Care Transformation Collaborative of RI

News & Updates | August 2023

Update on Medicaid Pediatric Recovery Program - Year 2

Immunization and lead screening rates demonstrate continued practice improvement

Congratulations to the practices that are participating in the Year 2 Medicaid Pediatric Healthcare Recovery Program who demonstrate continued success improving child health as demonstrated with increased childhood immunizations and lead screenings rates. We saw outstanding achievement with 80% of applicants enrolled in the Medicaid Pediatric Healthcare Recovery Program meeting 3 out of 4 Immunization and Lead Screening July targets (or improvement targets). Congratulations!

Successful Behavioral Health (BH) ECHO® learning series

An impressive 100% of the Medicaid Pediatric Healthcare Recovery Program applicants met the requirements for participating in the Behavioral Health ECHO® Learning Sessions. A remarkable accomplishment!


Thank you to all that participated, we hope you enjoyed it. Thank you to our didactic and case presenters, and a special thank you to Drs. Liz Cantor and Sarah Hagin for putting this program together. Those interested can view the didactic portion of the ECHO® sessions and earn 0.5 CME credits. Details.

Now open to new practices! DULCE call for applications

CTC-RI, with funding from UnitedHealthcare, RI Department of Health and HHS Administration of Children and Families, is pleased to offer two primary care practices* the opportunity to participate in: DULCE: Developmental Understanding & Legal Collaboration for Everyone. Apply by September 5!


  • Practice stipend ($35,000) to hire/on board CHW/Family Specialist and team participation
  • Trainings for the CHW/Family Specialist and interdisciplinary team to enhance infant-parent relationships (Brazelton Touchpoint and Newborn Behavioral Observations)
  • Integration of MLPB, as the Learning Collaborative team-facing legal partner
  • Practice facilitation support

Team implementing the DULCE approach will be successful in:

  • Building a culture that honors family-driven goals for care during a timeframe often marked by both joy and stress.
  • Implementing strengths-based screening for health-related social needs (HRSN) as well as more effective referral and response through the efforts of the CHW Family Specialist and the broader DULCE team.
  • Improving completion rates for key preventive care (well-child visits, immunizations and reducing avoidable emergency department care.

*Pediatric/primary care practices can partner with a practice that provides prenatal care and the CHW/Family Specialist can be assigned to provide a continuum of family support including the prenatal period.

View the call for applications here. Questions? Contact Michelle Mooney ([email protected])

Excellence in Innovation Award: Pharmacist Dr. Kelley Doherty Sanzen 


CTC-RI would like to extend a well-deserved congratulations to Dr. Kelley Doherty Sanzen for her recent National Alliance of State Pharmacy Associations Excellence in Innovation Award! This award recognizes pharmacists who have shown unusual and exemplary innovation in their practice setting.  


Dr. Doherty Sanzen has done just that! As a consultant for our successful projects that integrate pharmacists with primary care, she has helped us pilot efforts to reduce hospital/emergency department use, promote safe, effective, and efficient medication use in primary care, and implement professional-use CGM in primary care.


Echoing her nomination, she is “a true leader and innovator in the pharmacy community with a longstanding commitment to quality improvement. She has established herself as an exceptional pharmacist working for Brown Medicine's Division of Kidney Disease and Hypertension where in the midst of the Covid pandemic in 2020, she implemented remote patient monitoring for patients with chronic kidney disease and/or uncontrolled hypertension. Her passion for mentoring and teaching, led her to hire a pharmacy intern in 2021 to expand these services to primary care and since then other ambulatory care practices have hired pharmacy interns to support their pharmacy initiatives giving exposure earlier in their curriculum to a growing segment of pharmacy that historically was reserved for Advanced Pharmacy Practice Experiential students at the end of their curriculum.”


In addition to the above, Dr. Doherty Sanzen has spearheaded many other successful projects throughout the pharmacy community in Rhode Island, and we are lucky to have her in our community. Congratulations!

Did you register?

"Investing in Primary Care & Health Equity"

Annual Conference

CTC-RI’s annual conference promises to be a thought-provoking and insightful gathering on October 5 at the Crowne Plaza in Warwick. This event will be a prime opportunity to immerse yourself in discussions about the pivotal role of primary care in promoting health equity. 

We are thrilled to announce a lineup of fantastic vendors including the RI Department of Health, Parent Support Network of RI, Family Service of RI, Unite Us, the American Lung Association and more! These dynamic partners will be sharing an array of programs and resources designed to support healthcare practices. Don't miss this chance to engage with these partners and gain access to these valuable resources. Register now!

