Care Transformation Collaborative of Rhode Island News & Updates | November 2021
Thank You to Our Board of Directors

The October CTC-RI Board of Directors annual meeting marked not only a change in officers, but confirmation of our stellar slate of CTC-RI Board of Directors 2021-22. As expressed at the annual meeting, CTC-RI recognizes the important work and impact made by both Past President Thomas Bledsoe, MD, FACP, Brown Physicians, who will remain on the Board as an Ex-Officio member and Past Treasurer Al Charbonneau, MPS, Rhode Island Business Group on Health as an Employer representative member. Their expert direction and leadership over the past 6 years has been invaluable. Awards were presented with special thanks for their “inspirational leadership and commitment to collaborative learning and health system transformation in primary care from 2015-2021.”

The Board also welcomed in our new President Peter Hollmann, MD, Brown Physicians and Treasurer Noah Benedict, MHL, RI Primary Care Physician Corp. We feel fortunate to have such talented leadership in RI!
Spotlight: Dr. Elizabeth Lange, PCMH Kids Co-Director

Through this pandemic, the work of pediatric practices has proven to be a critical component to keeping children healthy. PCMH Kids has focused on helping pediatric practices get families back in the door to successfully address declining child vaccine and well-visit rates. Now, with the COVID-19 vaccine approved for children ages 5 and older, PCMH Kids co-director Dr. Elizabeth B. Lange weighs-in on the role of pediatric practices supporting vaccine efforts. Dr. Lange is a pediatrician at Waterman Pediatrics/Coastal Medical and president of the R.I. Medical Society.

How have pediatric primary care teams shifted and adapted through the pandemic this year?
Since the majority of pediatric healthcare is prevention care – vaccinations, developmental and mental health screens, vision and hearing screens – in the pandemic required times of shut down and social distancing, Rhode Island’s pediatric primary care teams had to be creative. Initially we prioritized vaccine-associated well-child visits and transitioned other amenable medical visits to telehealth delivered care. We increased our in-office medical visits as the pandemic safety conditions allowed, given that so much of children’s healthcare is based on observation of social, physical and language development. The fact that our offices are experienced with team-based care made all of these transitions and workflow changes as smooth as possible while maintaining quality patient care.

What unique challenges have pediatric teams faced in keeping our children/families healthy and well?
Since children live in family units pediatric medical care includes care of the whole family. Office staff and clinicians are skilled at engaging siblings who attend the appointment, the grandparents who have generational concerns and the parents who bring their lists of questions. We all love the opportunity to make the pediatric office experience as inviting and productive as possible. Certainly the pandemic and all of the mitigation measures has made in-office pediatric care more challenging but worth the effort to keep our patients healthy and on schedule with standard pediatric care,

What work is PCMH Kids focused on to support successful pediatric vaccination rates?
During the initial pandemic shut down, pediatric vaccination rates fell below 2019 levels. We were able to dramatically raise the vaccine rates by September 2020 due to a combination of factors – dedicated pediatric and family physician office staff and work flows, practice-specific vaccine data from the Department of Health and the Pediatric Relief Funding from the CARES Act as administered through RI’s Medicaid program. Unfortunately, as the pandemic has ensued, pediatric vaccination rates have again slipped from Rhode Island’s standard exemplary levels, so we now are trying to reinvigorate the efforts, and funding, that made our first push so successful. The strong PCMH Kids network and collaboration culture has made this work more efficient and effective.
Spotlight: Dr. Peter Pogacar, VP, RI Chapter of American Academy of Pediatrics

Dr. Peter Pogacar is a practicing pediatrician at East Greenwich Pediatrics, and Vice President of the RI Chapter of the American Academy of Pediatrics. As a pediatric practice helping support the safe COVID-19 vaccination of children in Rhode Island, Dr. Pogacar weighs in on his team's important work.

As a pediatrician, how are you (and your team) communicating with families about the approved COVID vaccine for young children? What messaging is most important for hesitant parents to hear?
We use our website and Facebook page for electronic communication. We also discuss the vaccine for all ages at almost every single visit. These one-on-one sessions are the most impactful. The most important thing for parents to hear is that not getting exposed to COVID is no longer an option. You are either going to get exposed and potentially contract COVID with or without the COVID vaccine. It is always better for you to be exposed to COVID with the vaccine than without it. Also, the health risks associated with COVID disease are all magnitudes higher than risks from the vaccine. The mRNA vaccines have proved to be very safe and effective for all ages. 

