Care Transformation Collaborative of RI

News & Updates | March 2023

Supporting weight management in children and adults

This month, 90 individuals attended our quarterly Breakfast of Champions meeting on weight management and advancements in the treatment of obesity including new medications and community-based interventions. 

Panelists included Angela Fitch, MD, FACP, FOMA, Chief Medical Officer, KnownWell and Stephen Kogut, Ph.D., M.B.A., Professor, URI College of Pharmacy. The panel presentation included: 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 shared their perspective on weight management in pediatric and adult populations. Participants had the opportunity to ask questions about the latest medications and strategies for shared decision-making.

Missed it? View the recording & claim CME credits here

Spotlight: St. Joseph Health Center's Dr. Jon Dooley on lessons learned in pediatric weight management

We asked Jon Dooley, MD FAAP, a pediatrician at St. Joseph Health Center - Pediatric Clinic to share his insight after participating in CTC-RI's 12-month learning collaborative on pediatric weight management, funded by Tufts Health Plan. The project aimed to help practices become better equipped to intervene and positively impact children with weight management concerns. 

Why did your practice apply to this learning collaborative, and what did you hope to gain?

We joined this awesome collaborative to enhance the way we approach weight management in our practice. By learning from local experts and engaging in group discussion, we gain insight on innovative ways to work together with our patients when tackling this difficult topic.

Through this work, what has been the most surprising, challenging, or helpful as you enhanced support for patients with weight management concerns?

One helpful takeaway thus far has been the importance of reminding patients about the ups and downs of eating habits, exercising, and weight management process. Explaining that setbacks are normal helps mitigate frustration and keeps patients on track instead of an all-or-nothing approach. Avoid extremes… small changes over time will add up to make a big difference.

What advice or lessons learned would you share with other pediatric practices interested in better supporting their patients in this area?

Find a way to relate to your patients when having the weight management discussion! Talking about weight is never fun… it is easy for our patients to feel judged or uncomfortable. Making a connection and letting your patients know they are not alone (instead of just lecturing them) helps to empower more change and increases the chances of continued engagement. 

Save the Date: CTC-RI Annual Conference

Our Annual Conference, Investing in Primary Care: Learning in Action, is taking place on October 5, 2023 at the Crowne Plaza Hotel in Warwick, RI. There will be learning opportunities across 3 tracks including team-based care, primary care and community linkages, and maternal child health. This conference will focus on identifying, developing, and utilizing strategies to advance integrated primary care and improve patient and family outcomes. Speakers will be invited from other states along with local best practice experts who will help inform clinical teams about policy, payment mechanisms, and clinical innovations that have improved population health and primary care. More details to come.

Welcome Our New CTC-RI Program Coordinator!

Meet Nijah Mangual

As a Program Coordinator, Nijah supports several important CTC-RI initiatives, such as a new primary care pilot initiative aimed at improving the care of those living with Alzheimer’s and their caregivers, to a demographic data pilot program, to the prior authorization project, to PCP-Specialist Collaboration enhanced referral and eConsults, to the team-based care track of the annual conference. She obtained her Bachelor's in Psychology with a minor of Human Development and Family Studies from the University of Rhode Island.

“In my previous role of assisting RI Works participants, I commonly worked with families who were presented with barriers like access to health care and costs. With my background of working with community-based organizations, I find that CTC-RI’s mission of improving integrated, accessible, affordable and equitable health care aligns well with my passion of assisting individuals and families,” said Nijah. “It’s rewarding to know that I will be challenged now with an amazing opportunity within CTC-RI to continue working toward my goals of improving the wellness of communities.”

February Clinical Strategy meeting focuses on LAN social risk adjustment and community-based platforms

Our February Clinical Strategy Committee meeting focused on the Health Care Payment Learning & Action Network's (LAN) social risk adjustment and community resource platforms to advance health equity. Craig Jones, MD, Primary Care Collaborative, presented on the LAN's creation of the Health Equity Advisory Team to prioritize Alternative Payment Models, influence design principles, and inform LAN efforts.

