Care Transformation Collaborative of Rhode Island News & Updates | June 2021
CTC-RI/PCMH Kids, with funding from UnitedHealthcare (UHC) and Rhode Island Department of Health (RIDOH), will again be offering Nurse Care Managers/Care Coordinators (NCM/CC) the opportunity to participate in a standardized evidence-based training program developed by GLearn. NCM/CCs who work in primary care practices that have participated in CTC-RI/PCMH Kids transformation program or work in primary care practices that are part of a system of care are eligible to apply.

The 12-15-week program, kicking off in September, consists of web-based interactive modules, weekly facilitated collaborative discussions, and the demonstration of skills through a case study capstone presentation. Participants will learn key care management concepts within their primary care practice setting and organization. While the training costs are covered by UHC and RIDOH, learners are asked to commit to completing the training modules and meeting weekly with a cohort of other NCM/CCs. Learners will be eligible to obtain up to 18.5 RN CEU’s and 18.54 CCM credits that can be applied toward Care Management certification. Learn more and apply by July 23.
Spotlight: RI Office of Innovation Work Supports Telehealth
As telehealth continues to serve as an important tool in primary care statewide, CTC-RI connected with Daniela Fairchild, Director of the RI Office of Innovation, who will participate in the June CTC-RI Clinical Strategy Committee panel discussing current and future state initiatives, from broadband access to telehealth and American Rescue Plan Act funds. In her work, Daniela leads collaborative, multi-partner projects in education, technology, and government innovation.
With over a decade of experience, from high school teaching to policy research to project implementation, Daniela brings a unique lens and set of experiences to her role, and served as RI-CAN’s director of strategy prior to her current role.
How do you see RI's technology advancements supporting primary care?
Through public-private partnerships and early support from the federal government, RI has invested in and built one of the most robust "middle-mile" broadband backbones in the nation. This broadband fiber runs throughout the state and provides necessary infrastructure for our residents, as well as our hospitals, primary care facilities, and other medical buildings. The infrastructure we've built could be further leveraged to support primary care – but will need smart planning and strong collaborations with public and private entities to come to bear. 
What innovation is happening at the state level that is impacting health care and the primary care industry?
Our world is only getting more connected – meaning that innovations within various sectors in the state impact others, including health care and primary care. In RI, we have been working to ensure digital literacy and device and internet access for all Rhode Islanders – critical to health and primary care. And separately, but related, the state passed a $20M bond in 2016 to bring entrepreneurs together with research institutions to grow access and new learnings in industries like healthcare, with Innovation Campuses like 401 Tech Bridge emerging. 

CTC-RI is excited to announce the completion of a white paper, "Primary Care Telehealth Practice Needs Assessment and Patient Survey Report: Rhode Island Telehealth Project. The paper summarizes the results of the CTC-RI-led Telehealth Needs Assessment that was informed by responses from 47 RI primary care practices and over 900 patients.

The Practice/Patient Needs Assessment was launched in August 2020 with funding from UnitedHealthcare and authorized CARES Act funding. The survey gather perspectives on the rapid switch to telehealth with the onset of COVID-19 and found that 91% of practices began telehealth usage only after the pandemic began in March 2020. Read more.

From the practices' perspective, top benefits of telehealth included improved work experience, increased patient access, reduction in no-shows, staff ability to work from home, and the ability to bill for on-call services. Read more.
CTC-RI Continues Telehealth Webinar Series on June 29
Mark your calendars for our final telehealth webinar "Virtual Care & Patient Self-Monitoring Tools – Strategies for RI Adult Primary Care Practices." This June 29 webinar from 12-1pm will feature presenters from EBCAP and Healthcentric Advisors with registration here.

This webinar will be the 7th in the "Advancing Team-Based Telehealth in RI Webinar Series,” funded by UnitedHealthcare and CARES Act funding. The webinars to date have reached approximately 350 attendees, designed to give tools to the RI primary care community in developing best practices around telehealth even after the pandemic recedes. 
Dr. Mick Connors from Anytime Pediatrics, a technology company focused on providing cost-effective and convenient pediatric care grounded in the medical home delivery model, shared his perspective on providing telehealth services to pediatric patients. The discussion touched on obstacles, opportunities, and the use of telehealth to manage chronic medical and behavioral health conditions and was moderated by Dr. Beth Lange. Access the presentation and more details here.
COVID-19 Vaccination Update: 56.1% of Rhode Islanders fully vaccinated
Across all eligible age groups, currently, 671,689 Rhode Islanders are partially vaccinated, and 592,688 Rhode Islanders are fully vaccinated. For the most recent COVID vaccine updates, visit
The May 21 Clinical Strategy Committee (CSC) meeting focused on data to improve performance and characteristics of high-performing CPC+ practices by invited speakers, Richard Shonk, MD, CMO, The Health Collaborative, OH, Diane Marriott, DrPH, Director, Multipayer Michigan Initiatives, CPC+ Statewide Convener, MI, and Jerome Finkel, MD, Henry Ford Health System Chief Primary Health Officer, MI. 

