Care Transformation Collaborative of Rhode Island News & Updates | July 2021
Success Spotlight:
EBCAP Nurse Care Manager Marilyn R. Saunders
CTC-RI recently interviewed Marilyn R. Saunders, BSN, NSM, CDOE of East Bay Community Action Program who previously completed the Nurse Care Manger/Care Coordinator Standardized Core Curriculum Program and shared her positive experience. As a reminder for NCMs/CCs interested in applying to the next program, applications are due July 23.

Why did you join the NCM Core Curriculum Training Program?
I joined the NCM curriculum training to improve patient outcomes. My goal was a team approach with patients, their families and providers for health education with buy-in. This started with meeting with patients to discuss their health goals and motivational interviewing.

What was one of the most surprising takeaways from your participation in the program?
I was introduced to motivational interviewing. This process helped patients and our health team understand an achievable goal setting. We also found that not all patients were interested in NCM support. We respect the needs of our patients and offer to check-in if a patient agrees. Patients also may graduate and we then add other patients who agree to NCM support.

How has the NCM Core Curriculum Program impacted your day-to-day workflow as a NCM today?
We start our day by reviewing the appointments scheduled, review patient’s current plan of care, then meet with providers to discuss health goals. The plan is fluid and adjustments are made with patient and health team input.

What advice would you give to other NCMs considering this program?
I believe working with patients and providers to write a health plan will improve health outcomes. Remember to adjust a plan, as needed, and to be aware that transitions in care due to ER admission, hospitalization, medication changes all need to be discussed with patient and provider. We also are interviewing patients often to determine current social determinants of health. Motivational interviewing helps patients set realistic goals and offer sense of accomplishment.
Success Spotlight: Taylor D'Addario, The Providence Center SBIRT Grant Manager and Lead Trainer
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, cost-effective strategy for addressing risky and problematic substance use. In an effort to promote universal screening for substance use among all populations, the RI SBIRT project screens individuals in both traditional health care settings as well non-traditional settings such as community based organizations and corrections facilities. This work is funded by a grant from SAMHSA to the BHDDH and CTC-RI operates as the lead organization to implement the grant and subcontracts with eight different organizations to support this work. We interviewed Taylor D'Addario, SBIRT Grant Manager and Lead Trainer with The Providence Center, on her important SBIRT work.

Why is SBIRT important to primary care?
SBIRT opens up dialogue between patient and provider. It gives the patient the opportunity to discuss any aspects related to their substance use in a non-judgmental manner. It also allows the provider to use the patient’s own reasons and motivations for change, so the patient remains autonomous in their decision-making and isn’t pushed to do anything they don’t want to. SBIRT helps bridge the gap between physical and mental health care.

What is unique about your SBIRT training?
It teaches providers how to address unhealthy substance use in adults/adolescents in a curious, caring, non-judgmental way. But, the very unique part about my training is that SBIRT is a technique that can be used to motivate anyone to make a healthy change beyond unhealthy substance use. This helps paint a holistic picture for the patient's overall health and wellness regardless of the change they want to make.

How can this training better support practices in their day-to-day work?
It gives providers confidence to have uncomfortable conversations with the patients they care for. It also helps support the practice by giving the providers resources in the community for them to refer their patients to. We were also able to provide free training to providers so they can integrate the work of SBIRT into their practice seamlessly. 

How has SBIRT impacted Rhode Islanders?
It gives Rhode Islanders a non-judgmental platform to discuss their substance use. SBIRT adopted the slogan of “We Ask Everyone,” which helps reduce the stigma of substance use, and further debunks the myth that only certain people can have the chronic disease of addiction. SBIRT has helped connect Rhode Islanders to the tailored services they need at any level of care.
NCM/CC Best Practice Sharing: Identifying Patients for Care Coordination
At the June Nurse Care Manager / Care Coordinator Best Practice Sharing meeting, practice facilitators Vicki Crowningshield and Suzanne Herzberg reviewed the PCMH Kids High-Risk Framework — its historical background, why it was designed, the elements, and process behind its development. Practice-level data was reported out and discussed. Daniella Pierre, MPH, Chief Quality Officer at Tri-County Medical Associates reviewed their use of Phreesia to help streamline and capture information from patients. Jennifer Gilman, NCM at Ocean State Pediatrics and Amy Perry, Director of Case Management at Providence Community Health Centers shared their care management strategies. Susanne Campbell, RN, MS, PCMH CCE, CTC-RI Senior Project Director and Carol Falcone, NCM Faculty at East Bay Community Action Program announced the fall 2021 NCM/CC Standardized Core Curriculum (GLearn) Program (applications are due July 23). 

