Care Transformation Collaborative of Rhode Island News & Updates | December 2021
Spotlight: Dr. Peter Hollmann, CTC-RI Board President

Dr. Peter Hollmann, Chief Medical Officer at Brown Medicine, serves as our current CTC-RI Board President. Dr. Hollmann weighs-in on the work of CTC-RI in 2021.

As board president, what was the biggest success of 2021 for CTC-RI?
2020 threw us a curveball and CTC-RI stepped up and helped practices with obtaining funding, implementing telehealth, and getting immunizations back on track. By the time we hit 2021, the waters had calmed somewhat and we were able to continue with core activities of getting behavioral health integrated into primary care, developing more pediatric practices into patient centered medical homes, and building upon the successes of the community health teams. CTC-RI also began drafting a plan for the next three years and transitioned from our founding President Tom Bledsoe, MD who deserves credit for these achievements, to his understudy.
What was a challenge for CTC-RI this year, and how have we addressed it and learned from it?
The biggest challenge for everyone is fatigue with all the stressors of 2020 to now. We addressed it by being a forum for collecting and hearing concerns and solutions. Staffing has been very difficult, and with the help of Rick Brooks, Executive Director, RI Governor's Workforce Board, EOHHS, we are looking at how systems of care and practices can partner with medical assistant training programs and provide primary care training placement sites. We are also looking for ways we can partner with our colleges to provide training sites for clinicians who want to provide integrated behavioral health services in primary care. We are seeking potential funding opportunities so we can provide stipends for students and practices that provide the supervision and training.

In addition, we learned that monthly payments for primary care can help practices weather storms more effectively, and we have brought in experts from other regions that are paid for primary care by managing populations and learned how they adjusted their practices to improve patient care, while not being bound by a fee-for-service revenue system. We learned that we can only ask so much of practices, but we need to continue to inform and foster a sense of optimism. We did this in part by showcasing the amazing work done by our primary care practices in creating better equity, better access, and better care.

What goal(s) does CTC-RI have for 2022 to support and advance primary care in Rhode Island?
We want to continue to assist practices in developing capacity and processes that help them care for populations, not just the person in the office that day. We want to work to have integrated behavioral health be something that can be taken for granted as existing in primary care. We want to sustain and build upon community programs that address the most complex patients and help those who are challenged by social disadvantage to use their strengths together with community resources to attain optimal health for themselves and their families.    

We hope that you can join us at tomorrow’s Breakfast of Champions meeting for a panel discussion focusing on addressing clinician and clinical team well-being during COVID-19.

  • Moderator: Patricia Flanagan, MD, Hasbro Children’s Hospital, & Brown Univ. Pediatrics Professor
  • Panelist: Jerome Finkel, MD, Henry Ford Health System Chief Primary Health Officer, MI
  • Panelist: Matthew Malek, MD, Medical Director of Provider Experience, Thundermist Health Center; Assistant Professor (Clinical), Department of Family Medicine, Alpert Medical School of Brown University
  • Panelist: Nicolas Nguyen, MD, Associate Chief Medical Officer, Beth Israel Lahey Health Primary Care South Region; Clinical Instructor Harvard Medical School

Please register via Eventbrite to receive the link to this virtual meeting. CME credits will be available through AAFP for physicians, PAs, RNs, and NPs.
National Primary Care Surveys Show Primary Care Teams Need Support

The Primary Care Collaborative (PCC) and the Larry A. Green Center continue to engage primary care practices across the country through their primary care survey series (see the latest fall 2021 data here). PCC and the Larry A. Green Center collect data and bring visibility to provider experiences (including Rhode Island practices). They have shared important American Medical Association tools to assist primary care based on the data they have received from practices across the U.S.:

  • Caring for the Caregiver during Crisis: A specific toolkit for leaders within a clinic or health system to help create a more resilient organization, that protects and supports the workers within.
  • Stress First Aid: Another specific toolkit within Steps Forward, written by experts in PTSD in the military, with guidance on how to recognize and support healthcare workers experiencing stress injury from a crisis, such as the COVID-19 pandemic.
  • PeerRxMed: A free online platform to support clinicians provide peer-to-peer support by signing up with a buddy and receiving weekly nudges to check-in with each other, along with weekly supportive thoughts for contemplation or conversation during this time of stress.

Provider burnout has reached US historic levels exacerbated by a global health pandemic. Reported burnout levels have been increasing for years, and concern around the wellbeing and sustainability of healthcare staff during peak times of need have come to the forefront during COVID-19. A 2021 study of nurses found that more than half the sample were experiencing moderate burnout and 28% experienced severe burnout.