The CSC has an exciting June 18 meeting scheduled (CME credits available) with a discussion on the current and future role of telehealth in RI by Daniela Fairchild, Director, RI Office of Innovation; Mary Jo Condon, Senior Consultant, Freedman HealthCare; Marea Tumber, Principal Policy Associate, OHIC; and moderated by Andrew Solomon, Senior Program Manager, Northeast Telehealth Resource Center. Read more.
Success spotlight: Providence Community Health Centers
With clinics throughout the city, Providence Community Health Centers (PCHC) is the only Federally Qualified Health Center in the city of Providence. With almost 60,000 patients (20,000 under the age of 18), about 90% of patients and families live at or below the 200% Federal Poverty Level. PCHC offers high-quality care regardless of a patient’s ability to pay. Services include family and adult medicine, pediatrics, behavioral health, OBGYN, asthma/allergy care, optometry, podiatry, dental care, health education, dermatology and nephrology. We interviewed Andrew Saal, MD, MPH, Chief Medical Officer and Jonathan Gates, MD, Chief Medical Officer of Accountable Care to learn more about their work.

How have you responded in the last 15 months to both the COVID crisis, while adapting and preparing for the future of health care delivery?
“For the last 7 years, we have challenged the assumptions of primary care delivery and tried to improve the system. If there are more effective way to improve the health of a population, then we want to explore those possibilities. We’ve been living in the fee-for-service world for 6 decades – most people assume that all care must be provided face-to-face in 15-minute increments. Primary care delivered only in a fee-for-service model basically means that health care is only provided only to those who show up. That’s not population health, that’s survival of the fittest (or at least limited access for those with the knowledge and the resources to interface with the healthcare system). Our team addresses the access paradox with a deeper question: Who isn’t showing up? And perhaps more importantly why aren’t they accessing care? What other visit types could we do to promote population health? We were already redesigning primary care with an eye on alternative visit types and access when the COVID-19 pandemic hit. In the space of a few days, we pivoted all of the clinics to meet the pandemic’s challenge ‘What if no one can show up to be seen today, how can we still deliver care?’ Our population health data and clinical infrastructure allowed us to better identify high-risk patients and deploy resources,” explained Dr. Saal.

“We have a process now where we can find our patients who are likely to need help for a variety of reasons – it could be from a chronic condition or because we haven’t seen them in a while. We’re shifting away from dependence on the day-to-day schedule as a way to manage our population. We are moving towards using technology to identify and deliver the right care to the right person at the right time,” added Dr. Gates.

How is PCHC approaching the challenges of improving maternal child health among your patients and in the community?
“As the largest community health center in RI, we deliver about 10% of women giving birth in the state, and also have about 10% of the overall pediatric volume. During the pandemic “rebuild,” we identified two foundational populations we were going to see if at all possible and with as few barriers to care as possible – pregnant women and children who needed vaccines. These goals gave our planning teams the compass point they needed to redesign the triage and direct care systems for all of the clinics. Our teams found ways to safely triage pregnant women and children and get them safely into the clinics for care. PCHC has been averaging about 1,100 deliveries per year. Though the number of pregnancies dropped in the first half of 2020, we saw the pregnancy rate rebound in the latter half of the year. Deliveries are now increasing again. We were pleasantly surprised to see that our pediatric vaccine rates remained fairly stable despite the restrictions of the pandemic. I am proud of our pediatricians, family physicians and care teams – PCHC is in the top tenth percentile in the nation for vaccinating children. Our maternal child health data tracks low birthweight, vaccines, postpartum depression screening, and a dozen other measures by race and ethnicity. This allows us to better identify and address healthcare disparities in our community. I’m happy to report that the teen pregnancy rate continues to slowly decline. There are still significant disparities in maternal child health outcomes between women who are Latinx, Black, and White right here in RI – so we all still have a lot of work to do to address these here in our community,” said Dr. Saal.

With nearly 100 attendees, CTC-RI engaged clinicians with an emphasis this month on complex issues directly affecting the RI practices today. Objectives included:
  • Learning about a Quality Improvement effort, collaborating with pharmacy, to reduce avoidable emergency department and inpatient utilization in patients with diabetes.
  • Understanding changes in clinician and clinical team workflows under primary care capitation for pediatric and adult practices.
  • Learning about practice-level data that supports performance improvement under capitation and opportunities to improve panel management.

