Care Transformation Collaborative of RI

News & Updates | February 2023

Welcome to our new board members!

CTC-RI is pleased to introduce the newest members of our Board of Directors. Our new leaders bring a wide range of expertise and experience to our organization, representing skill and knowledge in pediatrics, pharmacy, behavioral health, LGBTQ+, healthy aging, community health, and more. Join us in welcoming these talented leaders to our organization as we continue to grow and transform primary care for Rhode Islanders statewide.

We'd also like to give a special thanks to our departing institutional board member, Matthew Collins, MD, MBA, who served as Executive Vice President/Chief Medical Officer at Blue Cross & Blue Shield of RI. Dr. Collins' leadership and guidance has inspired us to provide more effective care for our patients and families. Thank you for the positive impact you have had on CTC-RI and on Rhode Island's primary care community.

"Blue Cross & Blue Shield’s vision is to improve health and well-being by leading access to high-quality, affordable, and equitable care. The partnership between BCBSRI and CTC-RI helps us to achieve this vision. Supporting CTC-RI through my involvement with the Board of Directors and other committees has been among the most rewarding and gratifying experiences." - Dr. Matt Collins

OHIC releases amendment to Affordability Standards for public comment

The Office of the Health Insurance Commissioner (OHIC) has released proposed amendments to 230-RICR-20-30-4: Powers and Duties of the Office of the Health Insurance Commissioner, which includes the Affordability Standards.

The proposed rule and supporting rulemaking documents can be found on the Secretary of State’s website here. The Rulemaking Documents tab includes the Notice of Proposed Rulemaking with public comment dates, the proposed amendments, public comments received from OHIC’s November 2021 Advance Notice of Proposed Rulemaking, and other documents that describe the proposed amendments. These documents have also been posted on OHIC’s website on the Regulations page.

The public comment period is January 23 - March 7. A virtual hearing will be February 27, 9:00AM. Public comments can be emailed directly to Cory King, Acting Health Insurance Commissioner ([email protected]).

Call for applications: 2023 Asthma Quality Improvement Initiative

In collaboration with the RI Dept. of Health and Tufts Health Plan, CTC-RI is offering the opportunity for up to 6 primary care practices to apply for funding to participate in a 6-month Asthma Quality Improvement Initiative.

CTC-RI will provide funding to support health care practices (pediatric, family medicine and adult medicine) in their efforts to participate in this data-driven initiative to improve the management of patients diagnosed with asthma.

The need for an Asthma Quality Improvement Initiative has grown out of the RIDOH Asthma Strategic Plan and RI data that shows striking racial/ethnic and socioeconomic disparities in pediatric asthma outcomes. Further, even though asthma is controllable, an estimated 50% of children have uncontrolled asthma and 40% of adults reported having one or more asthma attacks in the last year.

View the full call for applications and detailsApplications are due February 24. Project activities will begin April 12 and continue for 6 months.

White Paper: Health Transfer of Care Quality Improvement Project

In April 2021, with funding from the RI Department of Health and Tufts Health Plan and technical support from the National Alliance to Advance Adolescent Health, CTC-RI piloted a quality improvement initiative that focused on transitions of care from pediatric to adult practices. This pilot included 7 practice dyads, each consisting of a pediatric and an adult practice that applied together to participate in the initiative. There was successful engagement of all partners, with the resulting transfer of 29 young adults to adult primary care while an additional 12 were awaiting their first adult medicine appointment at the end of the program. The young adults and the providers reported positive experiences. Overall, the project succeeded in engaging youth in the process of transfer, and included the co-design and review of their medical summaries as well as an intentional, warm handoff to adult care. Read the full white paper here.

Telehealth updates with final RI Telehealth Project report

CTC-RI is pleased to share the final “Rhode Island Telehealth Project Report.” This 3-phase telehealth project, funded by UnitedHealthcare and Cares Act Funding ran from summer 2020 through spring of 2022. Please see the report for overall findings and results, including details on the needs assessment, webinar series, learning collaborative, telehealth planning committee, and participating practices. 

In other telehealth news, Health and Human Services announced the 90-day extension of the full Public Health Emergency (PHE) Flexibilities. Together with the "2023 Updates to Physician Medicare Fee Schedules and Telehealth" and the extension of the PHE, most telehealth flexibilities will be available throughout 2023. 

