Care Transformation Collaborative of Rhode Island News & Updates | October 2021
4-Year Statewide SBIRT Grant Program Successfully Concludes

In 2017, CTC-RI was awarded a multi-year contract from the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH) (approximately $1.1M each year) to oversee the implementation of the SBIRT grant (Screening, Brief Intervention and Referral to Treatment), with the goals of improving outcomes for adults with substance use disorders and increasing access to screening services for adults in primary care and other settings. September 2021 marked the end of grant funding for this project with impressive results. Working with 8 implementation partners, over 27,000 Rhode Islanders were screened in over 60 different sites. Individuals with a positive screen (approximately 16% of all those screened) received an intervention (e.g. education, brief treatment or referral to specialty services), dependent on their screening results. At follow-up, clients reported 40% less days of substance use in the previous month.

Read our 2 interviews below highlighting the success of the program from 2 leaders who have been deeply involved in guiding the SBIRT program success statewide. Learn more at
Spotlight: Linda Cabral, M.M., Program Manager, CTC-RI

Why was the SBIRT program necessary in Rhode Island, and from CTC-RI's perspective, what did you hope to achieve?
The SBIRT grant funding allowed for further spread and implementation of a best practice for the early identification and treatment of substance use disorders. SBIRT was part of the toolbox for addressing the growing opioid epidemic and high rates of alcohol misuse in RI. CTC-RI was proud to support a campaign that sought to destigmatize substance use conversations and implement substance use screenings in over 60 settings, including primary care, community-based settings, hospital emergency departments, correctional facilities, and more.

What was the biggest challenge or lesson learned of the SBIRT program?
SBIRT funding came with federal grant reporting requirements. Working with 8 different implementation partners on establishing workflows for collecting the necessary data was challenging. But our partners demonstrated flexibility and a commitment to the project to ensure that all reporting requirements were met. RI had the highest SBIRT screening follow-up rate of all the states in our funding cohort!
How has the SBIRT program changed primary care in Rhode Island?
Substance use screening is more common now in primary care and substance use conversations are more normalized as a part of overall wellness. The SBIRT grant has educated primary care practices on the screening tools available, how to engage in conversations about substance use, and motivational interviewing techniques to encourage behavior change. Our goal was to create sustainable change in primary care and beyond around substance use screenings and we believe we achieved this!  

Congratulations to 16 CTC-RI PCMH Kids Cohort 3 practices for successfully achieving National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home recognition! A practice that achieves this national recognition has demonstrated that their provided care for children and families is patient-centered, comprehensive, and accessible. It is especially noteworthy that our PCMH Kids practices have demonstrated their commitment to both quality and performance improvement as well as patient satisfaction and population health management during the challenging times of COVID-19.

NCQA PCMH recognition is a foundational requirement of the 3-year PCMH Kids contract and provides practices with eligibility for ongoing sustainability payments as made available through OHIC and Medicaid.
Health Plans in Rhode Island Receive High NCQA Ratings

Each year, NCQA rates more than 1,000 health plans in all 50 states, U.S. territories and the District of Columbia. NCQA recently released the 2021 Health Plan Ratings alongside a redesigned Report Cards website to make finding and comparing plans easier. 

NCQA’s Health Plan Ratings provide information to help consumers, employers and others understand a health plan’s quality. Ratings are based on performance in areas of prevention, treatment and patient experience, like quality of care patients receive, how happy patients are with their care, and health plans' efforts to keep improving.

Good news: health plans in Rhode Island received high ratings! Examples include:
  • Tufts Health Plan commercial plan (5 stars)
  • Blue Cross & Blue Shield of Rhode Island commercial plans (4.5 stars)
  • Neighborhood Health Plan of Rhode Island Medicaid plan (4.5 stars)
  • UnitedHealthcare commercial plan (4.5 stars)
  • UnitedHealthcare Medicare plan (4.5 stars)
  • UnitedHealthcare Medicaid plan (4.5 starts)

Learn more at
Reminder: Apply by Oct. 26 for Provider Relief Funds!

Healthcare providers can now apply for $25.5 billion in provider relief funds. The package includes:
  • $8.5 billion in American Rescue Plan (ARP) resources for those who serve rural patients covered by Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
  • $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers experiencing changes in operating revenues and expenses.
  • Qualified providers of health care, services, and support may receive Provider Relief Fund payments for healthcare-related expenses or lost revenues due to coronavirus.

