Care Transformation Collaborative of Rhode Island News & Updates
September 2020
OHIC Update: RI Patient-Centered Medical Home 2020 Performance Improvement Reporting Requirements 
RI Health Insurance Commissioner Marie Ganim, PhD, has provided guidance for primary care practices on the changes to the 2020 meaningful performance improvement requirements in response to the impact of COVID-19. A practice seeking OHIC PCMH recognition status has historically been required to meet OHIC’s definition of demonstrating “meaningful performance improvement,” meaning performance is at or above a predefined benchmark or performance has improved by at least three percentage points over one or two years. For reporting in 2020, however, OHIC has decided to move all measures to reporting-only status as it anticipates that COVID-19 will have a significant impact on quality measure performance. Therefore, practices only need to report performance on the appropriate measures from the PCMH Measure Set in order to meet this component of the PCMH definition. As a result, OHIC will use data from the 10/1/2018 – 9/30/2019 performance period to assess improvement for the 10/1/2020 – 9/30/2021 performance period. 

Primary care PCMH reports are due October 15 and include: a) 2020 OHIC Cost Management Survey and b) 2020 PCMH Quality Measurement and Integrated Behavioral Health Reporting Survey. In 2020, practices will need to report on the following measures for the 10/1/2019-9/30/20 using the updated measurement specifications. Lead screening has been added as a new measure for pediatric practices; however, practices will not need to submit data for “Lead Screening in Children” to OHIC. With practice permission (and practice provision of KIDSNET practice ID), RIDOH will provide OHIC with practice reports for the 10/1/2019-9/30/2020 measurement year for the measure. 
Questions? Visit OHIC’s PCMH webpage or contact Cory King (704-242-2292 or
Primary Care: Working Together to Improve Immunization Rates for Children 
The Governor’s Relief Fund provided primary care practices with essential financial support that has enabled practices to make substantial gains in providing children with preventive health care services prior to the start of the school year. Current Pediatric Immunization and Lead Screening Performance among the Pediatric Relief Fund Practices has continued to increase based on KIDSNET data (received 1st and 15th of the month).
Primary care practices providing care for children on Medicaid had the opportunity to apply for the Medicaid Pediatric Primary Care Rate Supplement Program with applications due September 10. Successful applicants will be eligible for monthly payments based on the number of RI Medicaid-covered children served by the practices with funds awarded upon demonstration of performance improvement on a standardized measure of primary care access. Program guidance is available here.
Dept. of Health Update: Flu Vaccines and Clinics Available
The flu vaccine is safe and is the best defense against the flu. The Office of Immunization provides flu vaccination at no cost for students in kindergarten through grade 12 at school-based clinics. Most evening school clinics are open to the public (age three and up). For the most up- to-date list of school clinics and to register for a school clinic, visit There are also a number of community clinics open to the public, some of which offer enhanced flu vaccine for people 65 years of age and older. Rhode Islanders can visit (English) or (Spanish) to find information about flu vaccination clinics in their community. Additional public flu vaccination clinics will be added as this information becomes available.
Rhode Island Diabetes Health Equity Challenge Concludes 5-Month "Learning and Doing" Action Network
Over 75 attendees participated in the RI Diabetes Health Equity Challenge “Learning and Doing” Action Network close-out session held on September 18. Stakeholders learned how the two Challenge pilot teams applied population health tools to rapidly assess and address equity issues alongside community partners to create short-, medium-, and long-term solutions. Over five months, teams received coaching from national experts and applied population health change principles to better support people with diabetes who are at high risk of poor outcomes in the context of the coronavirus. The teams celebrated their progress and plans for building sustainable community solutions that move from providing food to those that are hungry to making it easy of everyone to afford and access healthy foods. Somava Saha, MD, MS, Executive Director Lead from Well Being in the Nation facilitated the discussion on how we can leverage financial and nonfinancial resources to sustain and scale health equity in Rhode Island. (Click here for the presentation).
Navigating DCYF Training for Community Health Teams
Through our contract with the Medical Legal Partnership of Boston (MLPB), on September 8th, Community Health Teams (CHTs) participated in a training: “Navigating DCYF in General - and as a Family Impacted by SUD”. In this webinar, CHTs were able to better understand the DCYF intake and investigation process and identify the unique barriers and challenges for families impacted by substance use disorders in navigating the system. Jeannine Casselman, JD articulated how CHTs could apply advocacy strategies in partnership with individuals and families involved with DCYF. MLPB provided multiple resources and Community Health Workers were able to receive a completion certificate which could go toward their CHW certification.
National Primary Care Survey Shows Challenges Remain
According to the most recent results shared by the Primary Care Collaborative and Larry A. Green Center, national surveying of primary care teams throughout the country show some modest gains have happened recently but primary care remains in significant need of support: 35% say revenue and pay are still significantly lower than pre-pandemic levels and net losses threaten current and future viability. Another 30% of clinicians say the financial picture has been slowing improving but the workforce is fragile and in trouble. And 1 in 5 practices report they have clinicians who have chosen early retirement or left their jobs as a direct result of the pandemic.
EOHHS Presents HIT Strategic Roadmap to CTC-RI Board of Directors
On Friday, September 25, the CTC-RI Board of Directors had the opportunity to provide feedback on the statewide health information technology (HIT) strategic roadmap and implementation plan. Marti Rosenberg, EOHHS Dir. Policy, Planning, & Research and Amy Zimmerman, EOHHS RI State HIT Coordinator presented the goal of the 3-year vision for RI HIT. A new public-private statewide coordinating governance HIT Steering Committee will be established by December 2020 and will report to the Health Cabinet. The Committee is charged with aligning stakeholders and guiding statewide HIT decisions and investments, with a race equity lens. 6 strategies were presented: 1.) statewide planning, 2.) governance and coordination, 3.) data availability and technical alignment, 4.) health systems transformation and quality of care, 5.) public and population health and 6.) best practices. All Roadmap materials linked here. The deadline for public comment is Monday, October 12.
Update from CTC-RI Quarterly Breakfast of Champions
CTC-RI and PCMH Kids programs met on September 11 when a discussion of practices' plans for back-to-school and sick visits was co-led by Gregory Fox, MD, FAAP, President RIAAP and Beth Lange, MD, FAAP, PCMH Kids co-chair. Dr. Lange followed up with an update on the Pediatric Relief Fund / Pediatric Advisory Board. The meeting concluded with program updates on the Care Delivery Design by Pano Yeracaris, MD, MPH, CTC-RI Chief Clinical Strategist and both the Telehealth and Pharmacy QI projects by Susanne Campbell, RN, MS, PCMH CCE, CTC-RI Senior Project Director. See all presentations here.
RI Foundation Helps Fund Interviews of Patients Supported by Integrated Behavioral Health
Brown University has been awarded a grant from the RI Foundation to conduct a qualitative evaluation of patients who participated in our adult IBH pilot program. Understanding the IBH patient perspective will be the focus of the study. CTC-RI will partner with Brown to recruit patients to participate in focus groups and individual interviews. Practices will be provided with funding to help identify patients willing to participate. To date, CTC-RI has successfully demonstrated provider and team satisfaction in having IBH as part of the PCMH care team. We also demonstrated significant quality improvement and decreased total cost of care. This study will provide the patients’ perspective on IBH. Dr. Nelly Burdette, Sr. IBH Program Leader, will be reaching out to pilot sites with a one-pager for participation.
In the News
Convergence RI
Including mention of PCMH-Kids, a September 14 article in Convergence RI highlights how the rapid adoption of telehealth as a platform in the delivery of health care is redefining the office visit and the future relationship between patients and providers