From CMS: “For CY 2023, we are finalizing a number of policies related to Medicare telehealth services, including making several services that are temporarily available as telehealth services for the PHE available at least through CY 2023 in order to allow additional time for the collection of data that may support their inclusion as permanent additions to the Medicare Telehealth Services List.”

Please click on the following links sharing resources with more information:

New group of nurse care managers completes GLearn NCM Core Curriculum Training Program

18 learners representing 13 different practices from across the state with a range of experience completed the GLearn Nurse Care Manager Core Curriculum Training Program this month. Over the course of 12 weeks, the learners completed a series of online modules tailored to their experience and weekly group learning calls facilitated by RI-based program faculty. Learning culminates in each NCM giving a capstone presentation at CTC-RI’s Best Practices in Team-Based Care meeting.

This is the 5th year that CTC-RI has been able to offer this opportunity to RI nurse care managers. CTC-RI partners with Geisinger to develop and implement the program. Geisinger developed online modules covering disease-specific content as well as care management and patient engagement skills. Participating learners are eligible to earn CEUs to demonstrate their increased mastery of these skills.

The NCM Core Curriculum program is funded by UnitedHealthcare and the RI Department of Health. This support allows us to offer the program to RI NCMs at no cost. The 2nd half of the learners will be presenting their capstone presentations on February 21 at 8am. This group is comprised of learners who work in family practices. If you would like to attend, please email Sarah Summers ([email protected]) for the Zoom invitation. You can view the previous group's capstones focused on adult patients using this link.

Breakfast of Champions March meeting: Weight management and advancements in obesity treatment

CTC-RI will host its March 10 quarterly Breakfast of Champions Meeting focusing on advancements in treatment in obesity, including new medications and community-based interventions. Panelists will include Angela Fitch, MD, FACP, FOMA and Stephen Kogut, Ph.D., M.B.A. Dr. Fitch is the Associate Director of the Massachusetts General Hospital Weight Center, faculty at the Harvard Medical School and the Chief Medical Officer of KnownWell Health, and Dr. Kogut teaches courses at URI in pharmacoeconomics, health economic modeling, and health care systems and policy, and serves as Director for Tracking and Evaluation for Advance-CTR (RI’s hub of research resources and services for clinical and translational investigators).

The panel presentation will be followed by reactants who include LouAnne Giangreco, MD FACEP, Senior Medical Director-Medical Affairs, BCBS; Susan Andrews, MD, Medical Director, General Dynamics Electric Boat; and Sarah Hagin, PhD, Director, Feeding Program, Hasbro Children's Hospital who will share their perspectives on weight management and caring for patients.

Attendance is encouraged as topics are designed to improve effectiveness as primary care providers and to promote wellness for our teams. CME credits will be available through AAFP for physicians, PAs, NP, RNs, and Pharmacists. Register for this event here for March 10, 7:30am.

January Clinical Strategy meeting highlights approaches to dementia care

The January Clinical Strategy Committee meeting focused on approaches to dementia care in RI, moderated by Victoria Parker, MS, Alzheimer's Disease and Related Disorders Program Manager, RIDOH. Tom Bayer, MD, Brown Medicine Division of Geriatrics and Palliative Medicine, highlighted the importance of comprehensive, collaborative care for patients with dementia and ways Brown is connecting patients with dementia to care specialists and social workers through team-based care and leveraging evidence-based practices.

Ana Tuya Fulton, MD, MBA, FACP, AGSF, Chief Population Health Officer, Care New England & Executive Chief of Geriatrics, and Chief Medical Officer, Integra Community Care Network spoke to the patient care model for geriatric patients at Integra. Dr. Fulton also discussed integration with the Kent Hospital at Home program. Victoria Parker spoke about the Quality Improvement Collaborative, which convenes subject matter experts, state agencies, community-based organizations, and health system partners to understand and identify opportunities to support the care and management of patients with dementia in RI. Reactants were Matthew Collins, MD, MBA, Executive Vice President and Chief Medical Officer, BCBSRI; Kelley Hurley, BS, PTA-ADPI, Grant Program Coordinator, CareLink; and Robyn Early, MA, Chief Growth Officer, CareLink. Participants also learned about services through CareLink and their mission to provide post-acute and community-based services for RI older adults.

To view the recording, find additional resources and claim CME credit, check out our page on CME Coursework.

