Care Transformation Collaborative of Rhode Island News & Updates | January 2021
Happy Retirement, Health Insurance Commissioner Ganim, and Welcome, Commissioner Tigue!
The Care Transformation Collaborative of Rhode Island wishes former Rhode Island Health Insurance Commissioner Marie Ganim the best in her retirement this month and welcomes her successor, Commissioner Patrick Tigue.

Marie Ganim dedicated decades to state service and her work has been instrumental to health care policy. As a committed co-convener and leader on the Board of Directors for CTC-RI, she helped guide this organization through important strategic planning and governance steps to elevate its work and impact in Rhode Island.

Commissioner Tigue joins OHIC with a track record of expanding access to care and driving value in the health care system through delivery system reform and payment reform. Prior to joining OHIC, Commissioner Tigue served as the assistant secretary for health and Medicaid director for RI’s Executive Office of Health and Human Services where he led the state’s Medicaid program. During such a critical time for policies and developments that improve the quality and efficiency of health care service delivery and outcomes, CTC-RI looks forward to working collaboratively with Commissioner Tigue in the months ahead.
Last Call! Applications Due Jan. 29 for CTC-RI Integrated Behavioral Health (IBH) Learning Collaborative
CTC-RI / PCMH Kids is offering up to 15 primary care practices (child, family, and/ or adult) that provide integrated behavioral health services within primary care the opportunity to apply for funding that will assist practices with:
a) providing integrated behavioral health services virtually (via telehealth), and/or
b) achieving NCQA Behavioral Health Distinction.

The IBH Learning Collaborative is designed to help practices transition to providing integrated behavioral health either on-site (or virtually) and demonstrate NCQA Behavioral Health distinction competencies. It is expected that participating practices that implement an evidenced-based and systematic approach to virtual IBH will improve access to care, patient experience, team experience, clinical outcomes and position the practice for success in the value-based comprehensive primary care payment model.

This 12-month funding opportunity will include two IBH program cohorts with staggered start dates that will be eligible for one year of funding (based on each site's preferred start date): 

Cohort 1: March 1, 2021 - February 28, 2022
Cohort 2: May 1, 2021 - April 30, 2022
Completed practice applications are due January 29, 2021 by 5:00pm to: For additional application details, requirements, and timeline information, click here.
Rhode Island COVID-19 Vaccination Update
The RI Dept. of Health is working hard to distribute vaccines, but supply is very limited. Right now, RI is receiving enough first doses each week for about 1.5% of its population, and other states are in the same position. Rhode Island is administering its limited doses of vaccine in a way that will have the greatest impact on the health of the state. To date, vaccines administered include:
RI Dept. of Health and CTC-RI Announce Cohort 2 Practices Selected for RI MomsPRN Perinatal Behavioral Health Quality Improvement Initiative
RIDOH and CTC-RI are pleased to announce that 10 practices successfully applied to be part of the RI MomsPRN 15-month learning collaborative which will launched on February 23. The goal of the RI MomsPRN program is to help prenatal care practices increase the identification, early intervention and treatment of depression, anxiety and substance use among their pregnant and postpartum patients. RIDOH has partnered with Center for Women’s Behavioral Health at Women and Infants Hospital to provide a free consultation service staffed by perinatal behavioral health experts who can assist practices with a behavioral health diagnosis, treatment planning, medication management as well as identification of appropriate resources. Providers treating perinatal patients are welcome to call the RI MomsPRN psychiatry teleconsultation line Monday-Friday (401-430-2800) or learn more at by visiting their website. RIDOH has contracted with CTC-RI to provide project management, data and evaluation, and practice facilitation support for the practices that will be participating in this initiative.
Save the Date: Quarterly Breakfast of Champions on March 12
Please save the date for the next CTC-RI Quarterly Breakfast of Champions on March 12 from 7:30-9:00am on Zoom. All Clinical Practice Champions and practice site clinical and administrative leaders are expected to attend.

Planned agenda topics include COVID-19 pandemic updates and discussion, as well as progress in care delivery design.