MLPB and CTC-RI HRSN Phase II Program to begin in September

MLPB and CTC-RI are excited to begin working with primary care practices and older community constituents in MLPB’s Health-Related Social Needs (HRSN) Learning-And-Action Lab series! The series, set to begin in September, is the second of a two-phased initiative designed to inform and improve primary care -based HRSN screening, referral, and problem-solving strategies impacting older RI adults. Through generous funding from Blue Cross & Blue Shield of RI*, the Lab explores how the screening experience of older adults (age 55 and over) can be enhanced, and how care teams and insurers can be more responsive to patients’ goals.

In Phase II, a group of older adults who participated in the Phase I Learning Lab will share priorities for improving HRSN screening with staff from several Rhode Island primary care practices over five videoconference sessions. Phase II Action Lab participants will identify strategies to improve the screening and referral processes in the primary care setting. Videoconference sessions are scheduled to begin September 7 and run through January 2024.

CTC-RI will support MLPB with implementation of practice transformation strategies with up to seven primary care practices that will be selected to participate in these best practices for strengths-based screening, triage and response. Read more.

Register now for Breakfast for Champions!

On September 8 at 7:30am, CTC-RI will host it's quarterly Breakfast of Champions Meeting with ArchAngels. Unpaid caregivers are the backbone of our nation and there are a lot of us. Caregiver intensity is impacting all aspects of our health--moreso for “double-duty” caregivers and at-risk populations--and we’re coping however we can. The good news? We absolutely can do something about it. Join us as we dig into what we all can be doing--as business, healthcare, and community leaders AND as individuals--to support unpaid caregivers around us, and why it represents one of the biggest opportunities for creating top- and bottom-line impact with a massive side of social good. Speakers include:

  • Alexandra Drane, Co-founder and CEO of ARCHANGELS
  • Rebecca Preve, Executive Director, Association on Aging in New York
  • Bernie McGuiness, Health Care Executive, BMHC

Attendance is encouraged as topics are designed to improve effectiveness as primary care providers, and to promote wellness for our teams. CME credits and certificates of attendance will be available. Register now!

Clinical Strategy Committee focuses on primary care workforce

The July Clinical Strategy Committee (CSC) meeting included an update from Jeffrey Borkan, MD, PhD, and Denise Coppa, PhD on the Task Force for Primary Care Provider Workforce Development, highlighting the need for changes in Rhode Island to support primary care provider training, reduce burnout and address the anticipated provider deficit. Wayne Altman, MD, Jaharis Family Chair of Family Medicine and Professor, Chair of Family Medicine, Professor, Tufts University presented on "Primary Care for You (PC4You) S750 An Optional Primary Care Payment Model." The goal of PC4You is to double primary care investment, decreasing inequities and moving to a payment model which aligns incentives with patient-centeredness and team-based care.

Our next CSC meeting on August 18 will feature presentations from Edward McGookin, MD, MHCDS, FAAP, President of Coastal Medical, and Monica Kucks, RN, BS, CCM, Vice President of Care Integration and Transformation, CharterCARE with a focus on Care Design for Primary Care and Global Capitation. All are welcome to join! View the recording and claim CMEs

Committee looking to improve prior authorizations in Rhode Island

A group of representatives of Rhode Island’s health plans and other key stakeholders convened by CTC-RI have been meeting since May to continue the work produced by the OHIC Task Force on Prior Authorization. The committee is charged with developing concrete recommendations that consider the health plans, providers and patients’ needs for a more effective and less burdensome prior approval process. 

At its August meeting, the committee reviewed recently passed legislation that addresses uniformity of claims, annual review, improved transparency, continuity of care, adoption of technology, and selective prior authorization opportunities. The committee is working on drafting a report of seven recommendations to present to OHIC by November 2023. 

Practices selected for new demographic data collection project

Congratulations to the primary care practices selected to participate in our project aimed at improving how patient race and ethnicity information is collected and used to identify and address health inequities. The project, funded by RIDOH, EOHHS and CDC, asks practices to evaluate current processes for collecting race and ethnicity information, and survey patients to hear about their experience providing their information to their health care provider. 