Asthma Essentials ECHO on patient and family education

Our 5th Asthma Essentials ECHO brought together 36 participants and was facilitated by Pat Flanagan, MD. The didactic session, presented by June Tourangeau, Certified Asthma Educator, focused on “Patient and Family Education Considering Lower Income/Vulnerable Population” and provided participants with resources to help them with promoting asthma self-management education. Misotis Alsina, Program Manager of the Community Asthma Programs and Administrative Director of the Asthma Camp at Hasbro Children’s Hospital, provided the case presentation which allowed for richer discussion of caregiver supports, patient medication, and symptom identification.

Also, CTC-RI in collaboration with RI Department of Health (RIDOH) and Tufts Health Plan announced the call for applications for a 6-month Asthma Quality Improvement Initiative. Funding will be available for up to 6 primary care practices working within systems of care. To learn more and apply, please see the full call for applications.

Asthma Essentials ECHO is funded in part by RI Department of Health and Tufts Health Plan. Access materials and the recording from previous meetings here

Quarterly Integrated Behavioral Health Committee meeting

CTC-RI hosted the Quarterly Integrated Behavioral Health (IBH) Committee Meeting in February, bringing together over 30 RI professionals in the field for a great discussion. Attendees from several practices across the state joined the conversation, as well as members of community based service organizations, and insurance providers. A portion of the meeting was dedicated to discussing the barriers clinicians face joining the IBH workforce, as well as incentives and opportunities for clinicians to enter into IBH programs. 6 new projects being launched by CTC-RI were announced, including projects with a pediatric focus, IBH training series, and incentive programs for clinicians.

Several calls for applications will occur in 2023, and a full list of new IBH projects are below:

  • IBH Clinician Training – Workforce Development
  • Expanding IBH Capacity in Pediatrics
  • Reimagining High-Functioning, Team-Based Primary Care
  • Developmental Understanding and Legal Collaboration for Everyone (DULCE)
  • Restrictive Eating Disorders in Children
  • Incentivizing Community BH Providers to enter into IBH arrangements

Thank you to Blue Cross & Blue Shield of RI, UnitedHealthcare and RI Department of Health for this funding support.

This meeting also announced new OHIC Affordability Standards, which you can access via the link here. To view the Quarterly IBH Meeting recording, please use the link here.

Workshop focuses on intersection of depression and anxiety with common medical conditions

As part of a collaboration between Prospect Health Services RI's Accountable Entity and CTC-RI, Dr. Nelly Burdette, Senior Integrated Behavioral Health Program Leader, presented a workshop in January to the clinical nurse care managers and behavioral health team on how depression and anxiety intersect with common medical conditions.

Garry Bliss, Program Director-Medicaid AE, stated, "We are seeking to embed the integrated behavioral health approach across the board – from primary care to complex care management – so that the patients we work with realize the benefits of this holistic approach to health. This training session is just one example of the ways that CTC-RI is helping us build our capacity for addressing the dynamic interaction between physical and mental health." Jill Taormina, Director of Care Management stated, "Dr. Burdette’s January in-person IBH session on depression and anxiety and comorbid medical issues was truly appreciated by all in attendance. She fostered an environment where everyone felt comfortable sharing case studies and participating in dynamic group discussion, allowing our team to fully learn the skills needed to bridge the clinical and behavioral aspects of care management resulting in more successful patient engagement, increased confidence, and greater job satisfaction."

This workshop was a part of a series of trainings by Dr. Nelly Burdette, with an upcoming March session focused on Substance Use Disorder.

February update: Medicaid Pediatric Healthcare Recovery Program

Medicaid Pediatric Healthcare Recovery Program – Year 2 Update: 75% of practices enrolled in the Medicaid Pediatric Healthcare Recovery Program met 3 out of 4 January immunization / lead screening targets or improvement targets. Practices that achieved this milestone should have received their payment by February 13. Practices can expect to receive ongoing KIDSNET performance reports around the 18th of the month which will provide a status of the practice’s achievement in meeting 3 out of 4 immunization / lead screening targets or improvement targets for the next milestone in April. In addition, practices have available to them through KIDSNET, a new immunization report that will assist practices in identifying children that are due for immunizations. Instructions on the use of this report can be found here. Your Practice Facilitators are here to help. A special thank you to KIDSNET and RIDOH Lead Program staff for their heroic efforts in ensuring that immunization and lead screenings were properly reflected for the Medicaid Pediatric Healthcare Recovery Program January performance report.

