Care Transformation Collaborative of Rhode Island News & Updates | September 2021
Spotlight: Wendy A. Chicoine, Associate Vice President of Clinical Operations and Clinical Education, Providence Community Health Centers
This month, CTC-RI interviewed Wendy A. Chicoine, MSN, RN, PHNA, Associate Vice President of Clinical Operations and Clinical Education at Providence Community Health Centers. Wendy was recently honored by RI Monthly as the state's 2021 Community/Public Health Nurse of the Year for their "Excellence in Nursing" awards. We asked Wendy about her important work, but you can read her RI Monthly award interview here.

As primary care continues to transform, how has your work transformed in recent years to better support RI patients?
Healthcare transformation is needed if we are to meet the Triple/Quadruple Aim. At Providence Community Health Centers, we have worked to utilize each member of the care team to the fullest extent of their education. One example is the use of standing orders, which supports a team-based care approach. This moves us one step closer to improving patient health outcomes. 

As a nurse, what has been your greatest challenge working through this pandemic?
I feel one of the biggest challenges, especially in the very beginning, was keeping up with the frequent changes. I know many of my colleagues in healthcare can relate to this. Although the pandemic has created many challenges, it has also highlighted one of our greatest strengths: adaptability. In many ways, the pandemic has brought out the best in healthcare workers everywhere.

What best practices have you discovered and implemented throughout collaboration with other care team members, nurses, or practices?
A few years ago, we implemented monthly team meetings. During these meetings, our care teams have time to review their dashboard and identify a team-based quality improvement project. It is a mutually agreed-upon project that works to improve a quality measure or workflow. This allows the care teams to participate in the PDSA process with the goal of identifying a best practice that could be used organizationally. 
Unite Rhode Island connects community partners (such as social service organizations, government agencies, and health care providers) to deliver integrated whole person care through a shared technology platform (Unite Us) to address social determinants of health in Rhode Island. Emma Romey and Imani Podradsky of Unite Us provided an overview and demonstration of Unite Us functionality. Garry Bliss shared why Prospect Health Services selected Unite Us and then Rosemarie Sepe, Prospect Health Services, and Amy Neveu and Anna Flynn, both of Coastal Medical, provided firsthand accounts of their experiences working with the Unite Us platform and team. Community-based representatives such as Donald Laliberte of KidsLink, Emily Garthee of RIPIN and Allegra Scharff of RIDOH also shared their experiences with the Unite Us platform and team, from the receiving side of referrals.

EOHHS’s recent announcement and support is important for the continued success of the Unite Rhode Island network, as it expands across the state. Joining the network is free of cost for community-based organizations and nonprofits and many organizations that are considered part of the safety net, like community health centers, tribal clinics, and mental health centers.
The August Clinical Strategy Committee (CSC) meeting featured a special presentation on the new Community Resource Platform. Describing the program and implementation progress to date was Libby Bunzli, EOHHS and Laudine Koster, Unite Us Senior Engagement Manager.
CSC members also participated in a Jamboard session reflecting on a strategic planning discussion with Jim Berson, Fio Partners facilitating.

Finally, Nelly Burdette, PsyD, CTC-RI Senior IBH Program Leader led a clinical resiliency discussion inquiring CSC members on what are the needs, what are people doing and what would be helpful. This JAMA paper was provided as a resource.

CME credit is available for this CSC meeting.
With funding from the Rhode Island Department of Health and Tufts Health Plan, 5 teams of pediatric and adult practices who are participating in the CTC-RI/PCMH Kids 2021 Pediatric/Adult Health Care Transfer of Care Quality Improvement Initiative shared their successes, challenges and plans at the September Best Practice Sharing Meeting. Content experts from the National Alliance to Advance Adolescent Health provided technical assistance, answered questions and provided recommendations for the practice teams. Adult and pediatric practices are working with each other to apply “tests of change” on selected core elements from the Got Transitions tool kits and making improvements as needed to successfully prepare youth for transition of care from pediatric to adult care.
CTC-RI hosted its quarterly peer learning best practice sharing meeting in August. Seven practices working within systems of care 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 had the opportunity to present on how they plan to overcome the challenges they are facing.

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. During the infrastructure period of this initiative, staff members were asked to complete a well-being survey. Over 100 staff members completed the well-being survey and results of these findings were shared. At the end of the learning collaborative, team members will be asked to provide well-being feedback so that CTC-RI can assess if improving team-based care has had an impact on team well-being.
Breakfast of Champions Focuses on Improving Maternal Child Health: Addressing Health Disparities in Prenatal Care
In a groundbreaking session on September 10, the CTC-RI Breakfast of Champions brought together nearly 100 RI health care leaders to share and learn about how to improve maternal child health while addressing health disparities in prenatal care. State updates were presented by Aidea Downie, MA, RIDOH Maternal Child Health Program Disparities Specialist; 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; and Jim Beasley, MPA, RIDOH Program Manager, RI Maternal Psychiatry Resource Network Program (RI MomsPRN). A stimulating discussion was moderated by Patricia Flanagan, MD, Hasbro Children’s Hospital, Brown Univ. Pediatrics Professor, and PCMH-Kids Co-Chair.

