Workforce development in action: CTC-RI kicks off Rhode Island College senior nursing student pilot

Last month, CTC-RI kicked off its nursing student pilot program, designed to introduce senior nursing students to the nurse care manager role in primary care. Four students were placed in primary care practices as part of a pilot project between Rhode Island College of Nursing and CTC-RI.

Each week, students complete online modules then discuss the information with Jayne Daylor RN MS, a CTC-RI G-Learn faculty member who has an extraordinarily rich and diverse background in primary care. The online modules were developed by Geisinger Healthcare System to train their own nurses in primary care to assume the role of nurse care manager in the patient-centered medical home practice setting. Students also complete a home visit and capstone project. Read more.

Best Practices in Team-Based Care meeting showcases nurse care manager G-Learn capstone presentations

Over the last 12 weeks, with funding from UnitedHealthcare and RIDOH, CTC-RI offered 16 nurse care managers (NCMs) and care coordinators the opportunity to complete a standardized evidence-based training program where they learned and applied key patient-centered medical home care management concepts within their primary care practice settings. 

In January, 30 attendees joined our Best Practices in Team-Based Care meeting featuring participant capstone presentations and demonstration of ways they have applied their learning to patient situations. The presentations spoke to a variety of complex patient conditions and needs that. The NCMs helped address complex patient needs including uncontrolled chronic kidney disease, diabetes, substance use disorder, and social determinants of health that impact health outcomes including homelessness, food insecurity, lack of transportation and social support. Read more.

Apply by Feb. 29: Improving Demographic Data Collection in Primary Care to Address Health Disparities Quality Improvement Initiative

CTC-RI proudly presents the opportunity for primary care practices to apply for the 2024 Demographic Data Collection Quality Improvement Initiative, made possible with generous funding from UnitedHealthcare and Rhode Island Foundation.

Primary care practices are encouraged to participate in this nine-month initiative. Each selected practice will receive up to $10,000 to enhance their capacity for accurate and complete demographic data collection and reporting. New practices are eligible for extra funding ($2,100) for completing the baseline needs assessment and $500 (optional) for reviewing demographic data environmental scan reports and educational best practice webinar presentations.

The initiative targets pediatric, family medicine, and adult medicine practices that utilize electronic medical records and are capable of generating race, ethnicity, and language performance reports.

Applications are due by February 29 at 5pm. For comprehensive details and to apply, click here.

CTC-RI kicks off Asthma Collaborative focusing on pediatric and school nurse partnership

In January, CTC-RI kicked off its second asthma quality improvement initiative, this time focusing on strengthening partnerships with pediatric practices and elementary school nurses. Aimed at enhancing clinical competence, improving asthma management, and reducing school absenteeism among students with asthma and prescribed medications, practices identify their pediatric patients and a potential elementary school nurse partner to share and utilize asthma action plans and improve school attendance.

During the kick-off, Greg Fox, MD, Pediatric Endocrinology, Pediatric Associates spoke about his role as the school physician for the East Providence schools and how he currently works with schools and school nurses to help students with asthma stay in school. Dr. Fox talked about the importance of the asthma action plan as well as the roles parents play in communicating between providers and school nurses, and most importantly helping families clarify who actually has asthma and needs ongoing care. Finally, we heard from Janet Limoges, Provider Relations Manager, RIDOH KIDSNET and Ashley Robinette, MPH, Asthma Program Manager, RIDOH about updates to KIDSNET regarding asthma action plans and referrals to support programs.



Participating pediatric practices are Barrington Pediatric Associates, Pediatric Associates, Sunshine Pediatrics, and Blackstone Valley Pediatrics. Partnering school nurses Tracey Bradley, RN, Kent Heights School, and Alexandra Doty, BSN, RN-BC, Myron J Francis Elementary School, Colleen O’Donnell, BSN, RN, George J West Elementary.

Funding for this QI project is provided by RI Department of Health and Tufts Health Plan.

Clinical Strategy Meeting unveils insights into state approaches to Health and Human Services (HHS) primary care strategies

In a recent clinical strategy meeting moderated by Pano Yeracaris, MD, MPH, CTC-RI Chief Clinical Strategist, prominent speakers delved into primary care reform. Judith Steinberg, Former Senior Advisor to the Assistant Secretary for Health, provided a comprehensive overview of the federal HHS strategy, setting the stage for a fantastic discussion.

Dr. Lauryn Walker, Chief Strategy Officer at the Virginia Center for Health Innovation, brought a unique perspective in her discussion on how the state of Virginia has strategically mapped out its primary care approach based on the HHS framework. She highlighted the pivotal role played by the Virginia Task Force on Primary Care which was initiated in 2020 in response to COVID-19. This task force also developed a policy tracking tool to help advance primary care initiatives in Virginia. Christopher Koller, President of the Milbank Memorial Fund, discussed the important role that states have in taking action in response to the HHS Issues Brief, emphasizing the need for flexibility and adaptability.

Participants engaged in a dynamic conversation around what Rhode Island could do next to strengthen primary care. Attendees collectively explored the implications of HHS commitments for Rhode Island. View our CME page to see the recording, presentation and claim CME credits.

MLPB Phase II Learning and Action Lab: Best Practices for Strength-Based Screening, Triage and Response

MLPB hosted the fifth and final Phase II Health-Related Social Needs Learning and Action Lab session in January. The group of 25 participants, including older adults as well as healthcare and social services providers, reviewed the Phase I key takeaways, the three Phase II presentations, and broke into groups to reflect on what they learned and how they might use these insights to better meet the needs of older adults who are seen in primary care. The group exchanged ideas about how health-related social needs screening could be improved over the next five years. The session concluded with a brainstorming session about how an implementation phase might look, answering the question, "If there were to be a Phase III, what would you like to do next with the information we've learned?" Read more.

Upcoming CTC-RI Committee Meetings and Workgroups

• February 23, 07:30-08:45AM – Board of Directors
• March 13, 08:00-09:00AM – Task Force for Primary Care Provider Workforce Development
• March 15, 07:30-09:00AM – CTC-RI Clinical Strategy Committee Meeting
• March 22, 07:30-08:30AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

• February 21, 07:30-08:30AM – 4M Framework Learning Collaborative Meeting
• February 26, 12:00-01:00PM – Healthy Tomorrows Quarterly Learning Collaborative Meeting - Cohort 3 and Cohort 4
• February 27, 07:30-09:00AM – Pharmacy QI Learning Collaborative: CGM & ABPM
• February 29, 09:00-10:15AM – Demographic Data Collection Pilot Train-the-Trainer Webinar Series
• March 01, 08:00-08:30AM – Pharmacy QI Learning Collaborative: CGM
• March 08, 07:30-09:00AM – Breakfast of Champions
• March 14, 07:30-09:00AM – DULCE Learning Collaborative
• March 15, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
• March 19, 08:00-09:00AM – Best Practices in Team Based Care
• March 21, 07:30-08:30AM – ECHO: Increasing Access to Care for Children and Adolescents with Restrictive Eating Disorders by Optimizing Integrated Behavioral Health Care
• March 26, 07:30-08:30AM – Transition of Care Learning Collaborative