Catch up on the latest news from the Care Transformation Collaborative of Rhode Island.

April 2016 updates: Community Health Teams success, reduced hospital admissions + more!
Evaluation shows Community Health Teams valued by patients
We recently contracted with  Brown University faculty member, Dr. Roberta Goldman, and May Street Consultants to evaluate our Community Health Team pilot programs. Launched in 2014 in both South County and Blackstone Valley, the CHTs helped their participating practices better meet the care needs of complex patients,  particularly those with persistent high spending patterns, like repeat ED visits and impatient hospitalizations.

According to the evaluation, patients received an abundance of support from the CHTs, such as:
  • Moral support and anxiety reduction via home visits, phone calls, preparing patients for medical visits, accompanying patients at medical and legal appointments
  • ED avoidance strategies, and home contact following ED visits or hospitalizations
  • Completion of paperwork support (housing, health insurance, financial, social security, welfare, food stamps, long-term disability, medication assistance)
  • Individual and marital counseling
The ongoing challenge of the CHT program is to provide the right services to the right patients at the right time. To build on and enhance CHT success in Rhode Island, some key recommendations will need to be considered regarding structure, functioning, collaboration, and patient selection. Examples of recommendations by evaluators include:
  • Reduce time lag between identification of high-risk patients and enrollment in CHT program
  • Periodically re-educate patients about available CHT services
  • Enhance coordination between CHTs and case managers from other entities working with patients to avoid redundancy
Margaret Bublitz (right) a behavioral-medicine psychologist at Women's Medicine Collaborative speaks with nurse practitioner Kathy Ribeiro. (Credit: PBN PHOTO / MICHAEL SALERNO)
ICYMI: CTC in the news!
In case you missed it, catch up on the latest CTC features in the media:

Providence Business News (April 15, 2016)

Providence Journal (April 22, 2016)

Providence Business News (March 7, 2016)

Valley Breeze (February 23, 2016)
Reduced hospital admissions for patients in our practices
Compared to non-CTC practices, all three of our practice cohorts we've been tracking from March 2012-June 2015 have greater reduction rates of patient hospital admissions (from all causes) than the comparison group (non-CTC practices). The below inpatient data highlights the trends. We look forward to continuing to find ways to support our practices - and in turn their patients - to reduce avoidable, costly hospital admissions.
*The above data includes Blue Cross and Blue Shield of Rhode Island, UnitedHealthcare, and Neighborhood Health Plan of Rhode Island. Data does not include Medicaid or Medicare FFS or RHO Dual Eligible NHP members.
Practice Spotlight: East Bay Pediatrics and ED utilization
Linda Hughes, BSW, MA, Pediatric Care Coordinator at RI Physicians Corporation Primary Care analyzed the emergency department utilization of East Bay Pediatrics' patient population. Specifically, why and  when patients used the ED and how her team could intervene to better meet their needs.  Through her research and interventions, she found:
  • Children ages 18, 16, and 2 were the most frequent ED users, with orthopedic conditions being the leading reason
  • 22 children between the ages of 12-22 were seen in the ED for psychiatric reasons
  • The conditions of children with asthma were well controlled, with these children being seen in the ED only 7 times in a 12-month time period. 
Linda identified two areas that she thought she could make a difference: providing parents with information on how to treat a child with vomiting (a common reason for ED usage) and how she could provide active outreach for teenagers with ADD. As a result, Linda was able to proactively identify and connect with teens that were not frequently seen in the pediatric office. She conversed with them on how school was going, and formed relationships that resulted in teens calling her when they were experiencing distress, rather than visiting the ED.  
Maximizing the role of medical assistants in our practices
In conjunction with Stepping Up (a workforce development training program) ,  our Collaborative is offering our practices a unique Medical Assistant training program in May. The  role of the Medical Assistant in our practices expands beyond its "traditional" job description. New roles include pre-visit planning, reconciling medications, delivering and/or arranging for preventative services, health coaching, and providing telephone or in-person follow-up.

Through our training program,  Medical Assistants will learn essential skills for working as high-functioning care team members in the  patient-centered medical home primary care practice setting. 

Training will take place over four evening sessions on May 5, 12, 19, and 26, from 5:30-7:30pm at Thundermist Health Center in Warwick. Registration is currently full - please contact to be added to the waiting list.
NCQA Corner: Preparing for the renewal process
A number of our practices will soon be preparing for NCQA PCMH renewal, a requirement of our Collaborative.  Practice Facilitator Suzanne Hertzberg has been in touch with NCQA to obtain information on new 2017 renewal guidelines launching in March 2017.  The new process will eliminate the need for practices to renew, and instead establish an annual data submission tool that will streamline documentation and help practices sustain recognition from year to year.