Finally, there were presentations by the 4 RI health plans sharing their inspiring Initiatives on addressing health disparities in prenatal care: Blue Cross & Blue Shield of Rhode Island: Matthew Collins, MD, MBA, Executive Vice President, Clinical Affairs and Chief Medical Officer; Neighborhood Health Plan of Rhode Island: Christopher Ottiano, MD, Interim Medical Director and Yvonne Heredia, PhD, MS, Senior Manager; Tufts Health Plan: Claire Levesque, MD, Chief Medical Officer, Commercial Products and Michelle Wolfsberg, MPH, BSN, Director Clinical Strategic Initiatives; and UnitedHealthcare: Barry Fabius, MD, CMO and Sarah Coutu, BSN,RN, CCM, MNN, Health Services Director.

If you weren’t able to attend in-person, here are the links to the PowerPointwebinar recording, and the CME request via the evaluation link.
CTC-RI is excited to welcome our newest group of 49 nurse care managers/care coordinators (NCM/CC) who have successfully applied to participate in our GLearn Nurse Care Manager Core Curriculum Training Program. The 2021 launch marks the 4th year that CTC-RI/PCMH Kids has been able to offer this important workforce development program made possible through the generous funding from UnitedHealthcare and the RI Department of Health. This year participants come with a range of experience levels and represent 20 different practices and every RI system of care.

CTC-RI/PCMH Kids partnered with Geisinger and developed online modules covering disease-specific content as well as care management and patient engagement skills. Each module is supplemented by weekly group discussion calls facilitated by nurse care manager faculty who have successfully completed the GLearn training program. The 2021 training program will start mid-September and culminate this winter with nurse care managers sharing their capstone presentations at NCM/CC Best Practice Sharing meetings.

Rhode Island providers continue to participate in the Larry A. Green Center / Primary Care Collaborative Clinician Survey. These surveys are fielded nationally to better understand response to COVID-19 and capacity of primary care practices across the country. This information is compiled and used to inform key national leaders. Outlined below are some key messages from the August 13 – August 17 (Series 30) RI-specific clinician survey results with these additional details in the link:

  • RI providers are unable to hire staff for open positions (79% vs 54% nationally).
  • RI providers have seen a rise in mental health issues among children (e.g., depression, anxiety, ADHD) (79% vs 65% nationally).
  • RI providers are constantly worried about the poor mental health of practice members (67% vs 53% nationally).
  • COVID-19 is again surging in my area and I don’t know if I can take it. (59% vs 50% nationally).
  • RI providers personally know primary care clinicians who have retired early or left practice because of the pandemic (59% vs 45% nationally) and primary care practices that have closed during the pandemic (56% vs 29% nationally).
  • Only 18% of RI providers feel their practice is financially healthy (vs 26% nationally).
  • RI providers are experiencing the following with vaccine hesitancy:
  • Conversations with vaccine-hesitant patients take several minutes (85% vs 80% nationally).
  • For most vaccine-hesitant patients, it’s a gut or political opinion that cannot be changed (68% vs 67% nationally).
  • 2-3 conversations are needed to change the mind of vaccine-hesitant people (56% vs 52% nationally).
  • For most vaccine hesitant patients, education on the issues can make a difference (44% vs 26% nationally).
  • Use of telehealth has been essential to maintaining access to patients say 71% of RI providers (compared to 64% nationally); however, if pre-COVID telehealth regulations are restored, practices will not be able to provide telehealth services (47% vs 41% nationally).

Please note that you may use all data and reports for dissemination purposes both internally and externally without additional permissions, provided that you attribute the data to the Larry A. Green Center.
COVID-19 State Transmission and Vaccination Update
COVID-19 transmission continues to climb in Rhode Island, with the state being labeled as "high transmission" according to the CDC's latest transmission measures. Access the most recent transmission and vaccine data here.

As of September 15, 766,909 Rhode Islanders are partially vaccinated and 699,484 are fully vaccinated.
In The News
Evaluating the impact of integrated behavioral health intervention
Medicine Journal, August 27, 2021
A recent Medicine article highlights research on our Integrated Behavioral Health program. The aim of this study was to evaluate the impact of Integrated Behavioral Health program on health care utilization and costs. Integrated Behavioral Health intervention in Rhode Island was associated with reduction in healthcare utilization. Emergency department visits reduced by 6.4 per 1000 people per month and office visits reduced by 29.8 per 1000 people per month, corresponding to a reduction of 7% and 6%, respectively. Read the full article here.
People in the news: Peter Hollmann, MD, FACP, AGSF appointed president of American Geriatrics Society
Cranston Herald, September 8, 2021
Brown Medicine, a primary care, specialty outpatient and sub-specialty medical group practice with over 200 physicians and multiple patient care locations across the state, announces that Dr. Peter Hollmann, MD, FACP, AGSF has been named 2021-22 president of the American Geriatrics Society. Statewide, Hollmann co-chairs the multi-payer Patient-Centered Medical Home demonstration project (Care Transformation Collaborative of Rhode Island) Data and Evaluation Committee. Read the full article here.
Practice Resources
RentReliefRI Helping Rhode Islanders with Rent and Utility Assistance
RentReliefRI is continuing to help qualified Rhode Islanders across the state with important rent and utility assistance, a direct factor in helping families maintain housing stability -- a social determinant of health. Resources are available to continue to share this funding availability with patients who may need help. View the Fact Sheet here and learn more at