Presentations included:
  • “PDSA: Potentially Avoidable ED Visits" by Jay Gates, MD, Director of Integrated Care Delivery, Providence Community Health Centers and Lillian Nieves, PharmD, Clinical Pharmacist
  • “The Changing Role of the PCP (and Inter-Professional Care Team) Under Capitation” by Bryan Burns, DO, Physician, Esse Health, & Chief Medical Officer, Effectus Healthcare Solutions, MO and Susan Kressly, MD, Pediatrician & Owner, Kressly Pediatrics, & Medical Director, Office Practicum, PA. Patricia Flanagan, MD, Hasbro Children’s Hospital, & Brown University Pediatrics Professor (moderator).

CTC-RI/PCMH Kids is happy to announce that the Board of Directors has unanimously approved the Data and Evaluation Committee recommendations regarding the PCMH Kids Cohort 3 Performance Year 2 incentive payment plan. Details on the quality measures and targets were shared at the May 26 Practice Reporting/Transformation meeting. PCMH Kids Cohort 3 practices will be eligible to receive incentive payments for meeting 3 out of 5 clinical quality measures, fielding a CAHPS survey in the fall 2021 (reporting only) and obtaining/maintaining PCMH NCQA recognition. Components of the 2021-2022 Incentive Plan can be found here.
Nurse Care Manager/Care Coordinator Best Practice Sharing: Asthma Awareness
During Asthma Awareness Month, CTC-RI/PCMH Kids hosted a May 18 Nurse Care Manager/Care Coordinator Best Practice Sharing meeting on improving care for children, families and adults with asthma. Ashley Fogerty provided an overview of RI’s Asthma Control Program and informed the group of a possible scholarship opportunity for workers interested in becoming Asthma Educators. Ty-Eisha Rivera and Cindy Brosnan discussed their rewarding experiences as asthma educators and the many tools available to help families affected by asthma. Margarita Robledo Guedes and Kate Klinger explained the Green & Healthy Homes Initiative pilot program with Integra Community Care and shared a case study on how GHHI was able to successfully address various asthma-contributing factors in the home of a family with 3 asthmatic children. Trish Washburn concluded the meeting with an update on RI’s plan to bring COVID-19 vaccines into pediatric and family medicine practices to help address vaccinating eligible children.

Please be advised of a research opportunity for primary caregivers / parents of children ages 6 to 11 years old with severe asthma that will pay a total of $250 for participation, if eligible.
In Case You Missed It: News and Publications
National Initiative on Accelerating Child Health Transformation launched
Center for Health Care Strategies
May 25, 2021
The Center for Health Care Strategies (CHCS) announced the launch of Accelerating Child Health Transformation, a learning community that will work with 12 leading pediatric practices, a team of six family advisors, and subject matter experts in the field from across the nation to advance innovations for providing more equitable and family-focused care. One participating practice is Hasbro Children’s Hospital Pediatric Primary Care in Providence. Congratulations Dr. Pat Flanagan and team for being included in this national initiative! Read more.
Leveraging Medicaid Accountable Care Organizations to Address Health Equity
Center for Health Care Strategies
May 2021
Medicaid agencies are leveraging contracts and procurement processes to require investment and attention to health equity through a variety of opportunities. The Center for Health Care Strategies outlined promising examples of state incentives or requirements of accountable care organizations (ACOs), which can be used to advance health equity. ACOs can be a powerful resource for addressing health equity given their mission to facilitate better coordination and higher quality care across a spectrum of providers. RI's Accountable Entity program is highlighted here, read more.
NCQA Quality Innovation Series Features National Speakers, Including CTC-RI Leaders
This Learning Series From NCQA running June - November 2021 includes 50+ speakers from across the nation and 50+ courses, including two courses by CTC-RI leaders:
  • July 21: "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
  • October 6: "A Multi-Disciplinary Approach to Behavioral Health Distinction Can Position IBH Best Practices" led by Nelly Burdette, Psy.D, Senior Director of IBH with CTC-RI and Jennifer Etue, LICSW, IBH Manager with PCHC
Learners can participate in the entire series or in specific chapters, or take individual courses a la carte. Sessions will include presentations from NCQA leadership and staff, in addition to external subject matter experts, thought leaders and accelerators in health care as we continue to redefine the quality playbook.
Practice Resources
RIDOH Updates Ambulatory Care Guidance
RIDOH has updated its Guidance for Ambulatory Care Settings for Infection Prevention with COVID-19. The guidance highlights areas ambulatory care settings, including primary care clinics, should evaluate to ensure they are meeting acceptable infection prevention standards. 

CurrentCare and CurrentCare for Me Online Enrollment Now Available in Spanish and Portuguese
The Rhode Island Quality Institute (RIQI) is happy to announce you can now sign up for CurrentCare and CurrentCare for Me online in both Spanish and Portuguese., select your language and enroll today!

