Care Transformation Collaborative of RI
News & Updates | June 2022

Join CTC-RI/PCMH Kids as we spend the evening celebrating YOU! This exciting affair will be a celebration of our healthcare champions – 3 cohorts of PCMH Kids practices, participants from this year’s CTC-RI learning collaboratives, and all of our important and valued partners! Register now to join us on Tuesday, June 28 from 5-8pm at Narragansett Brewery (271 Tockwotton Street, Providence, RI 02903).

With plenty of parking, an open environment and patio, and a wonderful view of India Point Park and the waterfront, the evening promises to be a great time to network, honor all of the accomplishments from the past 2 years, and catch up with friends, both old and new! We look forward to spending a casual night with you, while enjoying light appetizers, catered by Pranzi Catering, and beverages including 2 free tickets for beer, non-alcoholic beverages or soft drinks. 

With the support of the RI Department of Health (RIDOH) and Tufts Health Plan, pediatric medical homes and providers from the family visiting program continue to improve communication and care coordination to enhance well-child care.

In May, participating pediatric medical homes and family visiting convened for their quarterly learning collaborative sharing their work, reviewing data and the KIDSNET family visiting report, and learning about the family experience from the family consultant. RIDOH shared data on participants' successes in areas such as screening, assessments, and adherence to medical visits. Caregivers and children received screenings such as maternal depression, substance use, age-appropriate development, and quality of the parent-child relationship. Vital medical visits, such as postpartum and well-child, were shown to have a higher completion rate for families enrolled with family visiting. Read more.

CTC-RI/PCMH Kids, in collaboration with Tufts Health Plan and the RI Department of Health, is pleased to announce that the following practices have been invited to join the 2022 Pediatric/Adult Primary Care Health Care Transfer of Care Quality Improvement Initiative:
  • Dr. Chad Nevola
  • Hasbro Children’s Hospital Pediatric Primary Care
  • Center for Primary Care
  • Children’s Choice Pediatrics
  • Greenwich Medical Associates
  • Dr. Chad Lamendola
  • Dr. Richard Ohnmacht

Practices will participate in a year-long learning collaborative focused on creating and refining an efficient and sustainable approach to assisting youth and young adults as they transfer from pediatric to adult care. Read more.

With support from the American Academy of Pediatrics and funding from Tufts Health Plan, CTC-RI received training in the ECHO model learning framework. Focusing on an “all teach, all learn” model, ECHO brings together clinicians and community members through a virtual community to share support, guidance, and feedback, while learning best practices for quality care and problem-solving case examples together.

Over the course of 4 training sessions in May, approximately 25 team members, partners and community providers received training and worked to lay the foundational work for CTC-RI’s initial ECHOs focused on asthma and pediatric weight management. Read more.

In May, the Clinical Strategy Committee Meeting hosted Ann Greiner, President and Chief Executive Officer of the Primary Care Collaborative. Ann talked about PCC’s Better Health — Now Campaign, which focuses on securing policy change that improves the health and well-being of patients by increasing investments in primary care and promoting payment models that ensure all communities have access to care. The meeting included a robust discussion about what we can learn from other states, required policy change, and the future of solo practices. Read more.
CTC-RI/PCMH Kids, with funding from UnitedHealthCare and the RI Department of Health, is pleased to offer up 25 Nurse Care Managers/Care Coordinators (NCM/CC) the opportunity to participate in a standardized evidence-based training program in which you will learn to apply key care management concepts within your primary care practice setting and organization. Applications are due July 22! Learn more.

At the May Nurse Care Manager/Care Coordinator (NCM/CC) Best Practice Sharing meeting, experts from the RI Geriatric Education Center, Office of Healthy Aging, and EOHHS shared valuable insight on resources and tools for caregivers supporting patients living with dementia. The upcoming June NCM/CC meeting will share best practices for a successful pediatric to adult transition of care, and the experiences of practices that participating in the first health transitions learning collaborative. Read more.

CTC-RI hosted its final quarterly learning collaborative for the Pharmacy Quality Improvement Initiative in May with 46 participants. Each practice has worked to reduce preventable hospitalizations and emergency department usage through team-based care, with a focus on a specific AIM. During the meeting, each of the 7 practices shared outcomes from the project, lessons learned, and next steps/plans for sustainability.

Be on the lookout for our next call for applications focused on improving population health in primary care through ambulatory blood pressure monitoring (ABPM) or professional use of continuous glucose monitoring (CGM) scheduled to start in August 2022. Read more.

