Care Transformation Collaborative of Rhode Island News & Updates | December 2020
Practices selected for 2021 Telehealth Learning Collaborative
CTC-RI is pleased to announce that 21 pediatric, adult, and family practices have been selected to join the CTC-RI / PCMH Kids Telehealth Learning Collaborative, which has been funded by UnitedHealthcare and authorized CARES Act funding. The following practices and practice organizations will be represented in the Collaborative:
  • A to Z Primary Care
  • Anchor Medical
  • Barrington Family Medicine
  • Barrington Pediatrics
  • CharterCARE—Dr. Yamada
  • Coastal Medical
  • Encompass Pediatrics
  • Hasbro Pediatrics
  • Kingstown Pediatrics
  • Medical Associates of RI
  • P.R.I.M.A., Inc
  • Richard Ohnmacht, MD
  • Santiago Medical Group
  • Wayland Medical Associates

The group will participate in a year-long learning collaborative designed to support practices in testing the use of telehealth technology to improve care for patients with chronic conditions. As their focus for the Learning Collaborative, practices have chosen a wide range of chronic conditions including asthma, hypertension, anxiety, ADHD and heart failure. Practices will also explore a variety of technology platforms to provide care including medical apps, remote monitoring technology and data management portals.

Practices in Cohort 1 will kick off in February 2021 and Cohort 2 will start in May 2021. Congratulations to all of the selected practices!
Learning From Others Corner: Tufts Health Plan On-Demand Webinar Focuses on Telehealth Workflow Proficiency
In response to the COVID-19 pandemic, the provider community rapidly enabled telehealth capabilities. Tufts Health Plan (THP) recognizes telehealth is a valuable method of communicating and treating patients, and offered a webinar learning opportunity to share perspectives on how to optimize the virtual experience in a meaningful way. THP partnered with the Northeast Telehealth Resource Center (, in conjunction with Stony Brook Medicine, to host a live webinar (now available on demand here using passcode: tGVGJJp2) to address enhancing proficiency with telehealth workflow while ensuring a quality visit for the patient. Speakers include Kimberly Noel, M.D., M.P.H., Director of Telehealth, Stony Brook Medicine, New York and Andrew P. Solomon, MPH, Senior Program Manager, Northeast Telehealth Resource Center.
Accessing and Utilizing the RI Dept. of Health Chronic Disease Self-Management Programs in the Virtual Environment
The Rhode Island Department of Health is now offering chronic disease self-management education programs in the virtual environment. At this month's Nurse Care Manager / Care Coordinator Best Practice Sharing meeting, Jasmine Franco, MS Chronic Disease Self-Management Education Program Manager, with Vicki Crowningshield and Kelsea Tucker, discussed how primary care practices and patients can take advantage of small group virtual workshops designed to increase patient confidence in managing chronic conditions such as diabetes, pre-diabetes, arthritis and chronic pain. New during COVID-19 has been a Care Giver Program that will be offered again in January 2021, and other self-directed, on-demand self-management programs. Patient referrals can be made by completing the CHN Referral Form, calling CHN (401 432 7217), or registering online. Staff from Community Health Network (CHN) program will contact and assist patients with being scheduled for a self-management program that will best meet their needs. CHN staff will provide feedback to practices regarding patient participation. 

Also at this month's Best Practice Sharing meeting, Ashley Fogarty, MPH, RI DOH Asthma Control Manager provided an update on how the Asthma Action Program has pivoted to providing services virtually, and how eligibility for the Home Asthma Response Program (HARP) has been expanded to provide services statewide.
In the News
Why Primary Care Can Make COVID-19 Vaccine Distribution More Successful
Milbank Memorial Fund Blog
December 1, 2020

In Rhode Island, the top-ranked adult flu vaccination state, officials of Coastal Medical, the state’s largest primary care group, viewed the flu vaccine administration this fall as a “dry run” for delivering a COVID-19 vaccine in high volume over a relatively short time frame while maintaining social distancing standards. Using state-purchased supplies and a well-honed statewide immunization registry, officials quickly devised and revised a drive-through model that worked very well for both patients and staff. Without suspending any existing services, Coastal’s leaders believe they can easily administer 600+ doses per day. Read the full blog post here.
Advancing Health, Equity, and Well-Being Through Community-State Data-Sharing
A November 2020 Report

