Care Transformation Collaborative of Rhode Island News & Updates | May 2021
Pediatric Immunization: A Quality Improvement Initiative in Response to COVID-19, Funded by Blue Cross & Blue Shield of Rhode Island and Coronavirus Relief Fund
In May 2020, the effects the COVID-19 pandemic on accessing well-child care as evidenced by declining pediatric immunization rates was brought to light at various committee meetings. Blue Cross & Blue Shield of Rhode Island (BCBSRI) requested that CTC-RI/PCMH Kids develop a proposal to address this emerging issue. CTC-RI/PCMH Kids’ Immunization Quality Improvement proposal submitted to BCBSRI addressed this need through a 4-pronged approach (leadership, information management, practice facilitation/performance improvement, and financial assistance).

Parallel and complimentary to this proposal RI American Academy of Pediatrics, through the Governor’s Task Force, was working with EOHHS and OHIC to address the financial viability of pediatric practices in Rhode Island given the devastating impact COVD-19 was having on the healthcare system. These efforts resulted in pediatric primary care practices successfully applying for additional funds (Pediatric Relief Funds, Medicaid Pediatric Care Rate Supplement Program) to further expand and support improvement in well-child outcomes. Read more.
Rhode Island COVID-19 Vaccination Update: Children 12+ Now Eligible
Adolescents ages 12+ can now schedule appointments for the Pfizer vaccine at with the help of a parent or guardian. Across all eligible age groups, currently, 609,519 Rhode Islanders are partially vaccinated, and 506,996 Rhode Islanders are fully vaccinated.
Success Spotlight: Using telemedicine to better support patients with chronic conditions
A to Z Primary Care, a family medicine practice in Warwick, is participating in the first cohort of CTC-RI's new Telehealth Learning Collaborative focused on using technology to improve care for patients with chronic conditions. The Learning Collaborative kicked off in February and runs through January 2022, funded through UnitedHealthcare and CARES Act funding. In the Learning Collaborative, family medicine practices are focused on chronic conditions including heart failure, hypertension, obesity, and asthma. Kathy Parker, APRN, a nurse practitioner at A to Z Primary Care, recently shared her experience with this work.

What was a surprising new practice or approach learned through your involvement in the Telehealth Learning Collaborative?
Our practice was surprised to learn how much our patients wanted to be involved with this project! They feel "special" – which they all are to us. They adapted quickly to their new equipment provided, were shown at their appointments, and now weekly check-ins with Maryellen the nurse care manager. Our patients truly want to be a part of our experience and have the best possible outcome for their CHF. Their ages range from age 36-97 – the 36 year old is now on the kidney transplant list in Boston and is so excited about our interest in him!

How have your practice's efforts shifted to more effectively utilize telehealth strategies to support patients?
Our practice has used telehealth to monitor our patients with CHF all through COVID! We kept at least 3 of them from being hospitalized during the pandemic, which they feared most, by sending them blood pressure cuffs and pulse oximeters and lots of phone calls. Now, telehealth allows us to listen to their breathing and see the amount of swelling in their legs and proceed accordingly. We partnered with home draw labs who went out weekly, providing us more objective data to use. We have a video system through Athena, patients use their smartphones, or use just the usual telephone system.

What lessons learned or advice can you share with other practices considering new telehealth strategies based on your experience?
Giving the patients options for telehealth with a chronic condition empowered them to feel safe during the pandemic and it continues at this time. Including their families along with the patient has provided good information about compliance and home life issues. The barriers of care were noted and addressed by the staff and each care plan is tailor-made for our patients. We did not anticipate all of the enrolled participants to be so engaged and compliant. I don't think they want to let us down – because we care – and in turn it has kept them healthier. Overall, communication and transparency is the key to success. Thanks to CTC-RI for continuing to help us help our patients stay well!
April's Nurse Care Manager/Care Coordinator Best Practice Sharing meeting highlighted different community clinical linkages to support childhood development and lead screening. Beth Lange, MD, PCMH Kids co-chair, facilitated a conversation on how PCMH Kids practices are improving care by standardizing workflows and using data to improve identification of children and families in need of follow-up.

