Care Transformation Collaborative of Rhode Island News & Updates | January 2022
Spotlight: Sara Remington, Family Home Visiting Implementation Manager, RIDOH

Sara Remington serves as the RI Department of Health's Family Home Visiting Implementation Manager, helping implement, guide, and support important home visiting efforts statewide, including the Healthy Tomorrows program with pediatric primary care practices.

How was the family home visiting program made possible in Rhode Island, and why was it important?
The three evidence-based programs available through the RI Department of Health (Healthy Families America, Nurse-Family Partnership and Parents as Teachers) are funded by the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program through HRSA. There is also some funding through the state’s Preschool Development Block Grant. There is a short term family visiting program, First Connections, that is supported by a mix of funding.

Through home visiting, what unique hurdles was the Healthy Tomorrows program able to target for families to improve care in RI, and why?
The family visiting program is excited to participate in the Healthy Tomorrows program. Programs and systems of care should not work with families in isolation. Healthy Tomorrows provides intentional opportunities for family visiting providers and pediatric medical homes to partner together and work alongside families. This is exciting, as families tell us that this is what they need. They want the different programs and services with which they are working to collaborate and work together. Read the full interview here.

The RI Office of the Health Insurance Commissioner (OHIC) provides primary care practices with the opportunity to submit their quality measure performance data in order to be considered for RI Patient Centered Medical Home (PCMH) designation. OHIC compares practice performance against established clinical quality benchmarks to determine if a practice qualifies for enhanced insurance payments. Read more about the modified 2020-2021 benchmarks here.

Thank you to the nearly 100 attendees and presenters who joined us at our December 10 Breakfast of Champions, with workforce wellbeing and resilience top of mind for many practices. Local, regional, and national presenters shared their approaches to provider and clinical team wellbeing. Missed it? Read a recap, access the presentations, or claim your CME credit here.

SAVE THE DATE! Our spring Breakfast of Champions is March 11 (7:30-9am) on pediatric and adult asthma strategies. More details to come.

The RI Geriatric Education Center presented Part 2 of their Geriatric Education Series on dementia at the December Nurse Care Managers/Care Coordinators Best Practice Sharing meeting. Christine Eisenhower, PharmD, BCPS discussed medications that may contribute to cognitive impairment, reviewed the safety and efficacy of approved treatments for early to mild cognitive impairment, and provided education regarding supplements and clinical trial opportunities.

This month and next month, NCM Core Curriculum program participants will graduate from and present their capstone projects. Read more.

The December Clinical Strategy Committee (CSC) concentrated on national and statewide data integration strategies. Two experts presented on how to use data to inform population health and deliver actionable information to providers. Craig Jones, MD conveyed the national primary care transformation perspective and Neil Sarkar, PhD, MLIS discussed opportunities for RI. Andrea Galgay, MBA moderated the discussion on how to leverage health information technology to improve clinical care, reduce health disparities, and reduce unnecessary utilization. Read more here and learn about January CSC meeting plans.

Our PCMH Kids January Stakeholder meeting focused on the tremendous work being done by primary care community to meet the needs of children and families. Drs. Flanagan and Lange kicked off the meeting by recognizing Dr. Clyne’s dedication and years of service with the RI Department of Health. Ellen Amore from KIDSNET presented COVID vaccine data and highlighted the outstanding work in providing children and adolescents with COVID vaccines and improving childhood immunization rates to pre-COVID levels. Dr. Beata Nelken and Carrie Bridges shared the work continuing in Central Falls and Providence to address COVID. Department of Health Dr. Alexander-Scott thanked the group for their efforts and answered questions from the audience.

A special thank you to Dr. Alexander Scott for her years of service to Rhode Island as she resigns from her position as Department of Health Director. She has been an invaluable state leader during this pandemic!

Read more on the meeting here. Mark your calendars! Virtual Coffee Breaks with Drs. Flanagan and Lange continue February 3 and March 3 (7:30-8am).

