Care Transformation Collaborative of RI

News & Updates | February 2024

Seeking support to address primary care access crisis

The CTC-RI Primary Care Workforce Task Force is seeking support for its strategic roadmap report, “Primary Care Access for All: A Strategic Roadmap for Patient Access and Primary Care Workforce Capacity Building.” The report presents recommended goals, objectives and action steps to help build primary care workforce capacity and close the patient access gap. 

With support from State Senator Pamela Lauria and Representative Kathleen Fogarty, two of those goals have been drafted into bills which will soon go before the state legislature for approval:

  • First bill proposes support for Rhode Islanders who want to become primary care doctors, nurse practitioners or physician assistants but may not be able to afford the high cost of tuition to obtain the advanced degrees required. The bill earmarks state funding for full scholarships for Rhode Island students in exchange for a commitment to stay in Rhode Island to practice primary care. 

  • Second bill seeks to promote interest in primary care practice and retention of trainees to practice in Rhode Island by increasing the number of clinical training sites for medical residents, nurse practitioner and physician assistant students. The bill includes development of a standardized enhanced curriculum that will provide trainees with high-quality, team-based, patient-centered, primary care clinical training in Rhode Island. 

Supporters are encouraged to contact their legislators to support the two bills. 

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.

Healthy Happy Teams Cohort 2 reaches project midpoint

The Healthy Happy Teams project reached the halfway point for Cohort 2, and so CTC-RI hosted a midpoint meeting this month. The participating practices shared their topics for the quality improvement project with a special highlight on Brown Medicine Warwick with their Plan-Do-Study-Act (PDSA) project. The Healthy Happy Teams project aims to support team-based care in primary care practices in Rhode Island, to promote team effectiveness and to improve outcomes. With funding provided by UnitedHealthcare, the teams work with CTC-RI’s practice facilitators to improve processes and workflows to maximize team-based care. Read more.

Foundational Training for Community Health Workers

CTC-RI hosted another session of the Foundational Training for Community Health Workers (CHWs), in partnership with Team UP (Transforming and Expanding Access to Mental Health Care in Urban Pediatrics) and the Hassenfeld Child Health Innovation Institute at Brown University. The Increasing Pediatric Integrated Behavioral Health (IBH) Provider Capacity with Community Health Workers project kicked off in June 2023 and will continue for two years.

This project aims to expand the CHW role to support integrated care in pediatric settings in Rhode Island. In January, this session brought together our cohort of five CHWs to learn about common mental health issues in children, analyze case vignettes, and practice clinical skills with subject matter experts. 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.

Register now for Breakfast of Champions!

On March 8 at 7:30AM, CTC-RI will host its quarterly Breakfast of Champions meeting (virtual), focused on the Rhode Island Life Index. This has important implications for the primary care landscape of the state, as well as aspects of health equity. The session will be moderated by Pano Yeracaris, MD, CTC-RI’s Chief Clinical Strategist, with a panel of experts as reactants. Speakers include:

  • Farah Shafi, MD, MBA, Chief Medical Officer, Blue Cross & Blue Shield of Rhode Island
  • Melissa Clark, PhD, Director of the Survey Research Center, Brown University School of Public Health

CME credits and certificates of attendance will be available. Register now! 

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.

Monthly CBO Spotlight: ONE Neighborhood Builders

Our primary care transformation efforts often include the support and partnership of community-based organizations (CBOs) statewide. CTC-RI is spotlighting a different CBO each month to recognize and appreciate their work in our communities. This month, we're spotlighting ONE Neighborhood Builders (ONE/NB). Founded in 1988, ONE/NB has established itself as a community development leader in RI, developing affordable housing and engaging neighbors across Greater Providence to cultivate safe, healthy, and vibrant communities.

In which ways does your organization, and this program, uniquely support Rhode Islanders?

ONE|NB is a nonprofit community development organization that improves lives across Rhode Island by building homes and connecting communities. We build and manage affordable homes for low- and moderate-income Rhode Islanders, providing supportive services that help our residents thrive. We also convene Central Providence Opportunities: A Health Equity Zone, a collaborative of more than 60 organizations working to address the root causes of health and economic inequities in the 02908 and 02909 zip codes in Providence.


How can a partnership with primary care providers strengthen your work?

Access to primary care is critical to the long-term health and well-being of residents that call our buildings home. We strive to ensure all of our residents are able to build sustained relationships with health care providers and access preventative care.


What's something you'd like the primary care community to understand about your organization?

