Care Transformation Collaborative of RI

News & Updates | January 2023

New CTC-RI projects and funding for 2023

With generous funding support from UnitedHealthcare, Rhode Island Department of Health and Blue Cross & Blue Shield of Rhode Island, CTC-RI will launch several innovative projects in 2023 to invest in and strengthen primary care capacity in several priority areas. Anticipated projects in the new year include:

  • Primary Care Team-Based Training and Support – Learning collaborative for up to 10 practices to train in best practices in team-based care, defining team roles, and developing strategies for primary care in a post-pandemic environment to strengthen staff and patient care experience.

  • Pediatric Population Health Pilots – Projects to support increasing care access for children with restrictive eating disorders and improving transitions of care for youth transitioning from pediatric to adult primary care.

  • Increasing Integrated Behavioral Health (IBH) Capacity in Pediatrics – Components under this area include offering IBH training to BH clinicians working in outpatient settings, developing incentives for outpatient BH clinicians to enter into IBH arrangements with primary care, and supporting a learning collaborative to increase IBH capacity in pediatrics by expanding the care team to include CHWs/BSWs.

  • Alzheimer’s Care Support – Pilot to improve the capacity of primary care practices to implement evidence-based clinical guidelines and improve care for patients with Alzheimer’s and their caregivers.

CTC-RI will be issuing several calls for applications with funding available for practices to participate in these projects. Stay tuned for more information to be shared in upcoming newsletters!

“Blue Cross & Blue Shield of Rhode Island is committed to improving the health and well-being of Rhode Islanders by improving access to high-quality, affordable, and equitable care. As an organization, we strive to find innovative ways to strengthen access to behavioral health services. We are pleased to fund projects in 2023 at CTC-RI that will increase the capacity of primary care providers to deliver integrated behavioral health services. We look forward to continued partnership with CTC-RI and other Rhode Island stakeholders to move this important work forward.”

Rena Sheehan

Vice President Clinical Integration at Blue Cross & Blue Shield of Rhode Island

“UnitedHealthcare is pleased to continue our support of CTC-RI’s primary care transformation efforts, specifically those programs that will support pediatric and adult integrated behavioral health. We recognize that the support of primary care physicians, with a focus on improving behavioral health and whole-person care, is vital to making the health system work better for everyone – ultimately leading to helping people live healthier lives.”

Tim Archer

CEO, New England Health Plan at UnitedHealthcare Employer & Individual

Clinical Strategy meeting focuses on supporting primary care providers in screening for pregnancy intent

CTC-RI’s December Clinical Strategy Committee meeting focused on the role of pregnancy intention in improving birth outcomes and access to same-day long acting reversable contraception (LARC). Patricia Flanagan, MD, set the stage with sharing data from the Pregnancy Risk Assessment Monitoring Syste (PRAMS) Databook, focusing on women's self-reported pregnancy desires. Julie Parker, LCMHC, CCM, Assistant Director, Vermont Blueprint for Health, Amy Ripley, LISCW, Community Initiatives & Community Health Team, Brattleboro Memorial Hospital and Rebecca Burns, BS, RN, Community Initiatives & Community Health Team, Brattleboro Memorial Hospital, then spoke about Vermont’s statewide program on improved birth outcomes through their pregnancy intent initiative and the additional support provided for pregnant and postpartum women at Brattleboro Memorial Hospital. This was followed by a presentation from Melanie Priestly, MS, Practice Transformation Director, and Seville Meli, MPH, Vice President, Practice Transformation, with Upstream USA who talked about their efforts to increase access to a full range of contraceptives and their current partnerships with primary care practices in RI. 

To view the recording, find additional resources, and claim CME credit, check out our page on CME Coursework.

Best Practices in Team-Based Care Meetings

December: Incontinence in Older Adults

Kendra-Llynn Bisconti, PT, DPT, a pelvic floor therapist from the Spaulding Pelvic Rehabilitation Center, presented at the December Best Practices in Team-Based Care meeting on the topic of incontinence in older adults. Her presentation began by raising awareness of the prevalence of urinary incontinence in older adults. She educated participants on the primary types and transient causes of urinary incontinence and recommended options for treatment. In addition, Kendra-Lynn shared referral sources to support patients with urinary incontinence (access the evaluation form here). This session was brought to you by the RI Geriatric Education Center.