CPC+ Newsletter
In its Payer Partner Updates newsletter, CPC+ highlighted CTC-RI's Integrated Behavioral Health pilot program work as a "Bright Spot" and showcased its positive results.
Monthly Committee Update: Nurse Care Manager/Best Practice Sharing
Linda Mencona and Kathy Marceau, Rhode Island Department of Health school nurse consultants, provided an important update on back-to-school program and coordination with pediatric practices at the September 15 NCM/CC meeting. Denise deHertogh and Cameron Condry (BCBSRI) presented a nurse care management update including key elements of NCQA care management standards and BCBSRI NCM reporting requirements; staff from RIPCPC and Coastal provided information on how they are using technology to connect with patients that are at high risk.
Update: CTC-RI Primary Care Telehealth Initiative
46 practices (34 adults and 12 pediatric) signed participative agreements for completing practice needs assessment/patient engagement surveys with a completion date of September 25. CTC-RI is working with Northeast Regional Telehealth Resource Center to analyze, aggregate and display the findings that will be used to inform: 
  • The development of the 6-month webinar series (scheduled to start in October 2020)
  • The development of a 12 month learning collaborative “Using Technology to Improve Management of Chronic Illness” (Call for Applications due to be released in November 2020) 
  • State policy
Monthly Committee Update: Clinical Strategy
The committee met on September 18 to discuss pandemic-related updates and other issues to include flu vaccine targets, outreach and supply. Expanding IBH, CHWs, and remote monitoring were some of the immediate issues and activities prioritized at practice and SOC levels. Infant home visiting programs with PCMHs (Healthy Tomorrows) is a new project. Because of the drop off in nursing home admissions, health plan priorities include determining if home health agencies are ready for same-day visits. Telemonitoring and telemedicine would be another interest for the group. A registry for adults which will be brought up with the HIT Roadmap Steering Committee. The Care Delivery Design work stream has commenced with a focus to help practices and SOC maximize success under comprehensive primary care capitation and Total Cost of Care risk. Pano Yeracaris, MD MPH, CTC-RI Chief Clinical Strategist, and Mary Jo Condon, Freedman Healthcare Senior Consultant, reviewed the ongoing Care Delivery Design for Comprehensive Primary Care Capitation to categorize competencies into “must have”, “good to have” and “not necessary” buckets. These will help inform the development of the practice and self-assessment tool. A steering committee has been formed and an intensification of meetings are planned through at least December. Finally, Matthew Collins, MD, BCBSRI Executive Vice President and Chief Medical Officer presented the AAMC Project Core. There was interest in a spring collaborative around the e-consult project and will reach out to AAMC to present at the next meeting.
Practice Resources
RIC Seeking Placements for MSW Students Focused on Integrated Behavioral Health, Substance and Opioid Use Education
Rhode Island College is seeking Fall and Spring internship placements for MSW interns in the RIICE (IBH) and RIISOE (Substance and Opioid Use Education) cohorts. Interns must complete 15 hours a week of internship, including the required 1 hour of weekly supervision with an MSW with at least 2 years post-graduation experience. RIC is able to provide the MSW off-site supervision in the event that an MSW is not available onsite. Contact Paula Coutinho if your practice is interested (, 401.456.9830).