As a VP on the board for the RI Chapter of the American Academy of Pediatrics, how has your board's work helped the state prepare for ramping up vaccines to children, and reaching more families?
The RI Chapter of the American Academy of Pediatrics has been partnering with the RIDOH and community pediatricians to ensure they are ready to deal with the logistical challenges involved with providing both adult Pfizer COVID vaccine to those under age 12, and now the pediatric Pfizer COVID vaccine to those ages 5-11. We have also partnered with RIDOH to create local town halls involving the local community pediatricians as well as social media video content promoting the vaccines directly to parents and children.  

What hurdle(s) has your practice had to overcome to get to its current success with vaccine rates (COVID + other vaccines), and what lessons learned may help other RI practice teams with their work to vaccinate more children?
Our biggest hurdle is continued underfunding. All the work our state pediatrician offices are pouring into redesigning their space and training their staff to adjust to COVID risks, yet still be available to provide all our preventative services and mental health care including vaccines, is effort not covered by any payment. Also, all the work pediatricians do in advocacy for children including during the pandemic is volunteer. The lack of resources coupled with the sheer amount of work to do has at times been overwhelming and frankly exhausting. The lessons we have learned is to be incredibly well-organized and involve the entire staff while being as informed as possible. We are lucky to have excellent partners at the RIDOH who have made themselves available to all pediatricians and their staff to help educate us regarding COVID and providing the COVID vaccine. Their electronic communication has proven invaluable as well.   
COVID-19 Vaccination Update
As of November 16, there are 852,949 Rhode Islanders who are now partially vaccinated, and 764,788 who have completed the primary vaccine series ("fully vaccinated"). The state continues to focus on getting more residents vaccinated, in particular children and youth who are now newly eligible. The current age breakdown is as follows:
Breakfast of Champions: Strategies for Workforce Well-Being and Resilience

We hope that you can join us for the December 10 Breakfast of Champions, 7:30-9:00am. Please register via Eventbrite to receive the Zoom link.

A Panel: Addressing Clinician and Clinical Team Well-being During the Pandemic
  • Moderator: Patricia Flanagan, MD, Hasbro Children’s Hospital, & Brown Univ. Pediatrics Professor
  • Jerome Finkel, MD, Henry Ford Health System Chief Primary Health Officer, MI
  • Matthew Malek, MD, Medical Director of Provider Experience, Thundermist Health Center; Assistant Professor (Clinical), Department of Family Medicine, Alpert Medical School of Brown University
  • Nicolas Nguyen, MD, Associate Chief Medical Officer, Beth Israel Lahey Health Primary Care South Region; Clinical Instructor Harvard Medical School

CME credit information for physicians, PAs, NPs, and RNs: The AAFP has reviewed ‘Advancing Comprehensive Primary Care Through Improving Care Delivery Design and Community Health,’ and deemed it acceptable for AAFP credit. Term of approval is from 03/12/2021 to 03/11/2022. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NPs and RNs can also receive credit through AAFP’s partnership with the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners Certification Board (AANPCB).

The October Clinical Strategy Committee (CSC) meeting featured an RIQI presentation by Neil Sarkar, PhD, RIQI President and CEO on Developing a System and Approach for Identifying and Addressing Disparities in Access to Testing and Vaccination for COVID-19. The 2nd half of the meeting included 2 workforce well-being presentations. Stephen Kogut, PhD MBA RPh, URI Pharmacoeconomics and Health Outcomes Research shared the Pharmacy Quality Improvement results of the “Survey of Clinician Well-Being” conducted during summer 2021. Following up was Randi Belhumeur, MS RD LDN CDOE, RIDOH Health Systems Transformation, Administrator/Policy Liaison, presenting an overview of the CDC award, “Community Health Workers for COVID Response and Resilient Communities.”