Funding Opportunity: Improving Capacity of Physician-led Practices to Prevent, Mitigate and Treat COVID-19
The American College of Preventive Medicine (ACPM) is partnering with the American Medical Association’s Center for Health Equity to create care coordination pilots that enhance the capacity of physician-led practices to implement COVID-19 prevention, vaccination, testing, and treatment strategies that improve the health of populations that have been disproportionately impacted by the pandemic, racial injustice, and other forms of oppression. ACPM aims to fund a total of $2 million to be distributed among 10-15 physician-led practices from November 1, 2021 – July 31, 2022 to implement strategies that center equity and aim to improve the health of communities. Applications are due October 1.

Telehealth Classroom: Self-Paced Training Available
The Northeast Telehealth Resource Center is pleased to announce a self-paced training opportunity for community health workers, Telehealth Basics for Community Health Workers. Learn more here.

Sept. 17 Training: Medicaid 101 for CHW Employers
How to prepare for the coming Medicaid reimbursement. Register here for the 2-4pm virtual training.

Seminar Series: Collaborative Conversations with Families to Advance the Clinical Care of Children with Medical Complexities and Disabilities
Collaborative Conversations with Families to Advance the Clinical Care of Children with Medical Complexities and Disabilities is a 10-part seminar series that builds on an international prioritization study, completed in 2020, designed to highlight key clinical research questions for the care of children with neurodisability and medical complexity. Sessions are delivered on every second Thursday of the month from 1-2pm. View the upcoming sessions here.

Bradley Conference: Fall 2021 Series
The Bradley Conference Fall 2021 series is grant-supported by the Rhode Island Department of Health Violence and Injury Prevention Program and focuses on Suicide Prevention and Response. View the upcoming October and November sessions here.

Emergency Broadband Benefit Offers Discounted Internet and Devices
Eligibility for the FCC’s Emergency Broadband Benefit has recently been expanded to include any household receiving free and reduced school lunch during the 2021-2022 school year. The program aims to expand broadband access by providing up to $50/month toward internet service, as well as discounts on devices. Households can also qualify based on income or participation in other social service programs. We encourage practices to let patients know about this opportunity.

Parent Support Network Offers Rich Resources for Families
Parent Support Network of RI dedicated its recent quarterly newsletter to provide its community with the most updated resources to better help families understand and navigate different obstacles. View the valuable list of resources here.

Webinar: Effective Interventions for Enhancing Mobility in Older Adults
This RI Geriatric Education Center webinar on Sept. 22 at 12pm will be lead by presenter Dr. Ward-Ritacco. Free CEUs are available for nurses and social workers as well as certificates of attendance. Register here.
Job Opportunities
Project Lead: Rhode Island Free Clinic
The full-time Bilingual Project Lead/Health Impact Programs will work as a strategic partner with Clinic staff and volunteers to further the Free Clinic's model of high-quality, community-based healthcare services for uninsured adults.

Community Health Worker: South County Hospital
This full-time Community Health Worker is a member of the Community Health Team; an interdisciplinary team comprised of Community Health Workers, Behavioral Health Clinicians and practice-based Nurse Care Managers. Find the job posting here.

Rhode Island COVID-19 Response
There’s still work to be done to crush COVID and there are several job openings available today!
September and October CTC-RI Committee Meetings and Workgroups
  • September 17, 07:30-09:00AM – Clinical Strategy Committee
  • September 21, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing
  • September 24, 07:30-08:45AM – Board of Directors
  • October 07, 07:30-08:30AM – Quarterly PCMH-Kids Stakeholder Meeting
  • October 08, 09:30-11:00AM – Community Health Team Best Practice Sharing
  • 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 21, 03:00-04:30PM – SBIRT/CHT Executive Committee
  • October 22, 07:30-08:45AM – Board of Directors
September CTC-RI Program and Initiative Meetings
  • September 29, 08:00-10:00AM – CCE Best Practices Sharing Meeting
Upcoming Learning Collaboratives and Professional Development
  • September 23, 07:30-09:00AM – RI MomsPRN Learning Collaborative
  • October 01, 07:30-09:00AM – Professional Education Session: Cannabis Use in the Perinatal Period
  • October 05, 12:00-03:00PM – Rhode to Equity Quarterly Momentum Session