Garry Bliss, Program Director, Prospect Medicaid AE, then discussed leveraging Unite Us for community referrals while Charlie Estabrook, MPH, EOHHS Director of Health System Transformation, discussed the platform's sustainability. Larry Warner, DrPH, United Way of RI Chief Impact & Equity Officer, spoke about their partnership with Blue Cross & Blue Shield of RI to expand access and resources. Read more.

Update on Medicaid Pediatric Healthcare Recovery Program – Year 2

The Pediatric Healthcare Recovery Program helps primary care practices increase their capacity to assist children and families with their mental health concerns. 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. Register for the March 23 session and learn more about upcoming sessions here.

March Asthma Essentials ECHO covers managing and preventing asthma exacerbations

Our final Asthma Essentials ECHO brought together 36 participants and was facilitated by CTC-RI's Pano Yeracaris, MD. The didactic session, presented by Andrew Foderaro, MD, Pulmonary, Critical Care and Sleep Medicine, East Providence, focused on managing and preventing asthma exacerbations while linking participants with resources to help with understanding root causes of asthma flare-ups and treatment. Thomas Warcup, MD, Block Island Health, provided the case presentation which allowed for richer discussion of treatment options, prescriptions, and specialist support via telehealth. Asthma Essentials ECHO is funded in part by RIDOH and Tufts Health Plan. Access materials and the recording from previous meetings here.

February Pharmacy Quality Improvement Learning Collaborative meeting

Practices participating in the Pharmacy QI Learning Collaborative met again in February to share their progress and lessons learned with implementing Professional Use Continuous Glucose Monitoring in primary care. Kelley Sanzen, PharmD and CTC-RI practice facilitator for this Pharmacy Initiative, reviewed the updated American Diabetes Association Practice Guidelines released in December 2022. The meeting concluded with a discussion on what practices are doing regarding chronic liver disease, often associated with glucose intolerance and diabetes. Special thanks to UnitedHealthcare and RIDOH who are funding this important quality improvement initiative.

Healthy Tomorrows participants complete final learning collaborative meeting

Last month, cohort 2 of the Healthy Tomorrows learning collaborative (4 pediatric practices and 4 Family Visiting agencies) met to share success stories, accomplishments, and opportunities for continued improvement. During this past year, these practices and agencies developed a process to support care coordination and communication to link families with services to improve health outcomes, from identifying a practice point person, to routine case conferences, to use of the KIDSNET Family Visiting report.

Post-program survey results show Family Visitors saw big improvements in their knowledge with working with pediatric practices, collaboration with the practice about shared families, and ability to interact with children’s medical practice and the health care system. Pediatric practice staff identified big improvements in their knowledge of family visiting and working with family visiting programs, reduction of barriers to making a referral to family visiting, increased collaboration with family visiting about shared families, and improvement of health for children based on increased collaboration and utilization. Read more.

DULCE and ECCS quarterly learning collaborative meeting

The Developmental Understanding and Legal Collaboration for Everyone (DULCE) and Early Childhood Comprehensive Systems (ECCS) learning collaborative met this month to continue learning about the DULCE approach and increase practice knowledge on strengthening families through the Family Visiting program. The participating practices, Family Care Center and Toll Gate Pediatrics, also provided updates both on their ongoing work in onboarding the family specialist and their highlighted success thus far. Charlyn Harper Browne and Patsy Hampton, from the Center for the Study of Social Policy, began the meeting by discussing racism, anti-racism, and how DULCE strives to create a more equitable distribution of power and resources while addressing inequitable systems that preclude families from living healthy lives. Sara Remington, RIDOH, shared information about the currently available Family Visiting evidence-based programs and how they have demonstrated improvements in a wide range of maternal and child health outcomes.