For the November CSC, the first part of the meeting will be a discussion of CTC-RI Board of Directors strategic planning and 2022-23 CSC priorities. Following will be workforce well-being with participation by Rick Brooks, Executive Director R.I. Governors Workforce Board, EOHHS.

CME credit is available for these CSC meetings.

Based on feedback received from our nurse care managers and care coordinators (NCM/CC) at the strategic planning meeting, our October NCM/CC session focused on patient engagement resources and how to take a “strength-based” approach when interviewing patients and families. Kathleen Kuiper, RIPIN Resource Coordinator, provided an overview of the Rhode Island Medical Home Portal and Care Notebook resource that can be used to assist families with children with special needs. Marsophia Ducheine of Medical-Legal Partnership Boston, led the NCM/CC volunteers through role-playing exercises of what a non-productive screening for health-related social needs might look like and then that same case performed as a productive encounter with group discussion. Thank you to our volunteers for their demonstration of what-not-to-do versus what-to-do performances. Through these interactive sessions, the group was able to practice and learn from others about what a productive strength-based screen looks like. For those who attended this meeting, please provide your feedback by filling out this survey.

The Rhode Island Geriatric Education Center is conducting a 2-part Geriatric Education Series on dementia at the November and December NCM/CC Best Practice Sharing meetings. Part 1 of the Geriatric Education Series, The Aging Brain: Signs and Symptoms of Cognitive Impairment was presented at the November meeting. On December 21, the meeting will showcase part 2 on the topic of Dementia Diagnosis: Treatment Options. Pre-registration is required for this event.
CTC-RI Participates in National PCC Summit

CTC-RI had the privilege to participate in the Primary Care Collaborative's national Summit this month, providing important insight in the Summit's opening video to set the scene and provide inspiration for the Summit's work.

The PCC working summit convened healthcare stakeholders to discuss the opportunities presented by the National Academies of Sciences, Engineering, and Medicine’s (NASEM) report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. PCC's goal with the summit is to catalyze and align broad, diverse leadership in order to formulate an action plan for implementing the high-quality primary care described in the NASEM report. The summit is an important kickoff to a coalition and campaign, led by the PCC, that will build through 2023. Watch the video below!
In The News
Rhode Island Joins the Peterson-Milbank Program on Sustainable Health Care Costs: A Q&A with the State’s Health Insurance Commissioner Patrick Tigue
Milbank Memorial Fund, November 11, 2021

This month, Rhode Island became the sixth state to join the Peterson-Milbank Program for Sustainable Health Care Costs, which provides technical assistance to states with health care cost growth target initiatives. These efforts aim to improve the affordability of health care by working with payers, providers, employers, and consumer advocates to track and analyze — and ultimately contain — unsustainable health care spending growth. Patrick Tigue, RI’s health insurance commissioner, spoke with Milbank about Rhode Island’s progress on cost containment and next steps to enhance transparency, promote collective accountability to the target, and ensure long-term impact.

A Rhode Island pediatrician weighs in on vaccinating kids against COVID-19
The Public's Radio, October 27, 2021

Rhode Island may begin vaccinating children as young as age 5 against COVID-19 as early as Nov. 8. Dr. Elizabeth Lange, a pediatrician and former president of the Rhode Island chapter of the American Academy of Pediatrics, spoke with Health Reporter Lynn Arditi about vaccinating children.

In October, NCQA featured Rhode Island in their policy forum. Nelly Burdette, PsyD, CTC-RI Senior IBH Program Leader; Libby Bunzli, EOHHS; and Marea Tumber, OHIC jointly presented on RI's work around integrated behavioral health. The presentation reached a national audience and gave an overview of the behavioral health integration work in the state so far, including the IBH pilot outcomes, policy levers, statewide integration efforts, and workforce development. A recording of the presentation is available on NCQA’s website.

On November 9, Nelly Burdette, PsyD, was again featured in an NCQA-hosted course alongside Jennifer Etue, LICSW, PCHC. The presentation, “How a Multi-Disciplinary Approach to Behavioral Health Distinction Can Position IBH Best Practices” was part of NCQA’s Quality Innovation Series on Behavioral Health.