Building trusting relationships with our residents is central to our ability to connect them with supports and services that may provide them value. We take this same relationship-building approach when collaborating with health care providers, supportive service agencies, and other organizations that may contribute to a resident’s success.

Want to get in touch?

Contact Grace Evans Pedanou, Vice President of Strategy & Chief of Staff ([email protected] or 401-575-6322).

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.

Find past CTC-RI learning sessions and CME/CEUs here!

CTC-RI offers CME credits for select meetings, including asynchronous viewing of meeting recordings. Learn more and access evaluation forms here.

Practice Resources and Information

Best Practices in Team Based Care Webinar: Deprescribing: Considerations, Implementation, and Best Practices

Our CTC-RI March 19 (8-9am) Best Practices in Team-Based Care meeting will be via the upcoming RI Geriatric Education Center's webinar. Details and registration here.

Primary care provider survey: Managing memory concerns for older adults in primary care

Improving routine screening is the first step toward detecting Alzheimer’s disease and related dementias early, before the onset of major symptoms. The FDA has recently approved a new medication that may slow or prevent Alzheimer’s with early intervention. Understanding the experiences and needs of primary care providers is critical as tools are studied to improve early disease detection. Take this quick survey and be entered to win a $500 Apple Store gift card.

CBOs and provider practices: Assistance for children and families renewing Medicaid coverage

The RI Health Center Association is available to provide in-person support to Medicaid members who must take action to renew their health coverage. If you are hosting a community event, Mobile Navigators are available to attend. They can raise awareness of Medicaid renewals and assist people in applying for or renewing their health coverage. If you are interested, please complete the mobile navigator request form. The Mobile Navigator Program is supported by the Executive Office of Health and Human Services and HealthSource RI.

Health Professional Loan Repayment Program closing on March 1

The Office of Primary Care and Rural Health (OPCRH) Health Professional Loan Repayment Program opened on December 18 for the 2024 cycle (the program closes March 1, 2024). The program is intended solely for licensed primary care (medical, dental, and mental) healthcare professionals working in a Health Professional Shortage Area (HPSA). The program provides loan repayment to those selected to be awarded and eligible for the program in exchange for a two-year service commitment. To learn more, please visit the Health Professional Loan Repayment Program web page on

Save the date: Public Health Summit 2024

Save the date for the RI Public Health Association's Public Health Summit on April 29 (8am-4pm) at the Crowne Plaza in Warwick. This year's conference is focused on inspiring the public health community with innovative strategies to improve health equity. For more details, email [email protected].

Paving a path to patient-centered contraceptive care in the Ocean State

Upstream is committed to ensuring that patient-centered contraceptive care is accessible to everyone. Upstream works with healthcare leaders in Rhode Island and nationally to make contraceptive care more affordable and accessible to millions of people. Partner with Upstream to champion equitable healthcare practices and break down barriers. Click here to learn more.

OHIC Resource: Rhode Island Market Summary

Each year, the Office of the Health Insurance Commissioner (OHIC) analyzes data from health insurance rate filings, federal medical loss ratio reports, insurer financial filings, and other sources to present trends in enrollment, premium, claims, loss ratios, and the underwriting performance of domestic health insurers. This third annual health insurance Market Summary incorporates data from 2022. OHIC hopes the Market Summary contributes to a data driven discourse on the cost of health care and health insurance in Rhode Island.

Job opportunity: Full-time Community Health Worker/Family Support Specialist

Blackstone Valley Community Health Care is hiring a full time Community Health Worker/Family Support Specialist. Learn more.

Recent News

Office of the Governor: Governor McKee Announces Rhode Island has Joined Compact for Interstate Nurse Licensing

Governor Dan McKee and the Rhode Island Department of Health announced on January 11 that Rhode Island has joined the national Nurse Licensure Compact, allowing nurses in 41 states who hold a Multi-State License to come to Rhode Island and work. Rhode Island nurses with Multi-State Licenses will also be able to work in any of these other states. Details.

PBN: Asthenis Pharmacy providing an alternative source for health care information

Looking to improve access to reliable health information, Eugenio Fernandez Jr. opened Asthenis LLC, doing business as Asthenis Pharmacy, in July 2018. The business generates revenue as an independent pharmacy, but it also helps fund a greater purpose: educating people. Read more from Providence Business News' recent interview with Eugenio Fernandez, pharmacist, business owner, and CTC-RI board member.

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
Care Transformation Collaborative of RI | [email protected] |