Sara Remington, RIDOH Office of Family Visiting, gave an overview of their program supporting children and families prenatally through age four. Casey Ferrara, M.Ed., Director Early Childhood Programs, introduced the Meeting Street programs, while her colleague Cris Massey presented a case study of a RI mother of four who engaged with the Healthy Families America program to address her needs, resulting in improved engagement with her pediatric practice. Michelle Almeida also provided an overview of lead screening efforts in the state, and Janet Limoges of KIDSNET demonstrated how practices can use their portal to track family visiting and lead screening. Read more.
Best Practice Sharing: PCHC Pharmacy Quality Improvement Efforts Target Patients with Diabetes and Avoidable ED Visits
Following participation in CTC-RI's 12-month learning collaborative focused on empowering safe, effective, and efficient use of medications in older adults, Providence Community Health Centers (PCHC) recently shared their success targeting efforts to reduce potentially avoidable ED visits. An analysis of avoidable ER visit diagnoses showed that many of their patients’ presenting complaints could be symptoms connected with poorly managed diabetes and hypertension. During a February presentation to the EOHHS Accountable Entity Advisory Committee, PCHC's Jonathan Gates, MD and Lillian T. Nieves, PharmD noted avoidable ED visits are often out of convenience and are historically well-managed by same-day appointments, but the practice was incredibly busy with all appointment slots commonly filling by 9:45am. PCHC believed high-utilization patients with diabetes and at risk for polypharmacy could reduce ED utilization through rigorous pharmacist medication therapy management and diabetes education. Many ‘causes’ of avoidable ER visits could be mitigated with a ‘sick day’ plan, and pharmacist counseling was first addressed by ‘Symptom Management’ with top 6 Avoidable ED visit diagnoses. After new targeted efforts were in place, ED use decreased an average of 1.5 visits per 6 months, A1c level decreased an average of 2.3, medications decreased an average of 5.3, doses per day decreased an average of 9 per day, and Systolic and Diastolic blood pressure declined 5 and 8 mmHg, respectively. Jonathan Gates, MD and Lillian T. Nieves, PharmD will be presenting their work at the June 11 Breakfast of Champions meeting (details here).
CTC-RI and RIDOH, in collaboration with faculty from University of Rhode Island College of Pharmacy, are pleased to announce that the following practices have been selected to join the 2021 Pharmacy Quality Improvement Initiative to reduce preventable hospitalizations and emergency department usage through team-based care.

The program kicked off on May 20 with over 40 participants. The teams were able to introduce themselves and learn more about the initiative. Congratulations to these practices! Thank you to UnitedHealthcare and RIDOH for providing funding for this initiative. Learn more.
CTC-RI is happy to announce that CME credits are now available for our quarterly Breakfast of Champions meetings. Please make note that the upcoming June 11 Breakfast of Champions discussions are relevant to both Adult and Pediatric practice leaders.

The event will include a presentation by Jay Gates, MD, Director of Integrated Care Delivery, Providence Community Health Centers and Lillian Nieves, PharmD, Clinical Pharmacist (featured in the above Best Practice Sharing spotlight) on their work to address avoidable ED visits, and a panel of adult and pediatric practice leaders from outside of RI will discuss the "Changing Role of the PCP (and inter-professional care team) Under Capitation."

Please use this link to register. Email for interest obtaining a CME Credit Request Form.
On April 27, CTC-RI continued the "Advancing Team-Based Telehealth in RI" series with a webinar addressing remote patient monitoring (RPM) being used in RI. Blue Cross & Blue Shield of RI has partnered with AMC Health while UnitedHealthcare has partnered with Vivify/Optum to offer RPM services for patients with Medicare Advantage health insurance. Darlene Dorocz, RI Director of Nursing at RIPCPC, provided an overview of how her team works with RPM companies to coordinate care for patients. Amy Perry, MBA, Director of Case Management at Providence Community Health Centers, described how PCHC is using funding through the Accountable Entity and partnering with Health Recovery Solutions to improve care for patients with chronic conditions. Representatives from RPM platforms (Vivify/Optum, Health Recovery Solutions, and AMC Health) presented on setting up services for primary care patients. Read more.
CTC-RI Continues Telehealth Webinar Series on May 25
Mark your calendars for our next telehealth webinar on Tuesday, May 25 at 12pm. This is the 6th webinar in the "Advancing Team-Based Telehealth in RI" series and will focus on strategies and considerations for pediatric practices. 

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, will share his perspective on providing telehealth services to pediatric patients. The discussion will touch on obstacles, opportunities, and the use of telehealth to manage chronic medical and behavioral health conditions. Beth Lange, MD, Co-Chair PCMH Kids, will serve as moderator.

Register here. Not able to attend the live session? You'll be able to access the recording and materials on our website. This webinar series is funded by UnitedHealthcare and authorized CARES Act funding.
Last week, 21 pediatric and adult primary care practices participating in our Telehealth Learning Collaborative came together for a quarterly meeting to share progress and challenges in implementing technology to improve care of patients with chronic conditions. The Learning Collaborative is funded by UnitedHealthcare and authorized CARES Act funds. The 9 practices in Cohort 1 kicked off their projects in March, so the May 12 meeting was a well-timed opportunity for practices in both Cohort 1 and Cohort 2 to engage and learn from eachother. Cohort 1 practices shared their experiences around staff and provider engagement, workflow, technology, and patient engagement. Learn more.