For July 20 NCM/CC Best Practice Sharing Meeting, NCM/CCs are asked to provide input for the CTC-RI/PCMH Kids strategic plan
The July 1 CTC-RI/PCMH Kids Stakeholder meeting provided an opportunity for attendees to offer input for the CTC-RI/PCMH Kids strategic plan. Drs. Flanagan and Lange provided historical background information on the CTC-RI/PCMH Kids Stakeholder committee which helped create the PCMH Kids program. Jim Berson from Fio Partners facilitated the strategic planning discussion using Google’s online collaborative whiteboard technology, Jamboard. We want to continue to capture as many great ideas as possible and over the next couple of weeks, you can continue to add comments to the Jamboard session by clicking on this link. Click here for more information on how to use Jamboard. Please feel free to share this link with your colleagues. Drs. Flanagan and Lange closed the meeting with a quick review of various pediatric initiatives that are taking place.

In addition, the PCMH Kids strategic planning survey is still open for comment. If you have not completed the survey, your feedback is greatly appreciated as the questions asked in the survey are different than those that are posed in the Jamboard session. Your input will help inform the CTC-RI/PCMH Kids strategic plan and is needed so that PCMH Kids can be positioned to meet the needs of our primary care practices, systems of care, community and children and families. 
7-Part CTC-RI Telehealth Webinar Series Draws Nearly 400 Attendees
On June 29, CTC-RI held its final telehealth series webinar, “Virtual Care & Patient Self-Monitoring Tools– Strategies for RI Adult Primary Care Practices” featuring speakers Sarah Reinstein MPH and Carol Falcone NCM from East Bay Community Action and Lauren Capizzo MPH and Brenda Jenkins RN CDOE from Healthcentric Advisors. The webinar focused on EBCAP’s experience piloting the National Association of Community Health Center’s “Leading Change: Transforming At-Home Care” program, followed by the sharing of strategies by Healthcentric Advisors on engaging high-risk patients in RPM, with data from RI practices using the PRiSM platform.

CTC-RI's “Advancing Team-Based Telehealth in RI” webinar series consisted of 7 webinars on a range of topics to help practices implement best practices in telehealth and remote patient monitoring. The series reached 398 attendees (83% of participants said they’d be able to use the webinar information within the next 6 months; 89% rated the webinar's relevance in the RI environment as “good” or “excellent").

CTC-RI sends a big thanks to UnitedHealthcare for funding this series along with CARES Act funding, as well as to all the speakers and panelists. In addition, a special thanks goes to the Northeast Telehealth Resource Center for their technical assistance and to the Core Telehealth Planning Committee for being instrumental in planning the series.

“Telehealth Today and Tomorrow” was the focus of the June Clinical Strategy Committee Meeting (CSC) with panelists providing information around the current status and future of telehealth in RI. Daniela Fairchild, MS Ed, Director, RI Office of Innovation discussed broadband access while noting that 50% of urban core cities lack in-home coverage and 20% of all Rhode Islanders are under-connected. Information also was provided on the Emergency Broadband Benefit Program.

Also at June's meeting, Mary Jo Condon, MPPA, Senior Consultant, Freedman Healthcare provided regional, national and RI telehealth utilization information observing that 50% of people in APCD had at least one telehealth service, with behavioral health being the most common diagnosis. Marea Tumber, JD, MPH, OHIC Principal Policy Associate, provided an update on the current status of telehealth-related RI legislative and regulatory activities. Health plans discussed current telehealth usage looking at both RI primary care practices and Teladoc services.

Useful resources from June's joint discussion include:

The CSC panel discussion was moderated by Andrew Solomon, MPH, Senior Program Manager, Northeast Telehealth Resource Center who also provided information on the upcoming NETRC conferenceCME credit is available for this CSC meeting and here is the recording.
The July Clinical Strategy Committee (CSC) meeting featured a special panel discussion on “Implementing High-Quality Primary Care: Implications for RI” with invited panelists:
  • Chris Koller, President at Milbank Memorial Fund and former RI Health Insurance Commissioner, and
  • Judith Steinberg, MD, CMO at Office of Infectious Disease and HIV/AIDS Policy, Office of the Assistant Secretary for Health, HHS and former CMO at Bureau of Primary Health Care, Health Resources and Services Administration.

CSC members heard national experts’ reflections on the National Academies of Science, Engineering, Medicine Consensus Study Report on “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care” issued May 2021. Chris Koller in his presentation recognized high-quality primary care as a public good, and encouraged adequate funding, greater transparency, and accountability. The meeting was moderated by Co-Chair Andrew Saal, MD, MPH, Chief Medical Officer, Providence Community Health Centers. CME credit is available for this CSC meeting.
At the June 25 CTC-RI Board of Directors meeting, Health Insurance Commissioner Patrick Tigue presented an overview of OHIC’s current priorities and accomplishments. Board members were especially interested in hearing about the new OHIC priorities this year, including:
  1. Ensure that Rhode Islanders receive adequate coverage for COVID-19 testing, treatment, and vaccinations;
  2. Leverage the regulatory structure within OHIC to accelerate delivery system reform;
  3. Continued implementation of the Affordability Standards;
  4. Continue to increase behavioral health (BH) care access and ensure parity between BH and physical health care services;
  5. Advance the statewide expansion of telehealth services; and
  6. Continue the success of the Rhode Island Health Care Cost Trends Project.