At the last quarterly Breakfast of Champions on December 11, there was discussion around the below timely topics as presented:
  • Review of COVID Relief Fund projects - Pano Yeracaris, MD, MPH, CTC-RI Chief Clinical Strategist
  • Review and celebration of Pediatric Immunization and Medicaid Access to Care Efforts - Patricia Flanagan, MD, FAAP, PCMH Kids Co- Chair and Susanne Campbell, CTC-RI Senior Project Director
  • Update on Comprehensive Primary Care Capitation and Best Practices in Pediatric Care Delivery Design - Beth Lange, MD, FAAP, PCMH Kids Co- Chair and Mary Jo Condon, Freedman Healthcare
  • Practice Check-In COVID Pandemic Challenges - Patricia Flanagan, MD, FAAP, PCMH Kids Co- Chair, Beth Lange, MD, FAAP, PCMH Kids Co- Chair, and Pano Yeracaris, MD, MPH
Telehealth Learning Collaborative to Kick-off Feb. 10
Planning is underway for the February 10 kick-off of the CTC-RI / PCMH Kids Telehealth Learning Collaborative, “Using Technology to Improve Care for Patients with Chronic Conditions.” Dr. Lisa Levine of The MAVEN Project, a telehealth nonprofit dedicated to increasing access to comprehensive care for vulnerable populations, will deliver the keynote address.
20 practices — 10 pediatric, 9 adult and 2 family — will participate in the year-long collaborative. Practices will work with CTC-RI practice facilitators and staff from the Northeast Telehealth Resource Center to plan and implement a telehealth project focused on a specific chronic condition. A wide range of conditions will be represented in the collaborative including heart failure, diabetes, asthma, anxiety, depression, and hypertension. A full list of practices and chronic conditions can be accessed here. This learning collaborative has been funded by UnitedHealthcare and authorized CARES Act funding. 
Update: Pediatric IBH Learning Collaborative Meeting
Liz Cantor, PhD, CTC-RI IBH Pediatric Consultant, facilitated the quarterly Pediatric IBH Learning Collaborative meeting on Jan. 14. Pediatric practices (Cohort 1 and 2) participating in the Rhode Island Foundation Pediatric Pilot program discussed their screening rates for selected pediatric areas of focus and key learnings from screening in a virtual environment. Julie Boergers, PhD, Co-Director, Pediatric Sleep Program at Hasbro Children’s Hospital presented on “Children’s Sleep Problems: Opportunities and Challenges During a Pandemic.” The presentation for the meeting can be found here.
Update: Nurse Care Manager / Care Coordinator Best Practice Sharing Meeting on Preparing for COVID-19 Vaccination
More than 60 people participated in the Jan. 19 NCM/CC Best Practice Sharing meeting which included an update from Beth Lange MD, FAAP Co-Chair PCMH Kids and member of the Vaccine Advisory Committee. Information was shared on the state's Phase 1 timeline for populations getting vaccinated, vaccine distribution locations, and “Frequently Asked Questions." Darlene Dorocz, RN, CDOE, Director of Nursing (RIPCPC) and Marilyn Boichat, RN Director of Practice Management (Coastal Medical) presented on work being done at primary care practices and within systems of care to develop and implement COVID-19 staff and patient vaccination plans. Topics included staff and patient education strategies, anticipated vaccine handling and storage, distribution and reporting needs and available resources.
RI AAP Launches "Tips to Keep Your Family Health During COVID" campaign
The RI Chapter of the American Academy of Pediatrics launched a new “Tips to Keep Your Family Healthy During COVID” public awareness campaign, designed to empower parents and teens with information and resources to stay healthy mentally and physically through the ongoing COVID-19 pandemic. Tips and resources on mental health, wellness, learning during COVID, parenting during COVID, and being a teen during COVID are available at In addition to this website, the campaign includes Facebook and Instagram targeted messages to Rhode Island parents and teens and focused interviews with pediatricians and content experts to raise awareness.
Pediatric Practice Immunization Rates Surpass Pre-COVID Rates
In July, OHIC and EOHHS, at the request of Governor Raimondo, issued one-time grant payments to pediatric primary care providers that experienced financial hardship during COVID-19, and in return asked that pediatric providers take targeted actions to ensure patients get caught up on immunizations. As a group, childhood immunizations (including lead screenings) have improved across all categories.