January: Nurse Care Manager/Care Coordinator Case Based Capstone Presentations

In September, CTC-RI offered 18 nurse care managers/care coordinators (NCM/CC) the opportunity to participate in the NCM Core Curriculum program. NCM/CC who have successfully completed the 12-week training program demonstrate how they are using their knowledge and skills by presenting their case-based capstone at the January and February Best Practices in Team-Based Care meetings. Congratulations! NCM Core Curriculum program is funded in part by UnitedHealthcare and the RI Department of Health.

Improving Care for People with Asthma: Working with Community Partners ECHO Session


Our 4th Asthma Essentials ECHO session brought together 48 participants and was facilitated by Pat Flanagan, MD. The didactic session, presented by Daniel Fitzgerald, MPH, ICPS, American Lung Association and Ashley Fogarty, MPH, Rhode Island Department of Health, focused on “Working with Community Partners.” Participants learned about resources available through the American Lung Association to support adults and through the RI Department of Health to support students and families. Marjorie Carges, MD, Bald Hill Coastal Medical, provided the case presentation which allowed for richer discussion of supporting patients with asthma in foster care and how to leverage community resources to support these patients. Access materials and the recording from previous meetings here. Funding for this program is provided by the RI Department of Health and Tufts Health Plan.

RI MomsPRN Learning Collaborative on alcohol use in perinatal women

The RI Maternal Psychiatry Resource Network (RI MomsPRN) program funded by the RI Department of Health, in partnership with CTC-RI, hosted our quarterly learning collaborative meeting this month which included a presentation by Mary Velasquez, PhD on alcohol use in perinatal women. Participating practices reported on their progress in implementing universal screening of their perinatal patient population. This event hosted 24 participants, including healthcare providers and staff from across the state (access the PPT and recording).

As a reminder, any providers and health care staff seeing pregnant and postpartum people are welcome to call the RI MomsPRN teleconsultation line at 401-430-2800, Monday through Friday, 8am-4pm for real-time assistance. Behavioral health clinicians from Women & Infants Hospital, including specialized psychiatrists, psychologists, and resource and referral specialists, are available for clinical consultation regarding behavioral health diagnosis, treatment planning, and medication safety and can also provide resource and referral support to community-based treatment and support services. 

Medicaid Pediatric Healthcare Recovery Program – Year 2

With funding from the Medicaid Pediatric Healthcare Recovery grant, KIDSNET has launched a new immunization report in the KIDSNET reporting system that will assist practices in identifying children that are due for immunizations. Instructions can be found here.

Practices should have received their January monthly KIDSNET performance report around January 18, providing a status of the practice’s eligibility for payment based on achievement of 3 out of 4 immunization/lead screening targets or improvement targets. Practices should have also received an EOHHS email outlining a one-time opportunity to appeal performance results, should practices uncover data missing from KIDSNET that would make them eligible for meeting targets. Your practice facilitators are available for support.

The second Medicaid Pediatric Healthcare Recovery Program payment is scheduled for early February and is contingent on meeting 3 out of 4 immunization/lead screening targets or improvement targets based on January 15 KIDSNET data.

Practices are additionally eligible for participation payment based on practice staff attending 4 out of 6 Behavioral Health ECHO® Learning Sessions with practice payment due in July 2023. Please register for the January 26 Behavioral Health ECHO learning session. View future monthly learning sessions here.

All practices participating in the Medicaid Pediatric Healthcare Recovery Program (Year 2) are encouraged to attend the February 2 Improving Child Health in RI meeting (moved from January 5). Information on how to access the new KIDSNET Immunization Reports and Family Visiting Reports will be shared. Zoom details here.

Please reach out to your practice facilitator or Carolyn Karner at [email protected] with questions.