The practices, Family Care Center and Toll Gate Pediatrics, are in the process of completing the Brazelton Touchpoints and Newborn Behavioral Observations trainings. They have been successful in developing patient materials to offer DULCE to families, scheduling their interdisciplinary team meetings, and developing workflows.

Thank you to RIDOH and UnitedHealthcare for funding this collaborative. Links to the meeting presentation can be accessed here and to the recording here.

Practice Resources, News, and Information

Studio 10 demonstrates at-home blood pressure monitoring

Dr. Kelley Doherty Sanzen, clinical pharmacist, from Brown Medicine’s Division of Kidney Disease and Hypertension, was on NBC's Studio 10 to spotlight everyday changes that reduce the risks of heart disease and demonstrates how to properly use home blood pressure machines. Watch here!

MLPB Blog: It’s Tax Time: Resources for Care Teams

MLPB Law and Policy Consultants who frequently field questions from care teams about how to help families maximize their household income share their insight. Tax season can feel daunting, but in reality, if taxes are filed correctly, low-income families can often end up with additional income. An expected tax rebate can even be used to help families stay housed. Care teams should encourage families to get their taxes filed and on time. Read more.

Rhode Island Psychiatry Resource Network Teleconsultation Programs for Providers

Providers are welcome to call Rhode Island's free mental health teleconsultation lines five days a week for real-time assistance for pregnant, postpartum, or pediatric patients. For pregnant and postpartum patients: call the Rhode Island Maternal Psychiatry Resource Network (RI MomsPRN) at Women & Infants Hospital (401-430-2800, Monday - Friday, 8am - 4pm). For pediatric patients: call the Pediatric Psychiatry Resource Network (PediPRN) at Bradley Hospital (401-432-1543, Monday - Friday, 8:30am - 5pm).

Substance Use Prevention Services in Primary Care Challenge

The National Institute on Drug Abuse (NIDA) is launching the “Substance Use Prevention Services in Primary Care” Challenge, seeking creative, visionary, and actionable plans to implement substance use prevention interventions in primary care. Winners will receive prizes of up to $25,000, and NIDA encourages the winners to utilize the awards to support the implementation of substance use prevention services in those primary care practices. Learn more.

Available at no cost: 2-gallon sharp containers

RIDOH currently has an excess of sharps containers that they would like to give away at no cost. They are 2-gallon containers with non-tortuous lid design to accommodate a variety of sharps sizes. If your practice is interested, please email [email protected].

Upcoming CTC-RI Committee Meetings and Workgroups

  • March 24, 07:30-08:45AM – Board of Directors
  • April 18, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • April 21, 07:30-09:00AM – Clinical Strategy Committee
  • April 28, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • March 23, 07:30-08:30AM – Medicaid Recovery Program BH ECHO Learning Session – School Avoidance
  • March 23, 02:00-03:00PM – 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
  • March 30, 07:30-08:30AM – ECHO Learning Session: Approaches to Dementia Care: Building Blocks for Becoming Age-Friendly
  • April 06, 07:30-08:30AM – Improving Child Health in RI (formerly PCMH-Kids Stakeholder Meeting)
  • April 06, 07:30-08:00AM – Virtual Coffee Breaks with Dr. Pat Flanagan & Dr. Beth Lange
  • April 14, 07:30-09:00AM – Asthma Quality Improvement Kickoff Meeting
  • April 20, 07:30-08:30AM – Pediatric Weight Management ECHO Session
  • April 21, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • April 24, 12:00-01:00PM – Healthy Tomorrows Quarterly Learning Collaborative Meeting - Cohort 3
  • April 26, 07:30-08:30AM – Medicaid Recovery Program BH ECHO Learning Session - CBT / Anxiety
  • April 27, 08:00-09:30AM – NCQA Behavioral Health Distinction Learning Collaborative
  • April 27, 02:00-03:00PM – Monthly Healthy Tomorrows
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