Practice Facilitation support was made possible through generous support from Blue Cross and Blue Shield of Rhode Island (BCBSRI). A huge thank you to BCBSRI and the practice facilitators, Vicki Crowningshield, Susan Dettling, and Suzanne Herzberg for assisting practices in any way needed. 

RIDOH’s KIDSNET assistance provided data twice per month, consulted at numerous meetings, and provided direct support to practices - all critically important to the success of this project. A special thanks to Ellen Amore and Janet Limoges.

A special shout out to Libby Bunzli, Director of Health System Transformation and Cory King, Director of Policy for their leadership and hard work with operationalizing the application and payment process, done in record speed and to the Governor’s task force, including members of RI AAP for recognizing the critical importance of pediatric practices in keeping our children safe and healthy. This project resulted in $4 million paid to pediatric practices and garnered national attention from the Center for Health Care Strategies (read their Nov. 9, 2020 blog article).

The last report on 2020 immunization and lead screening results was distributed to practices this month. It’s been CTC-RI/PCMH Kids’ pleasure to provide this information and witness the progress made by the participants of this program. We will resume reporting in the Spring, allowing KIDSNET time to adjust the time period and the lead screening criteria to match OHIC’s measurement specifications. We are happy to continue this effort, especially as COVID-19 continues to challenge Rhode Island’s healthcare system.

Below is the group’s performance over time. Great work!
In addition, EOHHS implemented the Medicaid Pediatric Primary Care Rate Supplement program through the end of calendar year 2020, to provide monthly financial incentives to pediatric primary care practices to ensure all children are up to date with the full array of essential, preventive healthcare services by overcoming COVID-19 related barriers to access. This group worked hard to improve Medicaid Access to Care performance, resulting in $3 million total funding provided to participating practices. Here is the group’s performance overtime. Outstanding performance!
Throughout the program, as relevant resources became available, CTC-RI collated a Pediatric Immunization Resource Guide to inform and assist practices. Here is the latest version of the Pediatric Immunization Resource Guide.
Partnering to Strengthen Clinical-Community Linkages: RI Diabetes Health Equity Challenge: Wave 2
On January 8, the Wave Two Team (East Bay Community Action Program) participated in a Momentum Session on Risk Satisfaction. Somava Saha MD, MS, Executive Director at Well Being in the Nation (the WE Team), facilitated a discussion on risk stratification strategies to support health equity. The Team now known as “Produce to People” is using Pathway to Population Health tools to identify short and long term goals to strengthen clinical-community linkages to provide people at high risk with better access to fresh fruits and vegetables and consider health care food policies that would lead to sustainable community solutions.
CTC-RI Continues Telehealth Webinar Series on Feb. 23
CTC-RI/PCMH Kids is hosting its next webinar in its new telehealth webinar series, "Advancing Team-Based Telehealth in RI," made possible by authorized CARES Act and UnitedHealthcare funding. The webinar will be held Tuesday, February 23 from 12-1pm. The webinar, "Rhode Island Telehealth Sustainability Strategies - Telehealth Workflow and Etiquette" will focus on two Rhode Island primary care practices, Barrington Family Medicine and Anchor Medical, sharing workflow strategies, challenges and successes. Northeast Telehealth Resource Center will offer additional resources around workflow best practices and telehealth etiquette (i.e.. how to have an effective telehealth visit). The event will offer participants a Q&A period.