The Health Resources and Services Administration is hosting a technical assistance webinar for applicants on October 21 from 3-4pm (register to attend).

In September, RI Health Insurance Commissioner Patrick Tigue, MPP presented an overview of OHIC’s behavioral health (BH) policy reform and regulatory enforcement to the CTC-RI Board of Directors. Joining Commissioner Tigue were Marea Berni Tumber, MPD, JD, OHIC Principal Policy Associate and Courtney Miner, MPA, Sr. Policy Analyst, RI Department of Business Regulation who discussed current efforts in areas of:
  • Annual Benefit Coverage Document Review
  • Consumer and Provider Complaint Resolution
  • Affordability Standards and Integrated BH
  • Interagency BH Work

Board members were especially interested in hearing of the future OHIC BH priorities which include:
  • State Flexibility to Stabilize the Market Cycle II Grant (State Flexibility Cycle II Grant)
  • Next Generation Affordability Standards and BH Spending
  • Market Conduct Examinations
  • Enhanced Complaints Analysis
  • Children’s BH Network Adequacy

Practices participating in the UnitedHealthcare-funded year-long learning collaborative are focusing on improving tele-IBH (integrated behavioral health) services and preparing to apply for or renew NCQA Behavioral Health (BH) Distinction. 

While the collaborative launched in March, this September meeting focused on 11 practices' progress and challenges in 6 key areas: patient engagement in telehealth, tele-IBH groups, virtual delivery of IBH tools, screening and workflow, specialty BH tracking, and clinical decision support.

Some of the projects that practices reported on include: establishing a standardized workflow for patients with a potential for suicide, increasing patient confidence in tele-IBH, and piloting a virtual stress management group. You can review all projects by taking a look at the meeting slide deck.
CTC-RI was pleased to have 3 team members present at the Northeast Telehealth Resource Center (NETRC) Regional Conference, “Telehealth Launchpad: Refueling for Sustainability." The conference brought together attendees from 8 NE states to share information about telehealth best practices, new technologies, and telehealth policy.

Susanne Campbell and Sue Dettling of CTC-RI teamed up with another organization, C3, for a presentation titled “Lessons Learned: Launching & Advancing a Statewide Quality Improvement Telehealth Program,” while Kristin David, a CTC-RI practice facilitator, shared an overview of the RI integrated behavioral health work as part of the pre-conference workshop, “TeleBehavioral Health 201.”

The full agenda of workshops over the 2 days can be found here. NETRC can provide other recordings via

CTC-RI has assembled a resource guide for RI practices implementing telehealth as part of our CTC-RI/PCMH Kids Telehealth Initiative launched last year through funding from UnitedHealthcare and the CARES Act. The guide, available on our website, contains resources on telehealth best practices, staff training, patient surveys, and coding and billing.

One recently added resource that we want to highlight is the digital navigation service offered through the public libraries. Providence Public Library on Empire Street in downtown Providence has just launched Digital Navigation/Learning Lounge services. Through this program, community members can receive help with technology in English or Spanish, as well as access private spaces and/or devices for telehealth appointments. The current hours of the program are Wednesdays 2-4pm and Fridays 10am-1pm. While patrons can receive drop-in support, anyone needing to use a private space for an appointment during these hours is encouraged to make a reservation by calling the library at 401-455-8000. The library hopes to expand the program to other RI communities in the future.

PCMH Kids October Stakeholder meeting provided another opportunity to hear from Quatia "Q" Osorio, BSBA CCHW, CLC, MCHS CPE MCHW, Doula, Founder of Our Journ3i, and past member of the Women’s Health Council Planning Committee. Access to doula services is estimated to increase based on anticipated inclusion of doula services in Medicaid fee schedules. Margaret Howard, PhD, Women & Infants Hospital continued to address prenatal care with PCMH Kids stakeholders by sharing information about the MomsPRN program and how it can help pediatricians and their families. Sara Hagin, PhD, Bradley Hospital, wrapped up the meeting reviewing expanded services offered by PediPRN to better help pediatricians meet the mental health needs of their patients. Presentation can be found here.