NCQA will stop selling the PCMH 2014 survey tools on March 31, 2017. Corporate survey submissions will not be accepted after this date, and single site survey submissions will not be accepted after September 30, 2017. Practices that are currently recognized under PCMH 2011 have two options:

Option #1: Renew prior to the deadlines started above.  Practices currently recognized as Level 2 or 3 PCMH can utilize the streamlined renewal process Upon achieving recognition, practices will be given a 3 year recognition period and won't need to move into annual reporting until expiration. Requirements for annual reporting will be sent at least 12 months prior to expiration.

Option #2:  Convert each single site to PCMH 2014 prior to September 30, 2014. Conversion is a more streamlined approach to moving to PCMH 2014 with only 6 elements requiring documentation (remaining information requires practice to attest "yes" or "no" based on capability and function). Practices must be at Level 3 PCMH 2011 to convert to PCMH 2014 and conversion will extend recognition by 1 year, at which time the practice would move to annual reporting. For this renewal option, practices must use the application portal to request an eligibility call closer to submission time (appx. 3-6 months out). The deadline for corporate submission for PCMH 2014 is March 31, 2017.

NCQA is offering monthly Q&A sessions on this topic. Specifically, practices can learn more on redesign, renewing and converting to PCMH 2014 through this session.
Report shows Rhode Island is a leading state in prevention
United Health Foundation recently released 2016 America's Health Rankings Spotlight: Prevention, shedding light on the use of preventive services by communities across the nation, where disparities in use exist, and other important opportunities for improvement.

At the highest level, key findings show that almost all prevention measures analyzed in the report vary by income, race, education, or geography; access to health care is strongly associated with overall prevention; and immunization coverage levels vary widely among states.

Specifically, state-level highlights include:
  • Rhode Island scored the second highest in prevention performance across the three categories of prevention (access to health care,  immunizations , and chronic disease prevention)
  • RI has the highest HPV vaccination coverage rate (42.9%) for males aged 13 to 17  
  • RI has the second highest HPV vaccine coverage rate (53.7%) for females ages 13 to 17
  • RI is among the top 5 states for highest adolescent MCV4 and adult influenza immunization rates
  • RI is among the top 5 states for Cholesterol Check and Colorectal Cancer Screening
CTC shares expertise at national conferences
CTC practices and individuals have been sharing their expertise with the greater health care community across the nation. Below are some highlights of recent and upcoming events:
Institute for Healthcare Improvement's 17th Annual Summit on Improving Patient Care in the Practice and Community
March 2016 in Orlando, FL
Presenters: Coastal Medical (Meryl Moss, Chief Operating Officer and Al Kurose, MD, MBA, FACP, President & CEO)
Coastal Medical's presentation, "Building the Primary Care Practice of the Future," highlighted work the practice has done to reinvent clinical programs, workflows, and care delivery systems that greatly improved patient outcomes, patient experience, and physician satisfaction.
5th Annual Leadership Summit on Integrated Behavioral Health and Primary Care Models
May 2016 in Orlando, FL
Presenter: Nelly Burdette, Psy.D, Director of Integrated Behavioral Health (IBH) at Providence Community Health Centers and CTC's IBH Consultant 
Nelly Burdette's presentation, "Incorporating Integrated Behavioral Health within Federally Qualified Health Centers," will highlight how the largest FQHC in Rhode Island used an innovative program to create the business case for integrated behavioral health in primary care.
PCMH Congress 2016
October 2016 in Chicago, IL
Presenters: Susanne Campbell, RN, MS, CTC Senior Project Director, Roberta Goldman, PhD, Alpert Medical School of Brown University and Scott Hewitt, MA, Blackstone Valley CHC Community Health Team Coordinator 
The group's presentation  will help primary care practices learn how they can get started with forming a medical neighborhood - extending clinical services beyond their office settings - by forming a community health team that delivers behavioral health and social support services to assist patients with high-cost, complex care needs. 
SIM grant works to shift focus to value vs. volume
Rhode Island's State Innovation Model Test Grant (SIM) is a payment reform grant, working to shift the system to focus more on value and less on volume.

According to SIM's Theory of Change, i f SIM makes investments to support providers and empower patients to adapt to these changes, and addresses the social and environmental determinants of health, then population health will improve, and we can move toward the Triple Aim.