Below, participants shared their feelings about their telehealth projects so far:
During the month of April, Community Health Teams and SBIRT screeners had the opportunity to participate in two unique trainings. On April 14, Jope Consulting Services hosted Part 2 of an online Motivational Interviewing training, giving 22 attendees an opportunity to enhance their work supporting individuals through facilitating behavior changes. Motivational interviewing is used in a wide variety of fields which is certified as an evidence-based practice by the Substance Abuse and Mental Health Services Administration. CTC-RI supported another training on April 28 with MLPB on Federal Disability Benefits, specifically on recognizing public policies that support (and harm) sick and disabled workers. Attendees learned to identify legal protections to keep employment during medical leave and available income supports for those who can no longer work.
In April 2020, CTC-RI was charged by OHIC and Medicaid to assist in accelerating the adoption of comprehensive primary care capitation. CTC-RI sponsored an accelerated 4-month effort to define critical factors of Care Delivery Design to “maximize success in Comprehensive Primary Care Capitation (CPCC) within Total Cost of Care (TCOC) risk.” Now CTC-RI is continuing to build on the care delivery design work we began last spring. A CTC-RI committee of 20 representatives from practices, health plans, OHIC, and other stakeholder groups has continued to meet to push the work forward. This work aligns well with the recently released report and recommendations on “High Quality Primary Care” from the National Academies of Science Engineering Medicine. Read more.
In Case You Missed It: News and Publications
Making primary care a primary investment
Richard Asinof
ConvergenceRI (May 10, 2021)
The COVID-19 pandemic has challenged the status quo in health care delivery. Here in Rhode Island, the Care Transformation Collaborative has been an innovative leader in pioneering new approaches, as detailed in an in-depth interview. Read the ConvergenceRI article here.
Social Care Matters: Do Teams Have What They Need to Succeed?
Rhode Island Medical Journal (May 2021)
This month's issue features a commentary highlighting the partnership between CTC-RI and MLPB (formerly known as Medical-Legal Partnership | Boston) on offering legal education and problem-solving skills to the community health workforce. Over the last 3 years, MLPB has brought legal expertise and consultation to the Community Health Teams (CHT) on a variety of complex social needs (e.g. immigration, housing, utility shutoff, guardianship). This commentary reflects on the value of lifting the skill set of CHT staff and highlights data points captured over the course of this partnership. Read more here.
As many RI groups have focused on value-based payment this year, CTC-RI’s Clinical Strategy Committee (CSC) is making significant strides to concentrate on how a capitated alternative payment model (APM) might possibly improve health care.

On April 16, Art Jones, MD, Principal, Health Management Associates and CMO, Medical Home Network, was our guest speaker presenting, “Value-Based Payment: Is It Disrupting Health Care for the Better?” Almost 40 physicians and health care leaders engaged in understanding how a Chicago health care system addressed issues such as: 1.) limitations of strict Fee-for-Service (FFS) reimbursement to support optimal outcomes and efficiency of new models of care, 2.) APMs that can be used to improve patient access to care and outcomes, 3.) linkages between payment reform and expanded use of the primary care workforce, and 4.) the clinician role in the adoption of APMs.

The CSC has an exciting May 21 meeting planned on data provided to practices to improve performance and characteristics of high-performing CPC+ practices. Many CSC meetings will now offer CME Credits. Feel free to reach out to CTC-RI for more information about obtaining a CME Credit Request Form. Learn more.
At the May 13 Integrated Behavioral Health (IBH) Committee meeting, Marti Rosenberg, MPS, RI EOHHS Director of Policy, Planning, and Research and Susan Lindberg, LICSW, RI DCYF Associate Director, Community Services & Behavioral Health, presented on the Children’s Behavioral Health System of Care. Marti set the stage on the current environment of children’s behavioral health in Rhode Island, pointing out that today’s system is fragmented and difficult to navigate for parents. Susan reviewed with the group a draft proposal of integrated “System of Care” for children’s behavioral health with the 1st-year priorities focused on a single point of access and statewide 24/7 mobile response and stabilization services. Read more.
*Please note, the next quarterly IBH meeting (focused on pediatrics) has been moved to July 15. Practices involved in the Pediatric IBH Learning Collaborative will share challenges and best practices, and content experts will discuss research involving adolescent eating disorders.
CTC-RI/PCMH Kids and RIDOH are pleased to announce that the following practices have been selected to join the 2021 Pediatric/Adult Health Care Transfer of Care Quality Improvement Initiative.