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
In the News
Op-ed: The need for primary care teams
By Christopher Koller
Boston Globe
December 28, 2020
Read the recent Boston Globe op-ed by former RI Health Insurance Commissioner Christopher Koller and is president of national health policy foundation Milbank Memorial Fund. In his op-ed, Koller notes health systems with more primary care do better by the people they serve -- their patient populations are healthier, live longer, and have fewer disparities in outcomes based on race, ethnicity, and income. Read the op-ed here.
RI pediatricians launch new public awareness campaign
By Barbara Morse
NBC 10
December 17, 2021
Rhode Island pediatricians have launch a new public awareness campaign. "All of us, as families, need some reminders how to keep ourselves on track," said Dr. Allison Brindle, a pediatrician at the children's clinic at Hasbro, and the vice president of the local chapter of the American Academy of Pediatrics, which is launching this campaign to help keep families healthy during COVID-19. It has started a Facebook page, and a resource page, identifying key areas we should be focusing. "Areas like general health and wellness, mental health and wellness, sleep structure -- really just some reminders of the things we all know, but under the current stress, just need some reminders about," said Brindle. The main message? Your pediatrician is there for you. View this full article here.
Five Questions With: Dr. Nelly Burdette
By Elizabeth Graham
Providence Business News
December 20, 2020
Dr. Nelly Burdette, associate vice president of integrated behavioral health at The Providence Community Health Centers Inc., was the sole employee in the behavioral health program when PCHC launched it five years ago. Today, the program is staffed by nearly 20 clinicians. Burdette discusses its growth, the effect of the COVID-19 pandemic on mental health needs and her take on what role telehealth is likely to play in behavioral health treatment in the future. Read the article here.
Clinical-Community Linkages as a Critical Component of Comprehensive Primary Care
On January 22, key stakeholders met for meeting #2 of “Building Clinical-Community Linkages” to continue discussions on a long-term payment strategy for Community Health Teams (CHTs) as a vehicle for addressing key priorities in RI to reduce health disparities and achieve population health goals. Somava Saha, MD, MS, Executive Director at Well Being in the Nation, led the discussion on the unique role of CHTs in supporting population health goals. Dr. Saha highlighted the CHWs and CHTS across a care management continuum for highest risk patients, medium risk/rising risk, and everyone else. CTC-RI showcased two unique CHT case examples. The first case presented came from the Family Service of RI Multidisciplinary Team that connects the CHT to the Family Home Visiting First Connections Team in innovative ways. Secondly, the South County CHT presented a case that was a referral from the ED. Lastly, Craig Jones, MD, Partner from Capitol Health Associates, presented payment model examples that could support CHTs. The discussion will continue during the last part of the series on February 26. Click here to view the webinar recording.
Update: Clinical Strategy Committee
Phase 2 of the Care Delivery Design and Community Health Project kicked off at the January 15 Clinical Strategy Committee meeting. Moderated by Pano Yeracaris MD, MPH, CTC-RI Chief Clinical Strategist, the group discussed our project plans and reviewed a fishbone diagram that describes how CTC-RI’s multiple work areas build toward comprehensive primary care, and health system transformation and community health.

At the committee meeting, there was also an engaging presentation by Andrew Saal, MD MPH, Chief Medical Officer, Providence Community Health Centers entitled “Population Health – More than Just Primary Care Delivery: Innovation, Best Practices, and Musings from a Multi-Specialty Urban Community Health Center” The meeting concluded with detailed updates and open discussion on pandemic-related issues including the status of hospitals, primary care practices, and vaccination rollout.

In more Clinical Strategy Committee news, the Adult and Pediatrics Components of the Care Delivery Models for CPCC/TCOC and Best Practice Decks are updated and posted online:
December results from national primary care survey
Results from the Larry A. Green Center / Primary Care Collaborative Primary Care Survey in December are now available, including both national and Rhode Island-specific results:

Update: PCMH Kids Stakeholder Meeting
At the quarterly PCMH Kids Stakeholder meeting on January 7, Drs. Flanagan and Lange provided an update on the Immunization and Lead Screening and Medicaid Access to Care results. RI pediatricians have demonstrated significant improvement across all categories, while continuing to address increased COVID-19 challenges. Through the meeting, successes and challenges that practices are experiencing in the Pediatric IBH Program were shared. Of note, pediatric practices pivoted quickly and effectively to tele-IBH to assist children and families.