Substantial accomplishments were shared which include:
  1. Significantly reduced commercial health insurance premiums for 2021;
  2. Small business health insurance premium reductions for 2020; and
  3. Consumer savings through consumer assistance helpline.
COVID-19 Vaccination Update: 71% of adult Rhode Islanders fully vaccinated
Despite low rates of COVID infection and hospitalization, Governor McKee is keeping the state's emergency order through August 6. As concerns grow around the delta variant, the best tool against COVID infection is the vaccine. For the most recent COVID vaccine updates, visit
In Case You Missed It: News and Publications
EOHHS, RIDOH select six teams for Rhode to Equity initiative
By James Bessette
Providence Business News
July 13, 2021
PROVIDENCE – The R.I. Executive Office of Health & Human Services and the R.I. Department of Health jointly announced that six teams participating in the Rhode to Equity program will receive funding to improve both health and social outcomes in the Ocean State. The departments said the Rhode to Equity program, an initiative created by EOHHS’s Health Systems Transformation Project and RIDOH, is a 12-month learning and action collaborative to provide the six cross-sector teams the chance to test and evaluate strategies in order to improve communities’ health and social outcomes. The teams will also engage with peers in learning sessions to explore “cross pollination” of ideas and understanding, EOHHS and RIDOH said. Read the full story here.
Did You Register? CTC-RI Senior Director of IBH to Lead National Course on Oct. 6
This course is an opportunity to learn how CTC-RI helped integrated behavioral health (IBH) practices respond to COVID by tele-IBH implementation and earn Behavioral Health Distinction. Areas of focus include working with state and payers to align expectations across the health care system for IBH and sustainability; developing and implementing a 12-month tele-IBH learning collaborative that gives PCMH practices an opportunity to test tele-IBH workflows while working toward earning Behavioral Health Distinction; and developing practical tools to strategically approach earning Behavioral Health Distinction. The Oct. 6 course will be lead by Nelly Burdette, Psy.D., Associate VP of IBH, Providence Community Health Centers (PCHC)/ Senior Director of IBH, CTC-RI and Jennifer M. Etue, LICSW, Manager/Float Provider of IBH, PCHC. Learn more here.
Practice Resources
This week! CTC-RI Leaders Presenting at NCQA 2021 Quality Innovation Series
The Learning Series From NCQA running continuously through November 2021 includes 50+ speakers from across the nation and 50+ courses, and includes a course this week by CTC-RI leaders. "Learning in Action: Implementing a Primary Care Telehealth Response During COVID-19" led by Susanne Campbell, RN, MS, PCMH CCE, Sue Dettling, BS, PCMH CCE, and Marna Heck-Jones with CTC-RI will be presented on July 21.

Job Opportunity: Nurse Care Manager at Anchor Pediatrics (Lincoln, RI)
Anchor Pediatrics is hiring a full-time pediatric Nurse Care Manager to provide comprehensive care coordination services to patients with high-risk or complex medical and/or behavioral health needs.

Behavioral Health ID, Treatment, and Referral in Primary Care: 3-Part On-Demand Series
This series will discuss best practices for the integration of behavioral care into a primary care setting. Part 1 (Depression and Follow-Up After Higher Levels of Care) is available now on demand. There are no fees for participating in or receiving credit for these activities. Learn more here.
July and August CTC-RI Committee Meetings and Workgroups
  • July 23, 07:30-08:45AM – Board of Directors
  • July 28, 07:30-09:00AM – Practice Reporting and Transformation Committee
  • August 12, 07:30-09:00AM – Quarterly Integrated Behavioral Health Committee
  • August 13, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • August 17, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • August 19, 03:00-04:30PM – SBIRT/CHT Executive Committee
  • August 20, 07:30-09:00AM – Clinical Strategy Committee
  • August 27, 07:30-08:45AM – Board of Directors
July CTC-RI Program and Initiative Meetings
  • July 29, 12:00-04:00PM – Rhode to Equity Kickoff (Part 2)
Summer Learning Collaboratives and Professional Development
  • August 18, 07:30-09:00AM – Telehealth Learning Collaborative Quarterly Meeting
  • August 19, 07:30-09:00AM – Pharmacy Quarterly Learning Collaborative: Reducing Preventable Hospitalizations and ED Usage