In an effort to combat these troubling trends, CTC-RI's senior director of IBH, Nelly Burdette, PsyD, delivered a training focused on burnout to a group of Prospect Medical Systems nurse care managers and social workers. Dr. Burdette's presentation, Burnout in Healthcare, provided an overview of the prevalence and symptoms of burnout in a healthcare setting. This 1st training is part of a 7-part series developed in cooperation with Prospect leadership and guided by feedback received from Prospect staff who completed the PPAQ self-assessment tool. Forthcoming topics include motivational interviewing, cognitive behavioral skills, and follow-up on depression screenings.

CTC-RI created a video showcasing our Community Health Teams (CHT) work ( Staff from Brown Family Medicine, Michelle Anvar, MD and LaNeir Johnson, RN along with Family Service of RI's Kinzel Thomas, LCSW discuss the value of CHT access to primary care in RI. The CHT model works as an extension of primary care to support patients by facilitating access to community-based services to address complex social, environmental, medical, and behavioral health needs. The partnership between Brown Family Medicine and Family Service of RI has served over 100 patients and together they continue to help patients achieve healthier lives. 
State COVID-19 Updates

Delayed Test Results
The laboratory that processes PCR tests from State-run sites is working to resolve some equipment issues. PCR test results are being processed as quickly as possible under the circumstances, but it is important to be aware that results will not be available within RIDOH’s normal turnaround times. The lab is estimating that results are taking about 72 hours to process. Patients will get a text or email when their result is available in RIDOH’s online result portal. For additional testing options, visit

Vaccination Rate
As of December 9, there are 893,014 Rhode Islanders who are now partially vaccinated, and 794,599 who have completed the primary vaccine series ("fully vaccinated"). The state continues to focus on getting more residents vaccinated, in particular children and youth who are now newly eligible. The current age breakdown is as follows:
OHIC Proposed Rulemaking: Affordability Standards

Office of the Health Insurance Commissioner issued an Advance Notice of Proposed Rulemaking regarding revisions to the Affordability Standards within 230-RICR-20-30-4 today. The Advance Notice is posted on the website of the Secretary of State and the OHIC website. In addition to the Advance Notice, OHIC has issued a brief paper titled Next Generation Affordability Standards: Concepts, Rationale, and Additional Information which contains an overview of potential policies that are currently under consideration by OHIC for incorporation into the regulation.

OHIC is requesting that interested parties review these proposals and provide public comment by December 23, 2021. Comments should be submitted electronically or by mail to:
Cory King, Chief of Staff
Office of the Health Insurance Commissioner
1511 Pontiac Avenue, Bldg. 69-­1
Cranston, RI 02920

At December’s Practice Reporting / Transformation meeting, Bernadette Parrillo, QI Specialist at RIPCPC, provided an overview of changes to the 2022 NCQA Annual Reporting requirements. Vicki Crowningshield and Suzanne Herzberg reviewed the core standards and measures not addressed in annual reporting requirements that practices are still expected to maintain as part of NCQA’s PCMH requirements. Clinical quality measures submitted to OHIC and CTC-RI in October were reviewed. Practices have until April 15 data submission to meet incentive payment targets. Overall, the practices are on-track to meet their PCMH Kids incentive payment targets. In addition, Amy Perry, Director of Case Management at PCHC, provided a summary of how pediatric high-risk patients are identified, outreach efforts performed using their Community Health Advocate Team, and programs available to high-risk patients and families at PCHC.

Next Practice Reporting / Transformation meeting is scheduled for February 23rd, 2022, 8:00-9:30AM.
In The News
R.I. Foundation names Dr. Alan Kurose as new board chair
Providence Business Journal
December 1, 2021

The Rhode Island Foundation has elected Dr. G. Alan Kurose as its new board chairman. Kurose is a primary care physician, president of Coastal Medical and senior vice president for primary care and population health at Lifespan Health System. He has served on the board of the Rhode Island Foundation since 2017.

During the December Board of Directors meeting, Nelly Burdette, Psy.D, CTC-RI IBH Senior Director presented a 2-year IBH project review. Joining Dr.Burdette on the IBH team are practice facilitators, Liz Cantor, PhD and Kristin David, PhD who have expanded their work over the years with current IBH initiatives including:
  • Expanding IBH systems of care with Prospect Medical Systems
  • Completion of new NCQA module to IBH Practice Facilitator Course
  • Planning and launch of new IBH Tele-IBH Learning Collaborative
  • Ongoing pediatric IBH expansion
  • Aligning IBH priorities with new RI administration in Governor’s Office and informing State policy
  • IBH workforce development planning with Department of Labor and Training, University of Rhode Island, University of Massachusetts and payor funding requests

Board members were especially interested in hearing of the IBH next steps which include:
  • IBH workforce development
  • Adult and pediatric expansion with IBH
  • Burnout in healthcare and IBH

Learn more at the CTC-RI IBH webpage.