Through new initiatives, like OHIC's Affordability Standards and  Medicaid's Accountable Entities, our state is on its way to payment reform. T o further make a measurable impact on Population Health and reform the healthcare system, the SIM Steering Committee has chosen to make investments in three major buckets of work: the state's provider workforce / practice transformation; patient empowerment; and increasing data capability and expertise.

CTC looks forward to supporting these efforts. For more information on SIM, contact SIM Project Director Marti Rosenberg at
Streamlining self-management support for patients with COPD
Chronic obstructive pulmonary disease (COPD) is one of the top drivers of unplanned hospital readmissions and increased health care costs. The Greater Providence Safe Transitions Community Coalition established a goal to reduce COPD readmissions by using standardized education materials across all settings, including the COPD Action Plan, a self-management tool created for patients with COPD. 

The intent is for patients to hear consistent messaging across all care settings to hopefully impact their ability to better self-manage. 

"Train the Trainer" sessions were offered last October, with 42 organizations (hospitals, home care, nursing homes, physician offices, DME, and payers) participated in this "Phase 1." These organizations are working towards training a total of 1,000 staff to use the materials for educating COPD patients. 

The program is now spreading to other providers around Rhode Island. For CTC practices that are not yet registered and would like to be included, contact Kathy Calandra at  or 401-528-3204.
Update for CTC Performance Year 2 Practices
There are currently 23 CTC practices in Performance Year 2 (PY 2), the final year of our Developmental Contract which ends 6/30/16. PY 2 practices will now have the opportunity to obtain a one-time lump sum payment for 12-months worth of PMPM performance incentives if: 
Last year, practices in PY 2 did not receive payment for meeting the All Cause Hospitalization threshold and did not receive the $1.25 PMPM incentive payment. Based on 2016 data, all PY 2 practices exceeded the utilization metric for All Cause Hospital Admission (5% reduction compared to the comparison group) and therefore PY 2 practices will receive a $1.25 PMPM payment.

True-up payment to PY 2 practices for quality will depend on if the practice did not receive full quality incentive payment last year and practice performance on 1st quarter 2016 meets the 2016 Contractual Performance Standards. True-up payment for customer experience will depend on if the practice did not receive full customer incentive payment last year and practice performance on current CAHPS survey results meet the 2016 Contractual Performance Standards. Potential payment amounts can be found in the PMPM payment document. Contact Susanne Campbell ( with questions regarding true-up payment eligibility.

Continuation of Sustainability Payment: Commercial health insurers have notified PY 2 practices of the infrastructure financial support payments they can expect to receive for the time period from 7/1/16 to 12/31/16. OHIC and EOHHS continue to discuss the Medicaid payment with the intent that PY 2 practices will continue to receive payment, but specific details are not yet determined.
Mark your calendar!

Upcoming Events
The Agency for Healthcare Research and Quality (AHRQ) and the Care Transformation Collaborative of Rhode Island are sponsoring a free one-day "train the trainer" workshop on shared decision making.

The New England Genetics Collaborative is leading a Tri-State webinar series with the child health improvement partnerships in ME, NH, and VT to highlight how  a team approach to caring for children with genetic and complex conditions within PCMHs will improve collaboration, coordination, and satisfaction for families and providers.  
April - June, 2016 - Brown University's Continuing Medical Education Series

Upcoming Meetings (for CTC members)
May 3, 2016 7:30-9:00AM -  Data and Evaluation Committee  (Memorial Hospital Center)
May 10, 2016 8:00-9:30AM -  Care Manager Coordinator Best Practice Sharing (RIQI)  (Pediatric Focus)
May 12, 2016 7:30-9:00AM -  Integrated Behavioral Health Committee (RIQI)
May 13, 2016 9:30-10:30AM -  Community Health Team (HealthCentric Advisors)
May 19, 2016 7:30-9:00AM -  Practice Transformation Committee (RIQI)
May 19, 2016 8:30-4:30PM -  AHRQ SHARE Approach Workshop ( RI Shriners-Imperial Room-Cranston)
May 20, 2016 7:30-9:30AM -  Clinical Strategy and Cost Committee  (Thundermist-Warwick)
May 23, 2016 9:00-10:30AM -  Program Evaluation Committee (RIQI)
May 24, 2016 7:30-9:00AM -  Contracting Committee (RIQI)
May 24, 2016 8:00-9:30AM -  Practice Reporting (RIQI)
May 27, 2016 7:30-9:00AM -  Board of Directors (HealthCentric Advisors)
May 27, 2016 9:30-10:30AM -  Community Health Team Program Development  (HealthCentric Advisors)
Care Transformation Collaborative of RI | 508-421-5919 | |