January’s Integrated Behavioral Health (IBH) meeting focused on CTC-RI’s Pediatric IBH program. Liz Cantor, PhD reviewed project expectations and screening results, highlighting the tremendous performance practices achieved. Susanne Campbell, RN, MS, PCMH CCE provided information on CTC-RI's efforts to partner with URI and RIC to address behavioral health workforce needs and future pediatric learning collaborative efforts. Marti Rosenberg, MPS, Director of Policy, Planning and Research for EOHHS, presented and solicited feedback from the audience on RI’s Behavioral Health system transformation plans across the lifespan. Read more and share feedback.

The Rhode to Equity Initiative teams have been hard at work for over 6 months focusing on their respective aims within their communities, and utilizing the pathways to population health framework. On January 6, the 6 health equity zones (HEZs), along with their partners (accountable entities, primary care clinics, community health teams, community-based organizations, and individuals with lived experience of inequities) came together and shared their project progress and brainstorm for Year 2. Read more.
Rhode Island COVID Updates

Launch of 401Health
Rhode Island’s new public health mobile app, 401Health, provides an easy way to track COVID symptoms; find COVID vaccine records; and learn about COVID testing, treatment, and vaccination.

Governor McKee and the RI Department of Health have been working to increase test result turnaround time, in addition to providing municipalities and community partners with additional rapid tests to meet demands.

As of January 19, the state's COVID transmission rate is showing a 21.2% decline from last week, but still remains high, with an 18.7% test-positive rate, and hospitalization rates continuing to increase.

As of January 19, nearly 92% of Rhode Islanders are partially vaccinated (99% for those 18+), 78% have completed their primary vaccine series (88% for those 18+), and 34.5% have received a booster dose (42% for those 18+).
In Case You Missed It: In the News
Changing the priorities of the "sick" care industry
By Richard Asinof, ConvergenceRI
January 3, 2022
The conflict over the future health care model for primary care is being played out on the streets of Rhode Island. As the health care delivery system is reconfigured amidst the continuing COVID pandemic, here is an in-depth interview with the leadership team of the Care Transformation Collaborative, looking to invest in strategies outside of the office. Read more.
Practice Resources
Rhode Island Data from National Primary Care Surveys
CTC-RI is sharing RI survey data fielded by the Primary Care Collaborative and the Larry A. Green Center. View Series 33 data here and Series 34 data here.

Geriatric Education Series: Exercise for Cognitive and Physical Function in Older Adults with Cognitive Impairment
Register now for the RI Geriatric Education Center's webinar on February 23 (12-1pm).

Milbank Memorial Fund Blog: Health Care Is an Action, Not a Transaction  
Does health care exist to meet the needs of a community or an individual? Now that large retail pharmacies and venture capitalists are in the primary care game, getting care may start to feel like getting motor oil. In a new View from Here, Fund President Christopher F. Koller explains why health care should be seen as an act of service for our communities, not a business transaction.
Job Opportunities
CTC-RI: Program Coordinator
Responsible for the development, coordination, implementation and evaluation of the tasks associated with executing interventions for the assigned projects, and the overall management of the projects. Learn more.

MLPB: Rhode Island-focused Law & Policy Consultant
Serving as a Law & Policy Consultant at MLPB is a chance to help pioneer and refine an important new tool that advances health justice. Learn more here (deadline is Jan. 31).

CTC-RI: Lead Community Health Worker Consultant
CTC-RI is hiring a lead CHW consultant for its Rhode to Equity project. Learn more.

The RI Department of Health is seeking a Senior Public Health Epidemiologist. Learn more.
Upcoming CTC-RI Committee Meetings and Workgroups
  • January 21, 07:30-09:00AM – Clinical Strategy Committee
  • January 28, 07:30-08:45AM – Board of Directors
  • February 15, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • February 18, 07:30-09:00AM – Clinical Strategy Committee
  • February 23, 08:00-09:30AM – Practice Reporting/Practice Transformation Committee
  • February 25, 07:30-08:45AM – Board of Directors
Upcoming Learning Collaboratives and Professional Development
  • January 27, 07:30-9:00AM – Telehealth Learning Collaborative Meeting Cohort 1 Meeting
  • March 11, 07:30-08:00AM – Quarterly CTC-RI Breakfast of Champions
  • March 14, 07:30-09:00AM – Pharmacy Quarterly Learning Collaborative: Reducing Preventable Hospitalizations and ED Usage