read more.

Breakfast of Champions September meeting addresses unconscious bias in healthcare 

CTC-RI proudly hosted expert Robert T. Jones, international education consultant, to talk about unconscious bias in healthcare at the September Breakfast of Champions. With global experience speaking to audiences on topics ranging from diversity, equity, and inclusion to communicating across cultural lines, Mr. Jones engaged more than 50 attendees around this subject in healthcare, sharing lived experiences, and discussing an action plan to bring to their practices. Read more.

Rhode to Equity hosts CommonSpirit Health speaker on housing and equitable neighborhoods

In August, Rhode to Equity invited Pablo Bravo, System Vice President of Community Health at CommonSpirit Health, for a subject matter expert session. As one of the largest nonprofit health systems in the U.S., CommonSpirit Health has made significant investments and partnerships with community service organizations to address the social and economic needs of their patients including funding community loans, investing in homeless health initiatives and launching a Pathways Community HUB Model. Pablo discussed health care systems investing in housing, and serving as a conduit to more equitable, affordable and safe neighborhoods. Read more.

CTC-RI/PCMH Kids begins 5th year of NCM workforce development training

This week, CTC-RI is excited to begin its 5th year of the GLearn Nurse Care Manager (NCM) Core Curriculum Training Program. Born out of requests from our local primary care community for more high-quality training for NCMs, nearly two dozen NCMs and care coordinators from 13 different practices across the state will be participating, bringing a wide range of experience levels to the program.

A big thank you to UnitedHealthcare and the RI Department of Health for funding this important workforce development opportunity, allowing CTC-RI to offer the program to NCMs at no cost. Read more.

2022 Commonwealth Fund ranks Rhode Island 6th in nation on State Health System Performance

Every year, the Commonwealth Fund’s Scorecard on State Health System Performance uses the latest data available to assess how well the health care system is working in every state. This year, Rhode Island ranked 6th overall, and notably scored 2nd in the nation on access & affordability, as well as racial & ethnic equity.

Rhode Island COVID-19 Updates

Rhode Island is now reporting new COVID-19 data every Thursday. As of September 8, 2022:

  • Cases per 100,000 previous week: 132
  • Hospitalized previous week: 94
  • Deaths previous week: 7
  • Total deaths to date: 3,632
  • Vaccinated with two shots: 84.9%
  • Vaccinated with booster: 56.1%
Practice Resources

6-Week "Rhode to Wellness" Challenge Starts October 2!

Leading up to RI World Diabetes Day, Rhode Islanders are encouraged to join this exciting 6-week Challenge to discover a wealth of resources throughout Rhode Island that connect us to healthy living. Participants can win giftcard prizes! Register.

October 14-16 International Symposium: The Patient and the Practitioner in the Age of Technology - Promoting Healing Relationships

This live international symposium, sponsored by Brown's Warren Alpert Medical School, will bring together researchers, innovators, and problem solvers from around the U.S. and world to address research, innovative projects, and practical solutions to promote compassionate, healing relationships in healthcare as technology transforms clinical interactions, incorporating lessons from the pandemic. Register here.

October 27 Training: Dismantling Bias in Maternal and Infant Healthcare

March of Dimes, in partnership with BCBS of RI, is pleased to offer this virtual training which provides authentic, compelling content for health care professionals caring for women before, during and after pregnancy. Register here.

Save the Date! 2022 RI World Diabetes Day on November 14

A free morning full of helpful, eye-opening, and inspirational presentations, discussions, and Q&A sessions. Whether you're a clinician, caretaker, or person living with diabetes, there will be sessions for you! Light refreshments will be available. Register.

Nominations Now Open for 2022 Grace Diaz Blue Light Award

Each year the Rhode Island World Diabetes Day Committee recognizes an individual or organization that has positively impacted diabetes in the state of Rhode Island by awarding the Grace Diaz Blue Light Award. In keeping with the international theme of World Diabetes Day 2022, "Access to Diabetes Care," this year's Blue Light Award will be presented to an individual or organization who has gone above and beyond in providing diabetes care. Details.

Job Opportunities

CTC-RI Administrative Assistant (Part-Time)

CTC-RI is hiring a candidate for 10 hours/week with experience in a professional office (supporting professionals and C-suite stakeholders) and has tremendous people skills, energy, customer service skills, communication skills, writing skills, attention to detail and patience. Candidate must be able to coordinate multiple projects and processes, coordinate meetings, manage materials, and coordinate calendars. Learn more.

Upcoming CTC-RI Committee Meetings and Workgroups

  • September 20, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • September 23, 07:30-08:45AM – Board of Directors
  • September 28, 08:00-09:30AM – Care Community Equity Best Practice Sharing
  • October 06, 07:30-08:30AM – Improving Child Health in RI (formerly PCMH-Kids Stakeholder Meeting)
  • October 13, 07:30-09:00AM – Quarterly Integrated Behavioral Health Committee
  • October 18, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • October 21, 07:30-09:00AM – Clinical Strategy Committee
  • October 28, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • October 12, 07:30-09:00AM – Asthma ECHO Kickoff
  • October 21, 12:00-01:00PM – Integrated Behavioral Health Practice Facilitator Meet & Eat
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