Care Transformation Collaborative of Rhode Island News & Updates | February 2021
"Rhode to Equity" Applications Now Open
The Rhode to Equity is an innovative funding opportunity made available through EOHHS Health Systems Transformation Project. The intent of this 12-month learning and action collaborative is to provide up to 6 cross-sector teams with the opportunity to test and evaluate strategies that will build leadership and operational capacity for clinical-community linkages, resulting in place-based communities that improve both health and social outcomes. This work will be guided by Somava Saha, MD, MS, Well Being and Equity in the World and Well Being in the Nation Network. Using the Pathways to Population Health tools developed through 100 Million Healthier Lives, the Rhode to Equity will bring together teams from:  

  1. Health Equity Zones (backbone agencies, CBO partners)
  2. Accountable Entities (at both the leadership- and clinic-level)
  3. Community Health Teams
  4. Persons with lived experience of inequity (PLE) 

Important Dates to Remember:

  • Application openedFebruary 5 (questions accepted on rolling basis to
  • Webinar information sessions: March 26 (2-3:30pm) and April 13, 2021 (11:30am-1pm)
  • Office hours (Q&A consultation): April 1, April 22, May 12 (10-11am)
  • Applications due: May 21 (click for application)
  • Teams notified: June 4
  • Participative Agreement due back with W-9: June 18
  • Teams complete Compass Assessment: June 18
  • Team participation in kickoff meeting: July 14 (1-5pm)
Rhode Island COVID-19 Vaccination Update
RIDOH is working hard to distribute vaccines. Eligible Rhode Islanders can now receive vaccines 4 ways: through a state-run site, through a local city/town vaccine site, or through a local pharmacy site (e.g. CVS).
Save the Date: March 12 Breakfast of Champions
Please save the date for the CTC-RI Quarterly Breakfast of Champions. All Clinical Practice Champions and practice site clinical and administrative leaders are expected to attend.
Friday, March 12, 7:30-9:00am
Planned agenda and topics to include:
  • Pharmacy-led initiative to improve ED and inpatient utilization in targeted high-risk patients with diabetes.
  • Evolution of community health teams in RI as extensions of primary care promoting improved health for patients, families, and communities and strengthening community-clinical linkages.
  • Highlights from Safe, Effective and Efficient Medication Use Among Older Adults: A Pharmacy-Led Quality Improvement Initiative.
Update: Clinical Strategy Committee
The February meeting started with a presentation by Somava Saha, MD, MS, Well Being and Equity (WE) in the World and Well Being In the Nation (WIN) Network and Craig Jones, MD, Partner, Capitol Health Associates on the community health team statewide core infrastructure investment and payment discussions. This was a preview of information which will be expanded upon at the CHT Oversight Committee – Building Community Clinical Linkages Meeting on February 26. Meeting time was also dedicated to a review of the February OHIC-Sponsored Meeting on Vermont Practice Experience with Capitation with next steps being discussed. There was also an announcement of a joint CTC-RI/PCMH Kids and RIAAP meeting on March 31, 5-6:30pm to provide education on the fundamental advancements of comprehensive primary care capitation with special attention to pediatrics. Discussants will include Cory King from OHIC, John Freedman MD, Mary Jo Condon, Pat Flanagan, and Beth Lange. Additional topics were discussed regarding pandemic-related issues to include decrease in office visits especially in pediatrics. The relaxation of the 366-day rule regarding well-visits in pediatrics is seen as very important. Finally, there was a panel discussion led by Andrea Galgay, MBA, COO RIPCPC; Edward McGookin, MD MS, Coastal Medical CMO; and Peter Hollmann, MD, Brown Medicine CMO on data dissemination to practices and providers to improve care. Andrea’s presentation shared general principles and reporting examples at the peer comparisons POD-level, practice-level provider patients to goal, and at the patient-level.
OHIC Releases Updated Measurement Specifications
OHIC released updated December 2020 CTC-RI/OHIC Measurement Specifications reflecting the following changes:
  • Updated and embedded the instructions for how to obtain HEDIS Value Set;
  • Added telehealth to the definition of an Active Patient for all measures;
  • Removed “Weight Assessment and Counseling” from the PCMH Measure Set*.

Adolescent Well-Child Visits include an age range of 12-21 with the understanding that practices would not include children in the denominator who have been discharged from the practice.

At this point in time, OHIC is expecting that quality improvement will be determined by having practices exceed 2018-2019 performance rates on clinical measures (except Controlling High Blood Pressure) which are outlined in the 1/4/21 memo. This decision will be re-visited in Spring 2021 to reassess whether any changes are needed based on the impact of COVID-19. 

OHIC has adopted the revised specifications for Controlling High Blood Pressure and this measure will be “report only” for 2020-21.