Mark your calendars, Virtual Coffee Breaks with Drs Flanagan and Lange continue, November 4 and December 2, 7:30-8:00am. These are meant to be informal opportunities to touch base, share and learn from each other. Come with your breakfast drink of choice. Slippers allowed.

CTC-RI/PCMH Kids was invited to present at the Milbank Multi-Payer Virtual Seminar on the work that Rhode Island is doing to improve linkages between primary care and maternal-child health practitioners. Pat Flanagan, MD FAAP, Co-Chair of PCMH Kids highlighted the foundational work done by PCMH Kids in creating a robust learning community that has enabled pediatric practices to test integrating behavioral health into pediatric primary care. Building on this experience, Susanne Campbell presented on the work that CTC-RI has done, in partnership with RI Department of Health, to build a learning community among OB/GYN providers who are implementing universal screening for depression, anxiety and substance use disorders among pregnant and postpartum women. Our work supporting healthy moms and healthy babies is anticipated to continue evolving with health plan support for community health workers, doulas, and our Healthy Tomorrows initiative that is working to improve care coordination between pediatric practices and family visiting organizations.

At the September RI MomsPRN learning collaborative, all 9 Cohort 2 practices shared their challenges and successes encountered while implementing universal screening for anxiety, depression, and substance use disorder amongst their perinatal patients. The practices are improving workflows to integrate evidence-based screening tools for long-term success and sustainability. In addition, Dr. Zobeida Diaz, an attending psychiatrist at the Center for Women’s Behavioral Health at Women & Infants Hospital, shared valuable case examples of supports offered by the RI MomsPRN teleconsultation line. Any provider seeing a pregnant and/or postpartum patient is welcome to call the RI MomsPRN teleconsultation line 401-430-2800 for real-time clinical assistance with addressing perinatal behavioral health matters. More details about this free statewide teleconsultation service for providers offered by Women and Infants behavioral health staff. RIDOH staff also offered clarification on program data reporting in light of the 2nd project report due. Other valuable resources to address patient needs were shared in the meeting:

The RI Maternal Psychiatry Resource (RI MomsPRN) Program, in partnership with CTC-RI, sponsored the October “Cannabis Use in the Perinatal Period” learning session. This event hosted more than 60 healthcare providers and staff across the state with valuable insight from clinical speakers Anupriya Gogne, MD and Chris Dorval MSW, LICSW LCDP, LCDCS (Recording Link).

In an effort to increase awareness of the RI MomsPRN teleconsultation line (401-430-2800), a general overview of the services provided was discussed as well. The RI MomsPRN information sheet may be found here. As a reminder, any providers and health care staff seeing pregnant and postpartum people are welcome to call the RI MomsPRN teleconsultation line (M-F 8-4 pm) for real-time assistance. Behavioral health clinicians, including specialized psychiatrists, psychologists, and resource and referral specialists, from Women & Infants Hospital are available for clinical consultation regarding behavioral health diagnosis, treatment planning, and medication safety and can also provide resource and referral support to community-based treatment and support services. 

RIDOH, with funding from the CDC, developed a network of community health teams (CHTs) which function as an extension of primary care with a focus on serving patients who are at high risk based on their chronic conditions management. CHWs completed the cardiovascular disease/diabetes mellitus (CVD/DM) specialty training and provided health coaching for patients with hypertension, diabetes and/or at risk for cardiovascular disease. The South County Hospital community health team (along with their partners Wood River Health) and East Bay Community Action Program recently met to wrap up the 1st year of the Cardiovascular Disease/ Diabetes Expansion Program. Evaluation results were discussed including improvements in patients’ levels of confidence in their chronic conditions management and improvements in CHWs levels of confidence in providing health coaching. During the meeting, teams reported out on their successes, challenges and recommendations for improving patient engagement during the 2nd year. South County Medical Group was welcomed as a year 2 participant with discussion on new goals, structure, and deliverables for the upcoming year. (Webinar Recording)

Rhode to Equity teams met recently for the 1st quarterly momentum session since the July program start. With over 50 attendees, the 6 health equity zones (HEZs), along with their partners (accountable entities, primary care clinics, community health teams, community-based organizations, and individuals with lived experience of inequities) were able to come together and share their project progress. Somava Saha, MD, MS, Well Being in the Nation facilitated a discussion on Risk Stratification. Dr. Saha emphasized the importance of looking at existing data from each team member, deciding on which factors to include in the stratification, and examine those who are “suffering”, “struggling", and “thriving” to inform the creation of a balanced strategy. Teams presented on their targeted aims, driver diagrams, and how they plan to create systemic change within their communities. (Webinar Recording)