Help us get the word out! We're looking for English- or Spanish-speaking patients, age 18+, who have received integrated behavioral health services in Rhode Island (substance use or mental health counseling through their primary care location). Patients will participate in a focus group run by Brown University and be provided with a $50 gift card. These focus groups will provide CTC-RI with valuable insight into IBH from a patient perspective. 
Please help us recruit for these groups by distributing flyers to patients in your practices who have received IBH services. (English flyer | Spanish flyer)
Clinical Strategy Committee

The first part of the November Clinical Strategy Committee (CSC) meeting was a discussion of CTC-RI Board of Directors strategic planning and 2022-23 CSC priorities led by Jim Berson, Fio Partners and Pano Yeracaris MD MPH, CTC-RI Chief Clinical Strategist. Following up was a workforce well-being conversation with participation by Rick Brooks, Executive Director R.I. Governors Workforce Board, EOHHS. Susanne Campbell, RN, MS, PCMH CCE, CTC-RI Senior Project Director presented a resource of medical assistant and behavioral health training programs in RI to include Community College of Rhode Island (Westerly Education Center), Rhode Island College, Genesis Center, and Department of Labor and Training (REAL Jobs RI). For more information on these programs, feel free to reach out to

For the December CSC meeting, there will be a panel discussion on Data Integration Opportunities in RI moderated by Andrea Galgay, MBA, Chief Operating Officer, Rhode Island Primary Care Physicians Corporation. There will be presentations on data integration use cases and implications for RI by Craig Jones, MD, Partner at Capitol Health Associates and the CurrentCare upgrade and opportunities for data integration by Neil Sarkar, PhD, MLIS, President and Chief Executive Officer, Rhode Island Quality Institute.

CME credit is available for these CSC meetings.

The 5 pediatric and adult dyad practice teams, participating in the RIDOH/CTC-RI/PCMH Kids 2021 Pediatric/Adult Health Care Transfer of Care QI Initiative, shared their progress and challenges at the December Best Practice Sharing Meeting. National Alliance to Advance Adolescent Health content experts continue to provide guidance and expertise on this initiative, and addressed questions and challenges raised at the meeting. In the next 4-5 months, the practices will complete their transition activities with the selected young adults and receive their feedback on the process. In addition, the program is developing a plan to identify costs associated with the transfer of care work to help inform the RI transfer of care cost & sustainability efforts. Special thanks are extended to Tufts Health Plan who has provided funding to support this important work.

The RI Geriatric Education Center is conducting a 2-part Geriatric Education Series on dementia with both sessions providing CME/CEU’s. Part 1 on The Aging Brain: Signs and Symptoms of Cognitive Impairment was presented at the November NCM/CC Best Practice Sharing meeting. John Stoukides, MD, RPh, explained the differences between normal and pathological memory loss, the appropriate tools used to identify cognitive loss, and methods for engaging families in evaluation and treatment of patients with cognitive loss.

Part 2 on the effects of medication on early cognitive impairment will be presented at the December 21 NCM/CC Best Practice Sharing meeting. All are welcome and pre-registration is required for this event.
Practice Resources
June 2021 Cancer Screening in RI Virtual Summit Approved for CME/CE Credits
The RISNA and AAFP has approved the Cancer Screening in Rhode Island virtual summit activity (held on 6/25/21) for up to 3.0 contact hours/enduring activity.  Participants may access and view the recorded event and submit a post-program evaluation to receive credit. The AAFP deemed this acceptable for up to 3.00 Enduring Materials, Self-Study AAFP Prescribed credit (term of approval is from 10/06/2021 to 10/06/2022). Physicians should claim only the credit commensurate with the extent of their participation in the activity. This nursing continuing professional development activity was approved by the RI State Nurses Association. This approval is valid for a period of two years, expiring October 19, 2023.

CHW Provider Enrollment & Billing Training
Now that Medicaid is preparing to begin reimbursing for some CHW services, CHWs need to learn how to bill for their time. The RI Executive Office of Health & Human Services is hoping to offer trainings on these dates: January 14 (11am-12:30pm) and January 20 (3-4:30pm).
Upcoming CTC-RI Committee Meetings and Workgroups
  • December 17, 07:30-09:00AM – Clinical Strategy Committee
  • December 21, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • January 06, 07:30-08:30AM – Quarterly PCMH-Kids Stakeholder Meeting
  • January 13, 07:30-09:00AM – Quarterly Pediatric IBH Meeting
  • January 18, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • January 21, 07:30-09:00AM – Clinical Strategy Committee
  • January 28, 07:30-08:45AM – Board of Directors
Upcoming CTC-RI Program and Initiative Meetings
  • December 10, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • December 15, 08:00-09:30AM – Care, Community, and Equity Best Practice Sharing
Upcoming Learning Collaboratives and Professional Development
  • December 10, 07:30-08:00AM – Quarterly CTC-RI Breakfast of Champions
  • January 13, 01:00-04:00PM – Rhode to Equity Quarterly Momentum Session
  • January 27, 07:30-09:00AM – Telehealth Learning Collaborative Meeting
  • March 11, 07:30-08:00AM – Quarterly CTC-RI Breakfast of Champions