These practices will work together to improve transition of care for youth as they transition from pediatric to adult care. Congratulations to all the selected practices as they kickoff this work! Special thanks for Tufts Health Plan and RIDOH for providing the funding for this initiative. Read more.
For April’s webinar momentum session, David Waters, MA, Chief Executive Officer of Community Servings, presented on actively engaging the community to provide medically tailored, nutritious, scratch-made meals to chronically and critically ill individuals and their families. Community Servings has over 30 years of experience delivering medically tailored meals and serves 3,200 people each year. With 15 medical diets tailored to nutritional and medical needs using whole, fresh ingredients, Community Servings has been able to demonstrate an ROI, such as a 16% reduction in monthly healthcare costs, 49% fewer hospitalizations, and 72% less admissions to skilled nursing facilities.

On May 14, teams met for a momentum session on advancing health equity in the context of COVID-19 using the pathways approach. Somava Saha, MD, MS, Well Being in the Nation, facilitated a discussion on how the COVID-19 “syndemic” requires a coordinated strategic response across sectors to address physical, mental and social health together. Read more.
Practice Resources
Leveraging Medicaid to Support Early Childhood and Parental Mental Health Amid the COVID-19 Pandemic and Beyond
Medicaid, often the first social sector to connect with at-risk infants and young children in low-income families, can play a role in addressing the mental health of parents, caregivers, children, and infants who are experiencing stressful situations, including the pandemic. This blog post highlights strategies for leveraging cross-agency collaborations and strengthening Medicaid to support early childhood and parental mental health during the pandemic and beyond.

CTC-RI COVID-19 Briefing
Please reference CTC-RI's last COVID-19 briefing for related updates, news, and practice resources.

Vaccine Communication Resources
The Association of Immunization Managers has compiled existing communications messaging and materials that you can use to support your vaccine communication efforts. All of these materials are either publicly available or have been shared by the CDC and Association for Immunization Managers members.

RI Geriatric Education Center Launches New Live Webinar Series
A new live webinar series, Coming Out of COVID-19, will give health care providers information and strategies to connect with resources to address challenges related to the ongoing and evolving impact of COVID-19 on older adults. Sessions will be held from 12-1pm and hosted over Zoom. Each session has its own registration link. (May 25: Decreased physical activity and deconditioning; June 8: Mental and behavioral health impact; and June 22: Reducing provider stress and maximizing well-being).

Obesity Care Advocacy Network 3-Part Webinar Series
Learn about how obesity can impact individuals throughout their lifetime, featuring medical experts in pediatric, adult and gerontological obesity. The first webinar is May 24 at 2pm.

Advancing Health Equity: The Essential Role of Primary Care
Access a presentation here by the Office of Infectious Disease and HIV/AIDS Policy at the 2021 Leadership and Faculty Development Program Conference.

Job Opportunity: Nursing Care Manager at Anchor Pediatrics in Lincoln
Responsible for care management of high risk/complex patients with medical and/or behavioral health conditions. Applicants should submit their resume and apply for Job ID: 19776 at]

Job Opportunity: East Bay Community Action Program is Hiring!
EBCAP is currently hiring for many different positions, from Clinical Medical Assistant positions to a Family Physician position. View the opportunities here.
May and June CTC-RI Committee Meetings and Workgroups
  • May 21, 07:30-09:30AM – Clinical Strategy Committee
  • May 26, 08:00-09:30AM – Practice Reporting/Practice Transformation Committee Meeting
  • May 28, 07:30-08:45AM – Board of Directors Meeting
  • May 28, 09:00-10:00AM – Community Health Team Oversight Committee
  • June 11, 09:30-11:00AM – Community Health Team Best Practice Meeting
  • June 15, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • June 17, 03:00-04:30PM – SBIRT/CHT Executive Committee
April and May CTC-RI Program and Initiative Meetings
  • May 20, 07:30-08:00AM – Reducing Preventable Hospitalizations and ED Usage Pharmacy Kickoff
  • May 24, 02:00-03:00PM – Healthy Tomorrows
  • June 03, 07:30-08:00AM – Virtual Coffee Breaks with Dr. Pat Flanagan & Dr. Beth Lange
Spring 2021 Learning Collaboratives and Professional Development
  • May 25, 12:00–01:00PM – Advancing Team-Based Telehealth in RI: Pediatric Virtual Care 2.0 Webinar
  • June 11, 07:30-09:00AM – Quarterly CTC-RI Breakfast of Champions
  • June 25, 08:30-11:30AM – RIHCA Cancer Screening In Rhode Island