Job Opportunity: East Side Pediatrics Triage Nurse/Care Coordinator
East Side Pediatrics is hiring a full-time RN to provide direct care to families. Click here for the job description.

Celebrate Rhode Island World Diabetes Day on November 14 and Participate in "Rhode to Wellness" Daily Challenge
This 8-week challenge encourages healthy eating, a healthy mind, healthy movement, and a healthy self. Learn more about the Rhode to Wellness Challenge happening now, and plan to participate in Rhode Island World Diabetes Day online on Saturday, November 14, a day filled with inspirational presentations, discussions, Q&A sessions, and more. RI World Diabetes Day also encourages nominations of a nurse to receive the Grace Diaz Blue Light Award.

Lifespan Community Health Institute Offering Free COVID-19 Testing
Symptomatic adults and children (ages 4+) are eligible to be tested. Testing clinics will occur Oct. 1 (11am-2pm) and Oct. 18 (10am-12:30pm) in Providence. Flyers with details available in English and Spanish.

weR1 Rhode Island Relief Fund Providing Cash Assistance to Support Undocumented Families Impacted by COVID-19
The weR1 Rhode Island Relief Fund is an initiative of Governor Raimondo to provide cash assistance to undocumented immigrants who have experienced financial hardship during the COVID-19 crisis, with help from 17 community organizations processing applications and distributing payments. Eligible individuals get a one-time payment of $400 on a pre-paid, no-fee debit card. Households can receive $400 per eligible adult family member. All monies in the fund are donations from individuals, philanthropic organizations, corporations, and
other private donors. See attached flyers in English and Spanish.

Day Health Strategy Hosting Healthcare 2020 Summit on Oct. 6
The Summit will focus on healthcare transformation as it relates to access and equity in the context of 2020’s significant challenges, and include two keynote speakers and three panels on these themes. Learn more.

Rhode Island Foundation Offers "Paths to Recovery" Fall Panel Series
This new panel series, “Paths to Recovery: Strategies for Getting Back to Work and to a Better Future,” will include events on Oct. 7, Nov. 10, and Dec. 9. The panels are free and open to the public. Registration is required, details here

Oct. 22 Training: Suicide Assessment Using the Columbia Suicide Severity Rating Scale (C-SSRS)
Review the current national and local suicide statics and trends, then review the evidence-based suicide assessment tool, C-SSRS. All participants will have the opportunity to practice using the C-SSRS in a safe and supportive environment. Details here.
Upcoming Meetings (for CTC-RI members)
  • October 01, 2020, 07:30-08:30AM - Quarterly PCMH-Kids Stakeholder Meeting
  • October 08, 2020, 07:30-09:00AM - Quarterly Pediatric IBH Meeting
  • October 09, 2020, 09:30-11:00AM - CHT Best Practice Meeting
  • October 15, 2020, 03:00-04:30PM - SBIRT/CHT Executive Committee Meeting
  • October 16, 2020, 07:30-09:30AM - Clinical Strategy Committee Meeting
  • October 20, 2020, 08:00-09:30AM - Care Manager/Coordinator Best Practice Sharing Meeting
  • October 23, 2020, 07:30-08:45AM - Board of Directors Meeting
  • October 28, 2020, 08:00-09:30AM - Practice Reporting/Practice Transformation Committee Meeting