In a stimulating June Breakfast of Champions meeting, CTC-RI hosted nearly 70 health care leaders to address diabetes from patient/clinical and community/clinical perspectives. Presentations featured diabetes management guidelines, a practice-based pharmacy-led intervention, and a collaborative effort to integrate clinical and community support for disease management. Read more, view the recording, resources, or claim CME credit here.
Congratulations to Lillian Nieves, PharmD and Kenny Correia, PharmD for Pharmacist Awards!

We congratulate Lillian Nieves, PharmD and Kenny Correia, PharmD for their contributions to quality clinical care and recent awards by the RI Pharmacist Association! Lillian Nieves was given the Guido L. Pettinicchio “RI Pharmacist of the Year” Award and Kenny Correia was given the Excellence in Innovation Award.

CTC-RI has been fortunate to work with both of these individuals in our Pharmacy Learning Collaborative. Their passion for quality and knowledge of medication management has vastly improved patient outcomes and systematically contributed to best practices in primary care. CTC-RI is a public/private partnership focused on improving population health through high-quality primary care.
Rhode Island COVID-19 Updates

COVID-19 Cases
COVID-19 cases have been declining over the last month. As of June 16, there were 218 new cases per 100,000, compared to 284 (June 4), 375 (May 28), and 498 (May 21).

COVID-19 Vaccines
As of June 15, 437,733 Rhode Islanders have received a booster vaccine (41.4%), 880,241 have completed their primary vaccine series (83.3%), and 1,044,920 are at least partially vaccinated (98.9%).
In the News
May 23, 2022
After a decade of leadership, MLPB’s CEO, Samantha Morton, is leaving her position, moving on to her next challenge. Among the partnerships that MLPB has developed under Morton’s leadership have been with the Care Transformation Collaborative and its ongoing initiatives with community health workers, and with the R.I. Life Index, a data survey of Rhode Islanders conducted annually with Blue Cross and Blue Shield of Rhode Island and the School of Public Health at Brown University, now gathering data for its fourth annual edition. Read more.
Practice Resources
Brown Webinar: Demystifying Palliative Care
Learn how to differentiate between palliative care and hospice care, as well as the importance of palliative care services for people living with serious illness. This June 28 webinar (12-1pm) will cover the role of healthcare professionals as part of the interprofessional palliative care team in the care of patients living with serious illness and barriers they are facing in practice, such as stigma surrounding end-of-life care.

bRIght Communities
Rhode Islanders are now encouraged to join bRIght communities, a free, interactive
text messaging program created to empower better health. This 6-month confidential program gives personalized tips for eating and exercise, helps overcome barriers to getting healthier with local resources, and more. The first 400 people to sign up will earn up to $50 in gift cards and all participants are entered into additional gift card drawings. Learn more in English and Spanish.

HopeHealth: Virtual Education Courses for Clinical Professionals
HopeHealth is offering the courses virtually this summer as part of their hospice and palliative care education curriculum for clinical professionals. All courses are free of charge and are held through Zoom. Educational credits available. Learn more.
Job Opportunity
Our CTC-RI Team is Growing!
Program Coordinator Position Available

The Care Transformation Collaborative of RI is hiring a Program Coordinator! Responsible for the development, coordination, implementation, and evaluation of the tasks associated with executing interventions for assigned projects, and the overall management of projects, the Program Coordinator assists the Program Administrator/Senior Program Administrator as well as Senior Management in planning activities to assure contract deliverables and other work are produced timely and in accordance with established protocols and procedures. Learn more.
Upcoming CTC-RI Committee Meetings and Workgroups

In order to respond to identified integrated learning priorities and provide Continuing Medical Education (CME) credits for MDs, DOs, NPs, PAs, RNs (and potentially pharmacists – who should check with their state regulatory body for particular activities), CTC-RI is restructuring many of its standing committee meetings as described below:

  • June 24, 07:30-08:45AM – Board of Directors
  • June 28, 05:00-08:00PM – Celebration of Champions
  • July 15, 07:30-09:00AM – Clinical Strategy Committee
  • July 19, 08:00-09:00AM – Best Practices in Team-Based Care (formerly Care Manager/Coordinator Best Practice Sharing)
  • July 22, 07:30-08:45AM – Board of Directors
Upcoming Learning Collaboratives and Professional Development
  • June 28, 07:30-09:00AM – RI MomsPRN Cohort 3 Kickoff
  • June 29, 07:30-09:00AM – Health Transition of Care Orientation Kickoff for New Practices
  • July 07, 07:30-08:30AM – Improving Child Health in RI (formerly PCMH Kids Stakeholder Meeting) 
  • July 07, 10:00-11:00AM – Year 2 NCQA Behavioral Health Learning Collaborative