80% of practices attended the 1st Behavioral Health ECHO® on Difficult Conversations which focused on vaccine hesitancy. Practices are eligible for participation payment based on practice staff attending 4 out of 6 Behavioral Health ECHO® Learning Sessions with practice payment due in July 2023. Completion of an evaluation for each session attended is required to receive credit for attendance. Please register for the February 22 Behavioral Health ECHO learning session with topics and dates listed here.

Read: The Unique Value Proposition of Pediatric Health Care

PCMH Kids co-director Dr. Pat Flanagan and the American Academy of Pediatrics Committee on Child Health Financing has released a document providing a framework for the value proposition of pediatric health care. It is intended to provide a succinct set of principles for establishing this proposition that demonstrates the short and long-term value to the child and family, the health care system, and society as a whole. Read more here.

Practice Resources

Special opportunity for RIAAP members to attend pediatric portion of RI Primary Care Conference at no cost!

Thanks to a generous grant from RI EOHHS Medicaid Pediatric Relief through CTC-RI, RIAAP members have the opportunity to attend the pediatric portion of the March 23 RI Primary Care Conference at no cost. Spots are limited, details here.

Save the date! Inaugural Public Health Summit

On April 17-18, join the RI Public Health Association and RI Health Center Association for this event to network and discuss innovative community and health system approaches to address public health.

FY2023 nursing workforce programs forecasted from HRSA’s Bureau of Health Workforce

Please find a list of FY2023 Nursing Workforce Programs forecasted from HRSA’s Bureau of Health Workforce here.

Read: Rhode Island Community Health Teams: Coordinating with Primary Care to Address Social and Behavioral Health Needs

Kelsey Brykman, Center for Health Care Strategies, highlights in a recent blog post that primary care plays a central role in providing and coordinating care for individuals with complex health and social needs. At the same time, primary care practices often lack the necessary staff and resources to coordinate care across the health system or comprehensively address patient behavioral health and social needs, which are important drivers of poor health outcomes. One model to address this challenge is implementation of community-based care teams that can coordinate with and supplement the work of primary care providers to improve patient access to medical care and social supports.

Job Opportunity

Brown Medicine: Nurse Care Manager - Nephrology

The Nurse Care Manager will work on an interdisciplinary healthcare team in a specialty care setting to conduct direct patient care and quality improvement activities. He/she will be part of a program charged with implementing strategies to meet specified quality measures. The Nurse Care Manager is responsible for providing comprehensive screenings, assessments, care coordination services, disease education, and self-management support to patients with chronic kidney disease. Learn more.

Upcoming CTC-RI Committee Meetings and Workgroups

  • February 17, 07:30-09:00AM – Clinical Strategy Committee
  • February 21, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • February 24, 07:30-08:45AM – Board of Directors
  • March 17, 07:30-09:00AM – Clinical Strategy Committee
  • March 21, 12:00-01:00AM – Best Practices in Team Based Care (formerly NCM/CC Best Practice Sharing)
  • March 24, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • February 22, 07:30-08:30AM – Medicaid Recovery Program BH ECHO Learning Session - Navigating Schools to Improve Connections
  • February 23, 02:00-03:00PM – Monthly Healthy Tomorrows
  • February 28, 07:30-09:00AM – Pharmacy QI Learning Collaborative: CGM & ABPM
  • March 02, 07:30-08:00AM – Virtual Coffee Breaks with Dr Pat Flanagan & Dr Beth Lange
  • March 08, 07:30-09:00AM – DULCE Learning Collaborative - Quarterly Meeting
  • March 08, 07:30-08:30AM – Asthma ECHO
  • March 10, 07:30-09:00AM – Breakfast of Champions
  • March 16, 07:30-08:30AM – Pediatric Weight Management ECHO
  • March 23, 07:30-08:30AM – Medicaid Recovery Program BH ECHO Learning Session – School Avoidance
  • March 23, 02:00-03:00AM – Monthly Healthy Tomorrows
  • March 29, 08:00-09:30AM – CCE Best Practice Sharing
  • March 30, 07:30-08:30AM – Quarterly Health Care Transitions Learning Collaborative
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