Susan Dettling reviewed results from the Telehealth Initiative, sharing key findings from the Practice/Patient Needs Assessment, including pediatric-specific recommendations. The new CTC-RI/PCMH telehealth webinar series “Advancing Team-Based Telehealth in Rhode Island” topics and content have been selected based on these findings and recommendations. Information was shared on the 2021 learning collaborative initiatives that are forthcoming. Matt Roman and Deborah Doran from Thundermist concluded the meeting by sharing information about their expanded behavioral health services in Kent and Washington Counties. The presentation for the meeting can be found here.
RIQI Launches New CurrentCare website
Rhode Island Quality Institute has launched a new CurrentCare and CurrentCare for Me Online Enrollment website. The new enrollment website makes signing up quick and simple for your patients.

Once your patients are enrolled, you can use CurrentCare Viewer to view COVID-19 test results, other lab and imaging test results, hospital visits, and more.

Encourage your patients to sign up today!
Practice Resources
OHIC Hosting Feb. 9 Webinar on Prospective Payment for Primary Care
The Office of the Health Insurance Commissioner is partnering with Bailit Health Purchasing to offer a webinar on the topic of prospective payment for primary care. Participants hear from two practices in Vermont about their experiences operating under prospective payment, including speakers from Chittenden Health Center and Primary Care Health Partners. Participation from clinicians is encouraged. Zoom access:

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.

CHW Sustainability Symposium for Health Equity in Pandemics and Beyond
Learn results of a statewide assessment of Community Health Workers (CHWs), CHW Supervisors, and CHW Employers from the Rhode Island Department of Health, RIC Institute for Education in Healthcare, and the Community Health Worker Association of RI, and participate in a virtual discussion about sustaining CHWs' work over the long-term. Hear from national CHW-financing expert Carl Rush and strategize potential payment models for the particulars of our state. Details and registration here.

RIPIN Launches New Chronic Pain Self-Management Virtual Classes
RIPIN's new Chronic Pain Self-Management program is designed for people living with chronic pain. The workshop provides participants with the tools to manage medications, fatigue nutrition, and more. Deadline to register is Feb. 1, 2021. Details, including class schedule and and registration, can be found here.

Milbank Blog: What Makes Michigan’s High-Performing Primary Care Practices Work Well?
Since the advent of the patient-centered medical home and team-based care concepts, health reformers have sought to unearth the specific interventions and techniques in primary care settings that are most likely to improve patient outcomes and value. For example, the Center for Medicare and Medicaid Services’ multipayer primary care demonstration projects, such as Comprehensive Primary Care Plus and Primary Care First, are using value-based payment and care delivery reforms to improve care quality and reduce unnecessary emergency department (ED) and inpatient utilization. Read Milbank's recent blog post, "What Makes Michigan’s High-Performing Primary Care Practices Work Well?"

Upcoming Meetings (for CTC-RI members)
February 10, 2021, 07:30-09:00AM – Telehealth Learning Collaborative Kickoff Meeting
February 11, 2021, 07:30-09:00AM – Quarterly Integrated Behavioral Health Meeting
February 12, 2021, 09:30-11:00AM – Community Health Team (CHT) Best Practice Meeting
February 16, 2021, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
February 18, 2021, 03:00-04:30PM – SBIRT/CHT Executive Committee
February 19, 2021, 07:30-09:30AM – Clinical Strategy Committee
February 23, 2021, 07:30-09:00AM – MomsPRN Kickoff
February 23, 2021, 12:00-01:00PM – Telehealth Webinar – Workflow
February 24, 2021, 08:00-09:30AM – Practice Reporting and Transformation Committee
February 25, 2021, 07:30-09:00AM – Pharmacy QI Initiative- Learning Network
February 26, 2021, 07:30-08:45AM – Board of Directors Meeting
February 26, 2021, 09:00-10:00AM – CHT Oversight Committee – Building Community Clinical Linkages