Practices will also participate in a six-session webinar series that will provide valuable information on why demographic information is important to providing quality health care services, best practices for obtaining information from patients in a sensitive way, and tools and resources that practices can use to train their staff and educate patients. Congratulations to the following practices selected to participate! CTC-RI looks forward to working with you on this important project:

July Team-Based Care: Alcohol and Opioid Use “Beyond the Basics”

In July, 120 people attended the Team-Based Care meeting for the RI primary care community. Nelly Burdette, PsyD, joined us for a presentation on ‘Substance Use Beyond the Basics.’ Dr. Burdette is the Associate Vice President of Integrated Behavioral Health at Providence Community Health Centers and the Senior Integrated Behavioral Health Program Leader for CTC-RI. Dr. Burdette’s presentation focused on alcohol and opioid use in RI and provided attendees with up-to-date RI data, treatment options, and information about co-morbidities. Penny Lee Palazzo, RN, of Wood River Health Services, rounded out the presentation with a case study from her work with a patient in opioid recovery (PPT and recording). Thank you to presenters, and to Prospect Health Systems, who initially developed this presentation with Dr. Burdette and graciously allowed us to present it to a wider audience.

Register now for the RI Geriatric Education Center's virtual learning session on September 19, “Social Isolation and Loneliness in Older Adults," in lieu of a CTC-RI-hosted Team-Based Care meeting in September. Details here.

Find past CTC-RI learning session and CME/CEUs here!

CTC-RI offers CME credits for select meetings, including asynchronous viewing of meeting recordings. Learn more and access evaluation forms here.

Practice Resources, News, and Information

EOHHS grant opportunity (up to $200,000!)

Staff recruitment and retention has been cited as a challenge across industries, especially in the direct service industry. Specifically, staff shortages in the homeless service provider and healthcare industries have been identified as a critical need. Upfront costs associated with recruiting staff and sustaining positions long-term have been cited as areas where additional resources and strategies are needed. This grant opportunity seeks to focus on workforce recruitment, retention, and sustainability through increasing organizational readiness to bill for specific Medicaid services aimed at assisting individuals who are experiencing homelessness. Deadline is November 10! Details here.

RI Association for Infant Mental Health: 2023 Community Conversation Series

Join the upcoming virtual session on September 12 (8:30-10:30am), "A Social-Ecological Theory of Racism and Anti-Racism." The speakers will explore how racism permeates the social ecology of children’s and families’ lives through the lens of the social-ecological model, and what it looks like to implement anti-racism strategies, policies, and practices at the individual, family, community, and societal levels. The presenters will draw from CSSP’s anti- racist intersectional frame and explore how we can apply an anti-racism approach to work with families. In particular, Patsy Harmon (from CSSP) will facilitate discussion about links to pediatric primary care by highlighting work of RI DULCE teams. Register.

Updated guide helps states and local communities improve brain health

The Alzheimer’s Association and CFC, have released the fourth edition of the Healthy Brain Initiative Road Map. This framework is designed to help public health officials lead with urgency and act for impact in their communities to improve brain health and support caregivers. We're thrilled to see our Rhode Island work highlighted in this document, including our focused ECHO Learning Series and Quality Improvement process.

Upcoming CTC-RI Committee Meetings and Workgroups

  • August 25, 07:30-08:45AM – Board of Directors
  • September 08, 07:30-09:00AM – Breakfast of Champions
  • September 13, 08:00-09:00AM – Taskforce of Primary Care Provider Workforce
  • September 14, 07:30-09:00AM – Prior Authorization Meeting
  • September 15, 07:30-09:00AM – Clinical Strategy Committee
  • September 22, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • August 23, 07:30-09:00AM – RI MomsPRN Final Learning Collaborative
  • August 28, 12:00-01:00PM – Healthy Tomorrows Quarterly Learning Collaborative Meeting - Cohort 3
  • August 30, 07:30-09:00AM – Care Coordination ECHO®
  • September 07, 07:30-08:30AM – Virtual Coffee Break with Dr. Pat Flanagan & Dr. Beth Lange
  • September 13, 07:30-09:00AM – 4M Framework Learning Collaborative
  • September 15, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • September 18, 08:00-09:30AM – CCE Best Practice Sharing Meeting
  • September 19, 08:00-09:00AM – Best Practices in Team-Based Care
  • September 21, 07:30-09:00AM – Restrictive Eating ECHO series Kickoff
  • September 27, 07:30-08:30AM – Care Coordination ECHO Series
  • September 28, 07:30-09:00AM – DULCE Year 2 Kickoff
Care Transformation Collaborative of RI | [email protected] |