Samantha Morton, JD, CEO of Medical-Legal Partnership Boston, presented the first of a 2-part training on strength-based screening at the September Nurse Care Manager/Care Coordinator (NCM/CC) Best Practice Sharing meeting. Samantha defined the topic, setting the stage for October's meeting, where NCM/CCs will have opportunity for an interactive session, learning and practicing strengths-based screening techniques. NCM/CCs should come to the October 19, 8-9:30am meeting ready to participate in this interactive learning experience. Presentation and additional resources can be found here:  A Strengths-Based Approach to Screening Families for Health-Related Social Needs and Strengths-Based Screening for Health-Related Social Needs: The ‘Why’ that Comes Before the ‘How’ (MLPB presentation)

  • Link to the full brief
  • Link to the 1-page Executive Summary
  • Link to our What You Can Do When There's Nothing to Do tool

The September Clinical Strategy Committee (CSC) meeting featured a special Regional Team Component of the Community Health Team (CHT) Hybrid Model – Addressing Health-Related Social Needs (HRSN) for All Rhode Islanders. Craig Jones, MD reviewed consensus design principles for CHTs in the Hybrid Model, including the need for shared learning and common metrics. Samantha Morton, JD, CEO of MLPB, presented on “Social Health, Prevention Imperatives, and Evolving Care Teams – Thoughts on Design Principles” and highlighted the importance of legal and ethical considerations.

CSC members also participated in discussion around “Workforce Development Challenges and Opportunities – How to Build Resilient Primary Care Teams”. Challenges, successes and recommendation for hiring and retaining the workforce were discussed. Rick Brooks, Executive Director R.I. Governors Workforce Board, EOHHS, was an invited guest and joined the conversation.

The October 15 CSC meeting will include a workforce well-being follow-up with presentations on the “Survey of Clinician Well-Being” conducted this past summer through the CTC-RI Preventing Avoidable Hospital Use Project, and a RIDOH overview of the CDC award, “Community Health Workers for COVID Response and Resilient Communities”. Another topic to be addressed will be “Improving Identification of Disparities within Local Communities”, an RIQI grant from CDC working with CHWs for community member engagement.

CME credit is available for these CSC meetings.
COVID-19 Vaccination Update
As of October 13, there are 808,322 Rhode Islanders who are now partially vaccinated, and 734,186 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 currently eligible. The current age breakdown is as follows:
U.S. Primary Care Survey Data Show Telemedicine Key to Patient Access to Care

Recent national primary care survey data collected and analyzed by The Larry A. Green Center and the Primary Care Collaborative show for nearly two thirds of U.S. primary care clinicians (64%), telemedicine has been key to maintaining patient access to care. If pre-pandemic regulations are restored, 41% of clinicians worry their practice will no longer be able to support telemedicine. The potential loss of this adaptive tool is yet another challenge for an overstretched workforce in which more than half report mental exhaustion is a constant worry as both COVID-19 and patient needs surge. Additionally, 7 in 10 patient visits now take more time, 65% say mental health concerns are increasing among children, and the majority are managing the care of people with long haul COVID-19, despite limited guidance on how to do so (58%). Read more results here.
In The News
When a woman pediatrician leads the R.I. Medical Society
ConvergenceRI, October 11, 2021
PROVIDENCE – These are the facts. All health care is personal. All health care is complex. All health care in the U.S. and Rhode Island is too expensive. And, all health care delivery systems have been disrupted by the COVID pandemic.

As a result, conversations about the future of health care delivery in Rhode Island are challenging these days, because, as Dr. Elizabeth B. Lange, MD, the new president of the R.I. Medical Society, told ConvergenceRI in a recent interview, “There is no concept of time during this pandemic.”

Lange, a pediatrician, has served as a member of the Coastal Medical board of directors, president of the R.I. Chapter of the American Academy of Pediatrics, and more importantly, the secretary of the Care Transformation Collaborative, whose mission is advancing integrated health care through a network of patient-centered medical homes.