*Health plans will continue to include BMI and counseling as part of the PCMH Kids Cohort 3 Performance Standards.
10 Practices Join RI MomsPRN Learning Collaborative Kickoff
CTC-RI, in collaboration with RIDOH, hosted the February 23 RI MomsPRN learning collaborative kickoff meeting for the 10 participating women’s health practices that care for pregnant and postpartum patients. Margaret Howard PhD, Division Director for Women’s Behavioral Health at Women and Infants Hospital, who was a founding member of the Day Hospital program, and also serves as the Executive Director for Women’s Mental Health at Care New England led a discussion on how to incorporate evidence-based screening tools for depression, anxiety and substance use disorders into the work done by the clinical team and resources available through teleconsultation services.
RIDOH has partnered with the Center for Women’s Behavioral Health (CWBH) at Women and Infants Hospital to provide a free statewide teleconsultation service staffed by perinatal behavioral health experts who can assist practices with behavioral health diagnosis, treatment planning, medication management as well as identification of appropriate community resources and services. Providers treating perinatal patients are welcome to call the RI MomsPRN psychiatry teleconsultation line M-F at 401-430-2800 or learn more by visiting their website ( RIDOH has contracted with CTC-RI to provide project management, data and evaluation support, as well as practice facilitation services for those involved in this learning cohort.
Partnering to Strengthen Clinical-Community Linkages: RI Diabetes Health Equity Challenge: Wave 2
On February 12, the Wave 2 Teams (East Bay Community Action Program and Central Falls/Pawtucket Team) participated in a Momentum Session about stratifying risk to ensure population health. Somava Saha, MD, MS, Well Being in the Nation facilitated a discussion on how to stratify for a particular population by using real-life RI patient case examples. Equity is about creating systems that reliably identify and give people the support they need. The discussion made the teams think about a broader community strategy to address underlying determinants in order to see and plan for the whole picture.
Telehealth Learning Collaborative Kickoff Held
On February 10, 21 practices came together virtually to kick off the Telehealth Learning Collaborative funded through UnitedHealthcare and authorized CARES Act funding. The kickoff featured a presentation by Lisa Bard Levine, former CEO and senior advisor to the Maven project, who shared her knowledge on the important considerations, challenges, and opportunities of telehealth implementation. In addition, the group shared their projects to include 24-hour ambulatory blood pressure monitoring, monitoring of adolescents with ADHD via a mobile app, and programs to support patients and families in the use of telehealth. The learning collaborative will run from Feb 2021 to Jan 2022 for cohort 1, and from May 2021 to April 2022 for cohort 2.
CTC-RI Continues Telehealth Webinar Series on March 19
CTC-RI/PCMH Kids' next telehealth webinar, made possible by authorized CARES Act and UnitedHealthcare funding, will be held Friday, March 19 from 9:00-10:30am. The webinar, "Rhode Island Telehealth Sustainability Strategies - Strategies for Community Health Workers and Patient Navigators" will focus on helping clients overcome technology barriers and get the most out of a telehealth visit. The target audience for this webinar is Community Health Workers (CHW) and Patient Navigators. Participants in this webinar are eligible for educational hours toward earning the CCHW certification for RI.

Register today. The recording will be made available on the CTC-RI website after the webinar. Questions? Reach out to Sue Dettling, CTC-RI, at
CTC-RI Holds Telehealth Workflow Webinar
As part of the Advancing Team-Based Telehealth webinar series funded by UnitedHealthcare, CTC-RI offered a February 23 webinar addressing telehealth workflow strategies. Barrington Family Medicine and Anchor Medical, 2 practices with significant experience implementing telehealth, served as panelists for the focused discussion.
In the News
Lowering A1c Through Integrated Behavioral Health Group Visits
By Dr. Markin Kerzer, Dr. Siddharth Marthi, Jamie Handy, Kristin David, PsyD
Rhode Island Medical Journal (February 2021)
Read this month's published article in the Rhode Island Medical Journal highlighting the work of Associates in Primary Care Medicine and their pilot study aimed to evaluate the effect that group visits, conducted using an integrated behavioral health model at a primary care practice, had on A1c and distress levels in diabetic adults. Read about their success here.
Rhode Island’s Cost Trends
Project: A Case Study on State
Cost Growth Targets
By Erin Taylor, MPH, Michael Bailit, MBA, Megan Burns, MPP, and Justine Zayhowski, MPP
Peterson-Milbank Program for Sustainable Health Care Costs (January 2021)
Rhode Island is among a few states that have implemented a cost growth target to
stimulate action to improve health care affordability and curb health care spending
growth. A health care cost growth target forms the basis for accountability for spending growth at the state, provider, and insurer levels. Rhode Island’s experience highlights how a small team of state staff, engaged state and private sector leadership, and committed stakeholders can address rising health care costs. Read the featured case study here.
Pediatric Alternative Payment Model Learning Session
Pediatric leaders are invited to participate in a virtual learning session scheduled for March 31, 6-7:30pm on where we’ve been and the opportunities going forward regarding Alternative Payment Models. There will be presentations and discussion about special considerations related to pediatric care lead by Cory King, Director of Policy at OHIC, as well as John Freedman and Mary Jo Condon with Freedman Health.