Marea Tumber, OHIC Principal Policy Associate, presented at the November quarterly IBH Committee meeting, outlining the next generation of affordability standards that are considering health plan behavioral health spending requirements. Marea fielded questions from the audience on these future plans, as well as current status of health plan policies that have been developed to comply with current IBH affordability standards. Charlie Estabrook, EOHHS Accountable Entity Program Manager, requested feedback from the IBH Committee members of a one-time HSTP investment opportunity for addressing behavioral health needs in the Accountable Entity program. He shared initial findings from interviews conducted thus far and asked if other areas should be considered for this funding source. Key stakeholders provided a number of suggestions and recommendations for his consideration. The presentations for this meeting can be found here.

There is no IBH meeting planned for December. The next IBH meeting, focused on pediatrics, will be January 13, 7:30-9:00am.

CTC-RI hosted its quarterly peer learning best practice sharing meeting in November. Neil Sakar, President & CEO of the Rhode Island Quality Institute, along with Rob McConeghy, Health Data Analyst, and Sarah Eltinge, Health Data Science Manager, led a discussion on hypertension and hospitalizations using data from the RI Health Information Exchange. The 7 practices working within systems of care also reported out on their data-driven pharmacy quality improvement performance plans aimed to reduce preventable hospitalizations and emergency department usage through team-based care. Each team is focusing on a particular AIM and presented on what they have learned from their project implementation and patient encounters. As teams embark on the next quarter of quality improvement, they will focus on how they want to risk-stratify their populations by looking at data such as age, gender, insurance, race, ethnicity, and place of residence.

The Pharmacy Quality Improvement Initiative is funded by UnitedHealthcare and the Rhode Island Department of Health, offered in collaboration with the University of Rhode Island College of Pharmacy, with Kelley Doherty Sanzen, PharmD, PAHM, CDOE providing content expert pharmacy practice facilitation services for participating practices. (Recording) (Presentation)

In November, the 6 Rhode to Equity teams had the opportunity to attend a subject matter expert coaching call on risk stratification in order to enhance and inform their work in their communities. Risk stratification can help identify people and places who might be the most likely to have poor outcomes and to plan resources and supports to mitigate these risks. Elizabeth Romero, Senior Fellow at WE in the World, led a discussion about how the state of Delaware stratified their population of interest (youth with behavioral health needs transitioning to the adult system) and used the stories of people with lived experience to identify strategies to address health equity outcomes across the system. Participants left with a deeper understanding of how the R2E tools work together to build equity in both process and outcomes. 

The November Practice Reporting / Transformation meeting is rescheduled to December 8, 8:00-9:30AM, due to the Thanksgiving holiday. At that meeting, CTC-RI practice facilitators and PCMH practice leads will be discussing the January 2022 NCQA’s PCMH annual reporting requirements. In addition, Cohort 3 clinical quality results and engagement with high-risk/rising-risk patients will be reviewed and discussed.

The Telehealth Learning Collaborative, "Using Technology to Improve Care for Patients with Chronic Conditions" came together for their 4th learning collaborative meeting this month. The 21 primary care practices are exploring different technology options such as remote patient monitoring, apps, and ambulatory blood pressure devices to improve care of patients with chronic conditions. The group also is exploring how to use the team-based approach and community linkages to improve patient experiences and outcomes. This quarter, practices reflected on their experiences to date. You can view all of the practice reflections in the meeting presentation; below are a selection of comments:

  • Better management of chronic conditions: Prior to using ambulatory blood pressure monitoring, there was no way to detect white coat hypertension, white coat effect, masked hypertension, nocturnal patterns of blood pressure, or the effect of antihypertensive treatment.
  • Better patient engagement: The remote patient monitoring expansion has helped with engaging the “right patient” at the “right time”. Support for patients with chronic conditions every day and not just on the days of their appointments or scheduled follow-up calls. Patients bring up barriers that they would never bring up to their PCP in a visit.
  • Better patient experience: Teens are more comfortable talking with provider using telehealth.
  • Better use of staff: Due to the times that work best for many of our families, it was important to advocate that these nurses be able to work from home on this project to accommodate the scheduling needs of families such as weekends and evenings.
  • Need for community linkages: The project provided insight into family relationships and supports and helped with understanding that some patients really don’t have family support, which contributes to mental health concerns. Many of our patients may need support outside of their families.