Practice Resources
CDC Releases “I Get It” Flu Vaccine Campaign
The CDC invites communicators to join them in encouraging everyone 6 months and older to get a flu vaccine this year with their new I Get It’ campaign The CDC asks everyone to share their flu vaccine photo on social media with a message on why they are getting a flu vaccine this year. Tag @CDCFlu on Twitter or CDC on Facebook, Instagram or LinkedIn.

CDC Provider Alert: Expansion of Recall of LeadCare Blood Lead Tests Due to Risk of Falsely Low Results
Magellan Diagnostics, Inc. and the U.S. Food and Drug Administration (FDA) have issued notifications about the expansion of Magellan Diagnostics’ recall of LeadCare II, LeadCare Plus, and LeadCare Ultra Blood Lead Tests, which were distributed from October 27, 2020, to August 19, 2021. Additional LeadCare II product lots, including lots previously reported to be unaffected, were recalled due to a significant risk of falsely low results. The use of these devices may cause serious injuries because they might underestimate blood lead levels. FDA has identified this as a Class I recall, the most serious type of recall. Read more.

CHW Virtual Training in Cardiovascular Health/Diabetes Management
If you are a certified CHW and want to develop skills for supporting clients with cardiac and diabetes challenges, come learn from RIC Nursing Professor Deborah Kutenplon in this intensive course that prepares you for the RI Certification in Cardiovascular Disease and Diabetes Management. Course runs October 25-December 13. Apply here.

RI Adult Protective Services Virtual Conference on Oct. 27
Hosted by the RI Office of Healthy Aging from 9am-4pm, attendees will hear from DHS, the Attorney General's Office, Commission for Care and Safety of the Elderly, and more. Learn more and register.

Rhode to Wellness Challenge and RI World Diabetes Day
Leading up to RI World Diabetes Day, the challenge encourages participants to set one or more SMART goals focused on building healthy habits. Each week participants will receive an email with resources and guidance and will complete a brief online survey. The more resources used and surveys completed, the more chances participants have to win a prize. In addition to the challenge, 2021 Rhode Island World Diabetes Day will be celebrated virtually on Nov. 13 with a full morning of events. Learn more.

2021 Pediatric Sleep Medicine Virtual Conference Dec. 1-3
Join the 11th Biennial Pediatric Sleep Medicine Conference, giving attendees access to live interactive sessions throughout the event and on-demand content post-event. The conference brings together a multi-disciplinary group of basic and clinical researchers, clinicians, educators, policy makers, and trainees involved in pediatric and adolescent sleep medicine. Learn more.
Job Opportunities
Hiring for RIDOH COVID-19 Unit
RIDOH has retained Knowledge Services to provide temporary staffing to support the RIDOH Covid-19 Unit. Here is a list of assignments that are open through Knowledge Services and their respective staffing vendors. To find out more information about an assignment, please select it from the drop down menu and click next. If you feel that you meet the requirements and are interested in hearing more or applying, please select "Yes" in the appropriate section and enter your name and contact information. Someone from Knowledge Services will reach out to you with official application instructions as well as a list of staffing vendors that you can apply through. Thank you for your interest in helping to Crush COVID!
Upcoming CTC-RI Committee Meetings and Workgroups
  • October 14, 07:30-09:00AM – Quarterly Pediatric IBH Meeting
  • October 15, 07:30-09:00AM – Clinical Strategy Committee
  • October 19, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • October 22, 07:30-08:45AM – Board of Directors
  • November 04, 07:30-09:00AM – Quarterly Integrated Behavioral Health Committee
  • November 12, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • November 16, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • November 19, 07:30-09:00AM – Clinical Strategy Committee
  • November 24, 08:00-09:30AM – Practice Reporting/Practice Transformation Committee
Upcoming CTC-RI Program and Initiative Meetings
  • November 04, 07:30-08:00AM – Virtual Coffee Break with Dr. Pat Flanagan & Dr. Beth Lange
Upcoming Learning Collaboratives and Professional Development
  • November 10, 07:30-09:00AM – Pharmacy Quarterly Learning Collaborative: Reducing Preventable Hospitalizations and ED Usage
  • November 17, 07:30-09:00AM – Quarterly Telehealth Learning Collaborative