Meeting ID: 959 6302 4930
Passcode: 646876
One tap mobile: +13126266799,,95963024930#,,,,*646876#
Update: Nurse Care Manager/Care Coordinator Best Practice Sharing
Adolescent well-child care was the topic discussed at the February 16 NCM/CC meeting. Some PCMH Kids practices (Tri-County, PCHC, Ocean State Pediatrics and Partners in Pediatrics) have implemented targeted strategies for improving outreach to families to increase the number of well-child visits. These efforts include setting up a resource fund that staff can use if families are having difficulty with transportation, opening up schedules on evenings and weekends to better accommodate family needs, and medical assistants and community health workers using KIDSNET reports to identify pediatric patients who have not been in and making direct outreach calls to families.

Sarah Hagan, PhD discussed how PediPRN can help practices with diagnostic clarification, treatment planning, pharmacological and psychotherapy guidance and when unable to access behavioral health resources. Pat Flanagan MD, FAAP shared her recommendations for using a strength-based approach to the adolescent well-child interview and the importance of outreach to connect with adolescents during COVID-19. 
January Results from National Primary Care Survey
Thank you for your efforts in completing the Larry A. Green Center / Primary Care Collaborative Primary Care Surveys. This month, the Series 25 data led to a New York Times article: Primary Care Doctors Are Left Out of the Vaccine Rollout. Please note that for data to be generalizable, Rhode Island needs just 15 providers to respond to the survey. The January results are now available, including both national and Rhode Island-specific results:

Update: Practice Reporting and Transformation Best Practice Sharing Committee
During the February 24 meeting, PCMH Kids Cohort 3 practices discussed outcomes from implementing their Performance Improvement Plans, many of which show improving immunization rates within their practices. Some practices indicated that they have learned how to use the KIDSNET registry for immunization data reports and other functions. Some targeted repointing strategies included:
  • using visit cancellation reports and working with front desk staff to maximize efforts to reschedule appointments at the time that the parent is cancelling the visit;
  • generating reports that capture children who are overdue and capturing if children have another scheduled appointment;
  • looking at obtaining data that captures children behind on well-child visits and immunizations and addressing both issues at the same time;
  • assuring that reports are accurate and discharging patients who no longer are coming into the practice;
  • standardizing the frequency when reports are generated and reviewed by the team; and
  • how to use reports to help inform pre-visit planning. 

Practices have also used information and parent feedback to identify scheduling needs and added scheduling opportunities such as: vaccine-only appointments, Saturday/evening appointments, appointments with more than one child. Personalized outreach using community health workers who can use designated funds to address barriers to care have been very successful. Some practices are exploring how to make better use of technology (such as texting, increasing use of the portal) to improve communication and reduce staff time. While most practices focused on improving immunizations, Santiago joined forces with the Home Asthma Response Program (HARP) to identify children who had two or more emergency department visits and have home visits made through St. Joseph’s Health Center to improve asthma knowledge, and trigger exposures, which has been very effective in reducing ED visits for asthma conditions.
Healthcentric Advisors Hosts Free 6-Week Diabetes Education Trainings
Healthcentric Advisors invites practices to share with their patients ways to learn how to navigate the physical and mental ups and downs of life with diabetes. Their free, 6-week program, brings people together who are living with diabetes to share their experiences and to discover new ways to manage it. Register for the course to develop a personalized diabetes management strategy:
  • Setting goals
  • Problem-solving
  • Healthy eating
  • Exercise
  • Tools and resources
These classes are aimed for people living with diabetes, pre-diabetes, family members and caregivers.

Practice Resources
POSTPONED: 2021 CTC-RI Annual Conference
The CTC-RI Annual Conference is being postponed to May 12, 2022. Please stay tuned for more updates and details as they become available.

RIPIN Hosts Virtual Diabetes Self-Management Program
This workshop teaches adults how to manage Diabetes symptoms and medications, communicate with family and doctors, relieve stress, eat well, exercise, and set attainable goals. Sessions are 2.5 hours per week for 6 weeks. Sessions run through the end of March (March 9 is the last day to register).

CTC-RI COVID-19 Briefing
Please reference CTC-RI's latest COVID-19 briefing for related updates, news, and practice resources.
Upcoming Meetings (for CTC-RI members)
March 04, 2021, 07:30-08:00AM – Virtual Coffee Breaks with Dr Pat Flanagan & Dr Beth Lange
March 05, 2021, 09:00-10:00AM – Integrated Behavioral Health Tele-IBH/NCQA BH Distinction Kickoff
March 12, 2021, 07:30-09:00AM – Quarterly CTC-RI Breakfast of Champions
March 12, 2021, 09:30-11:00AM – Community Health Team (CHT) Best Practice Meeting
March 16, 2021, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
March 18, 2021, 03:00-04:30PM – SBIRT/CHT Executive Committee
March 19, 2021, 07:30-09:30AM – Clinical Strategy Committee
March 26, 2021, 07:30-08:45AM – Board of Directors Meeting
March 26, 2021, 09:00-10:00AM – CHT Oversight Committee