Application launched for UMASS Integrated Behavioral Health training

CTC-RI is excited to launch a new application for the spring session of the UMass Chan Medical School Certificate Course in Primary Care Behavioral Health. This project is funded by UnitedHealthcare and Blue Cross & Blue Shield of Rhode Island with the goal of increasing integrated behavioral health (IBH) clinician capacity in RI. This course is designed for behavioral health clinicians, (i.e. LICSW, LCSW, PhD, Psy.D, LMHC) working in RI who are committed to moving into an IBH role at a primary care practice in RI. For these learners, CTC-RI will offer a no-cost enrollment in the UMass certificate course and a $500 stipend upon successful completion of the course. The course consists of 22 pre-recorded modules that can be completed at your own pace (March 1 - May 31). For more on the program, application information, and a detailed timeline, click here.

CTC-RI celebrates with Rhode to Equity teams at Biannual Conference

Note: This is a corrected version of the article originally posted in our December newsletter acknowledging our RIDOH and EOHHS convening and funding partners for the Rhode to Equity Work.

In December, CTC-RI was pleased to support the 1st in-person convening of the Rhode to Equity (R2E) project which began in July 2021. RIDOH and EOHHS are funders and key partners in this project. There were 6 multi-stakeholder teams coming together to address health inequities in their communities. Approximately 100 people gathered at the Boys and Girls Club of Pawtucket, including R2E team members, state agency staff, managed care organization staff, community health workers and other relevant stakeholders.

Highlights of the day included subject matter expert sessions with national and local leaders on healthy housing, food justice, and housing first models. Keith Stokes, Director of Business Development for the City of Providence provided the keynote presentation. In his role at the City, he advances a social and economic justice process that will strategically deploy federal American Rescue Plan Act funds in neighborhoods and city populations that have faced historical racial discrimination practices that have been exacerbated through the COVID-19 pandemic. He shared the history of slavery in RI and its impact on current day racial injustice and inequities. 

Valerie Tutson, Executive Director, RI Black Storytellers, led the group in an exercise to amplify the power of storytelling to give people agency and voice. Attendees practiced both telling and listening to stories.

The day ended with everyone reflecting on what they were going to take away from the conference proceedings and incorporate into their R2E projects. We look forward to the next in-person meeting in June 2023!


Study: R.I. tops in nation for COVID-19, flu child vaccination rates

By Claudia Chiappa, Providence Business News

PROVIDENCE – Rhode Island ranked first in the nation for child vaccination rates for COVID-19 and flu, according to a study by QuoteWizard by Lendingtree released Monday. Analysts looked at vaccination rates for COVID-19 and the flu among school-aged children younger than 17. They collected data from the Centers for Disease Control and Prevention and the American Academy of Pediatrics, combining the score of flu and COVID-19 vaccination rates to determine each state’s overall vaccination rates. Data for COVID-19 vaccination rates studied the number of children that received at least an initial dose of the coronavirus vaccine. Read 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

  • January 27, 07:30-08:45AM – Board of Directors
  • February 02, 07:30-08:30AM – Improving Child Health in RI (formerly PCMH-Kids Stakeholder Meeting)
  • February 09, 07:30-09:00AM – Quarterly Integrated Behavioral Health Committee
  • February 17, 07:30-09:00AM – Clinical Strategy Committee
  • February 21, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • February 24, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • 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
  • February 08, 07:30-08:30AM – Asthma Essentials ECHO
  • February 16, 07:30-08:30AM – Pediatric Weight Management ECHO
  • February 22, 07:30-08:30AM – Medicaid Recovery Program BH ECHO Learning Session - Navigating Schools to Improve Connections
  • February 23, 07:30-08:30AM – Quarterly Health Care Transitions Learning Collaborative
  • February 23, 02:00-03:00PM – Monthly Healthy Tomorrows
  • February 28, 07:30-09:00AM – Pharmacy QI Learning Collaborative: CGM & ABPM
Care Transformation Collaborative of RI | [email protected] |