In Rhode Island, the state’s Care Transformation Collaborative, in collaboration with Well-being and Equity (WE) in the World, launched a “Diabetes Health Equity Challenge” to improve population health for people with diabetes who are at higher risk for COVID-19. The Rhode Island Diabetes Health Equity Challenge uses funds from the CARES Act for a five month Initiative that engages key partners, including: a Health Equity Zone, a community health team, an Accountable Entity (Medicaid ACO), a primary care practice that serves vulnerable populations, and a patient with lived experience of inequities with diabetes. Read the full report here.
Community—Clinical Linkages as a Critical Component of Comprehensive Primary Care
On December 4, CTC-RI launched the first of its three-part series, “Building Community—Clinical Linkages”. Rhode Island has a unique opportunity to promote a statewide Community Health Team (CHT) network, as an extension of primary care, to help meet patient needs, spur innovation, and strengthen community—clinical linkages. The purpose of these meetings is to create a multi-sector investment and payment strategy that advances work led by the Rhode Island Foundation, Health in Rhode Island: A Long Term Vision; the RI Medicaid AE/SDOH strategy, including the Rhode to Equity, and primary care / health system-based community—clinical linkage strategies. Somava Saha, MD, MS, Executive Director Lead from Well Being in the Nation, facilitated the discussion on the key roles of CHTs and sustainable multi-sector payment strategies to support community CHTs across the nation. Craig Jones, MD, Partner from Capitol Health Associates, facilitated the discussion on the Vermont’s Community Health Teams Blueprint Model and lessons learned that could be applied to Rhode Island. This discussion will continue during Part Two of the series on January 22. Click here for the recorded webinar.
RIQI Launches COVID-19 Dashboard
Rhode Island Quality Institute launched a COVID-19 Dashboard within the Care Management Dashboard, which includes COVID-19 lab test results data and a risk dashboard to Rhode Island medical providers. The Dashboard includes near real-time lab test result data from Rhode Island’s Health Information Exchange, CurrentCare, including CVS Health drive-thru testing results. A COVID-19 risk score is also included based upon the latest evidence-based risk factors.

The COVID-19 dashboard receives data from participating partners and displays information that is specific to each provider. This helps the Rhode Island medical community understand the needs and risks of their patient population so they can provide more effective and efficient care.

RIQI is now receiving COVID-19 lab test result data from East Side Clinical Laboratory (ESCL) in the COVID-19 Dashboard for both CurrentCare and non-CurrentCare enrolled patients. Test results include PreK-12 students and staff antigen tests. In addition to ESCL, the Dashboard is also receiving test result data from Coastal Medical laboratories. RIQI is actively working with Dominion Diagnostics to share their COVID-19 lab test result data.
For a full list of RIQI COVID-19 lab data availability, click here.

COVID-19 lab test results are also available in CurrentCare Viewer for medical professionals and CurrentCare for Me for patients. View RIQI's guide to understanding COVID-19 results in CurrentCare here or RIQI's guide to understanding COVID-19 results in CurrentCare for Me here.
CTC-RI Clinical Strategy Committee Update
The Care Delivery Design project supported by the Clinical Strategy Committee (CSC) has continued to make progress on a “core competencies in PC capitation best practices” document for pediatric and adult care. An online practice and system of care capitation readiness self-assessment document has been produced which participating practices and SOC have begun to complete. The 11/20 CSC meeting included a well-received panel discussion with presentations from Steve Strongwater, MD, CEO of Atrius Health and Gail Sillman, founder and former CEO of Central MA IPA. They discussed primary care delivery advances in their respective organizations that support improved performance in risk contracts. A CSC subgroup has also met monthly to help inform the CSC agenda and Care Delivery Design. Planning for 2021 efforts are underway.
December 11 CTC-RI/PCMH Kids Breakfast of Champions
The December 11 CTC-RI/PCMH Kids Breakfast of Champions hosted almost 80 participants representing clinical practice champions and practice site clinical and administrative leaders. The event included presentations and discussions covering the following topics:
  • Review of Pediatric Immunization and Medicaid Access Efforts
  • Review of “Care Delivery Design for Pediatric Practices to Maximize Success in Comprehensive Primary Care Capitation”
  • Current COVID Pandemic Challenges for Practices

Please join the December 18 CTC-RI Clinical Strategy Committee meeting (7:30-9am) when the Care Delivery Design for Adult Practices will be on the agenda.
Practice Resources
CTC-RI List of Resources for Community, Fitness, Counseling Support, Stress Management, Volunteering, and More
Please reference CTC-RI's growing list of resources throughout the community.

On-Demand Webinar: Caring for Older Adults - The Impact of COVID-19
Project ECHO® is a free, practical, case-based tele-education series. This session's topics include: reopening Rhode Island during the pandemic, an update on COVID-19 in long-term congregate care settings, prevention and management of COVID-19 in the elderly, and more.

Resources for Survivors of Domestic Violence During COVID-19
People who are surviving violence in their relationships or families may be experiencing increased isolation and danger caused by social distancing measures during the COVID-19 pandemic. This important list of resources remains open and accessible to anyone who needs them, offering clinical, support and advocacy services.

Job Opening: Director of Behavioral Health, Wood River Health Services
Wood River Health Services provides team-based care consistent with the principles and standards of a Patient Centered Medical Home (PCMH). Behavioral Health staff are core members of a team that provides services aligned with PCMH. Under the administrative leadership of the President and CEO, the Director of Behavioral Health will be responsible for the behavioral health services at WRHS. Click here for details.
Upcoming Meetings (for CTC-RI members)
January 07, 2021, 07:30-08:30AM – Quarterly PCMH-Kids Stakeholder Meeting
January 08, 2021, 09:30-11:00AM – Community Health Team (CHT) Best Practice Meeting
January 14, 2021, 07:30-09:00AM – Quarterly Pediatric IBH Meeting
January 15, 2021, 07:30-09:30AM – Clinical Strategy Committee Meeting
January 19, 2021, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing Meeting
January 22, 2021, 07:30-08:45AM – Board of Directors Meeting
January 22, 2021, 09:00-10:30AM – CHT Oversight Meeting - Building Community Clinical Linkages