The year-long learning collaborative is funded through authorized CARES Act funding, UnitedHealthcare and Rhode Island Department of Health.

Help us get the word out! We're looking for English- or Spanish-speaking patients, age 18+, who have received integrated behavioral health services in Rhode Island (substance use or mental health counseling through their primary care location). Patients will participate in a focus group run by Brown University and be provided with a $50 gift card. These focus groups will provide CTC-RI with valuable insight into IBH from a patient perspective. 
Please help us recruit for these groups by distributing flyers to patients in your practices who have received IBH services. (English flyer | Spanish flyer)
Practice Resources
Brown School of Public Health and BCBSRI Release 2021 RI Life Index
The 2021 RI Life Index is now available. Visit www.rilifeindex.org, where you’ll find the full report and the video recording of the Nov. 8 launch event, along with all the data that was presented. A copy of the video is linked here for your convenience.

Expansion of Recall of LeadCare Blood Lead Tests Due to Risk of Falsely Low Results
The CDC issued a Health Alert Network Health Update following its October 15 HAN Update 454: Expansion of Recall of LeadCare Blood Lead Tests Due to Risk of Falsely Low Results Update. The purpose of this HAN Update is to clarify options for retesting children who were tested with the recalled LeadCare test kits. The information in this HAN Update remains the same as HAN Update 454, except for the new information added in bold in the Recommendations for Clinicians section. Access the Update here.
Job Opportunities
Integrated Behavioral Health Clinician, Anchor Medical Associates, Pediatrics (Lincoln)
Anchor Medical Associates has an exciting opportunity to join a well-established, innovative and forward-thinking pediatric practice and play a key role in the Integrated Behavioral Health program serving children, adolescents and families within a primary care setting. Full time preferred but may consider part time for the right candidate. Details here.

CEO, Rhode Island Free Clinic
Rhode Island Free Clinic CEO Marie Ghazal has announced plans to retire in the Spring of 2022. An active search for her successor is underway. Under the oversight of the Rhode Island Free Clinic Board of Directors, the CEO provides leadership to advance the mission of the organization in all facets of Clinic operations, management, and development. Additional details can be found here.

RIPIN Community Health Worker, Policy & Systems Specialist
The CHW is a peer who has experience navigating RI’s health system for themselves, a family member, or through previous employment. This CHW will work collaboratively with RIPIN and RIDOH to identify the unique needs of RI communities to help address health disparities related to race, income, geographic location, or other sociodemographic characteristics. The CHW will serve as a link between health/social services and the community to facilitate access to services and improve service delivery. Learn more here.

RIPIN Community Health Worker, Communications & Evaluations Specialist
The CHW will work collaboratively with RIPIN and RIDOH to conduct outreach activities to support the evaluation of the impacts of CHWs through collecting stories, tracking encounters/data, reporting qualitative and quantitative examples of CHWs in action. The CHW will identify the unique needs of RI communities to help address health disparities related to race, income, geographic location, or other sociodemographic characteristics. Learn more here.
Upcoming CTC-RI Committee Meetings and Workgroups
  • November 19, 07:30-09:00AM – Clinical Strategy Committee
  • December 03, 07:30-08:45AM – Board of Directors
  • December 08, 08:00-09:30AM – Practice Reporting/Practice Transformation Committee
  • December 17, 07:30-09:00AM – Clinical Strategy Committee
  • December 21, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
Upcoming CTC-RI Program and Initiative Meetings
  • November 19, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • December 02, 07:30-08:00AM – Virtual Coffee Break with Dr Pat Flanagan & Dr Beth Lange
  • December 07, 09:30-11:00AM – Community Health Team Expansion Pilot Best Practice Sharing
  • December 10, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • December 15, 08:00-09:30AM – Care, Community, and Equity Best Practice Sharing
Upcoming Learning Collaboratives and Professional Development
  • December 01, 08:00-09:00AM – Quarterly Healthcare Transfer of Care Quality Improvement Learning Collaborative
  • December 10, 07:30-08:00AM – Quarterly CTC-RI Breakfast of Champions
Care Transformation Collaborative of RI | ctc-ri@ctc-ri.org | ctc-ri.org