FCC Announces Emergency Connectivity Fund
From June 29, 2021 to August 13, 2021, eligible schools and libraries can apply for financial support to purchase connected devices like laptops and tablets, Wi-Fi hotspots, modems, routers, and broadband connectivity to meet unmet needs for off-campus use by students, school staff, and library patrons during the COVID-19 emergency period. During this application filing window, eligible schools and libraries, in addition to consortia of schools and libraries, can submit requests for funding to purchase eligible equipment and services between July 1, 2021, and June 30, 2022. Learn more.

Vaccinate Your Family Launches 'Don't Skip' Campaign
Vaccinate Your Family, in collaboration with Merck, announced the recent launch of a new public health campaign called Don’t Skip with actress, activist and author Gabrielle Union-Wade to encourage families to schedule their well-visits and stay up to date on all recommended vaccines. Access information and resources at

Clinical Teleconsultation Lines at Women & Infants Hospital and Bradley Hospital Can Help Providers Address Patient Behavioral Health
In RI, there are two psychiatric teleconsultation lines providers treating pregnant, postpartum, pediatric, or adolescent patients can call for free clinical consultation and/or referral support. Behavioral health clinicians, including specialized psychiatrists, psychologists, and resource and referral specialists, from Women & Infants Hospital (RI MomsPRN) and Bradley Hospital (PediPRN) are available for clinical consultation regarding diagnosis, treatment planning, and medication safety and can also provide resource and referral support to community-based treatment and support services. Providers are welcome to call these two free teleconsultation lines five days a week for real-time assistance. Learn more.

New HealthSource RI Enrollment Period Through August 15, 2021
HealthSource RI is offering a New Enrollment Period (NEP) to give RI residents additional time to sign up for 2021 coverage. This NEP began on February 15th and will continue through August 15th, 2021 and is open to eligible Rhode Islanders. Lawfully present immigrants (asylees, green card holders, refugees, etc.) can enroll in health coverage. Coverage starts the first of the month following a complete enrollment. The American Rescue Plan Act provides most HealthSource RI customers with additional financial help to reduce their monthly coverage costs. Additionally, customers who were not eligible to receive financial help in the past may now be eligible. To learn more, call 1-855-840-4774 to see what financial help you may be eligible for. Additional messages for providers interested in sharing can be found here.

Free Caregiver Support Groups
Offered by volunteers of Village Common of RI, caregiver support groups provide opportunities to share experiences with other caregivers and get information about resources that can help. Individuals can decide to attend one, two or more sessions right from home. Learn more.

Fall 2021 Bradley Conference: Suicide Prevention, Screening, and Response Training for the General Public
Coming in October and November! The presenters for these courses will be Scott Sylvester, LMHC, Kimberly Lafountain, LMHC and Margaret Paccione-Dyszlewski, PhD. Learn more.

RIGEC and LCB Senior Living Present: Sex and Seniors - Supporting the Rights of Sexual Expression While Protecting the Vulnerable
This session on June 22 from 12-1pm will review opportunities to support individuals you care for around sexual expression. Learn the difference between sex and intimacy, and why this may be seen as taboo. From frontline associates and family education to LGBT advocacy, join us as we share tools and examples. Lecture, presentation with slides, and a sample policy handout. Register here.
June and July CTC-RI Committee Meetings and Workgroups
  • June 17, 03:00-04:30PM – SBIRT/CHT Executive Committee
  • June 18, 07:30-09:00AM – Clinical Strategy Committee
  • June 25, 07:30-08:45AM – Board of Directors
  • July 01, 07:30-08:45AM – Quarterly PCMH-Kids Stakeholders
  • July 09, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • July 15, 07:30-09:00AM – Quarterly Pediatric Integrated Behavioral Health
  • July 15, 03:00-04:30PM – SBIRT/CHT Executive Committee
  • July 16, 07:30-09:00AM – Clinical Strategy Committee
  • July 20, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • July 23, 07:30-08:45AM – Board of Directors
  • July 28, 07:30-09:00AM – Practice Reporting and Transformation Committee
June and July CTC-RI Program and Initiative Meetings
  • June 23, 08:00-10:00AM – Care Community and Equity Best Practice Sharing
  • June 24, 02:00-03:00PM – Healthy Tomorrows
  • July 14, 01:00-05:00PM – Rhode to Equity Kickoff (Part 1)
  • July 22, 02:00-03:00PM – Healthy Tomorrows
  • July 29, 12:00-04:00PM – Rhode to Equity Kickoff (Part 2)
Summer 2021 Learning Collaboratives and Professional Development
  • June 29, 12:00-01:00PM – CTC-RI Telehealth Webinar: Virtual Care and Patient Self-Monitoring Tools – Strategies for RI Adult Primary Care Practices