Care Transformation Collaborative of Rhode Island News & Updates | April 2022

AS CTC-RI concludes its 12-month Telehealth Learning Collaborative focused on using technology to improve care for patients with chronic conditions made possible by UnitedHealthcare, RI Department of Health, and CARES Act funds we’re enjoying hearing from participating practices about their experiences! The goal of the Learning Collaborative was to help primary care practices expand the use of technology to help patients better manage chronic conditions and enable practices to further physical distancing measures, reduce unnecessary in-person visits, and thereby mitigate the spread of COVID-19. We asked a Cohort 1 participant, Dr. Richard Ohnmacht, a Cranston-based pediatrician and Clinical Associate Professor of Pediatrics at Brown University’s Warren Alpert School of Medicine, to weigh-in on his experience.

During this pandemic, what new opportunities did telehealth present to you via this learning collaborative?  
While telehealth had opened numerous opportunities for many healthcare providers, it had opened a skeptic’s eyes (myself) to the potential benefits to both the patient and practice in a setting where the emphasis is on talking rather than looking for physical finding during an examination. 

What challenges in your practice have you been able to better address/target using what was learned in the telehealth learning collaborative?  
Offering telehealth has the advantage of fewer missed appointments, lesser weather-related cancellations, and added convenience for families traveling a distance for follow-up appointments (this is Rhode Island, after all...)

What success, advice, or best practices would you offer to other practices considering new telehealth solutions?  
I think that establishing parameters by which both you and the patient feel comfortable for these visits and allowing for in-person follow-ups should the need arise is my best advice for success.

The RI Department of Health, Tufts Health Plan, CTC-RI and PCMH Kids are pleased to offer pediatric and adult practices the opportunity to apply for funding to participate in the 2022 Pediatric/Adult Primary Care Health Care Transfer of Care Quality Improvement Initiative. Family medicine practices are also welcome to apply, providing the practice is willing to partner and accept referrals from a pediatric practice. Please refer to the full call for applications for new practices here.
A 2nd opportunity “Application for Extended Participation 2022 Pediatric/Adult Primary Care Transfer of Care Quality Improvement Initative” is available for select pediatric and adult practice teams that participated in the 2021 Health Transfer of Care Quality Improvement Initative. Please refer to the full call for application for extended participation here

Both 12-month learning collaboratives will run from June 29, 2022 to June 28, 2023. Completed practice applications are due June 1, 2022 by 5pm EST. CTC-RI will be offering a Q&A session to interested parties on:

Registration is not required and interested practices may join any session here. Any additional questions can be directed to
Call for Applications: RI MomsPRN Learning Collaborative (May 25 Deadline)

The RI Department of Health and CTC-RI are pleased to announce another funding opportunity/call for applications for practices providing prenatal and postpartum clinical care. A 3rd RI MomsPRN learning collaborative will start in June to help practices optimize behavioral health screening, treatment, and referral workflows for depression, anxiety, and substance use disorder among perinatal patients. Customized CEU training from experts, including clinicians from the Center for Women's Behavioral Health at Women & Infants Hospital, will be offered as well as virtual peer learning and practice-specific support. For those practices with already established screening protocols and/or integrated behavioral health supports, this funding opportunity can help maximize internal referral protocols and improve provider self-efficacy with perinatal patients. Learn more and apply here.

Centers for Medicare and Medicaid Services (CMS) is reviewing a proposal from RI Executive Office of Health and Human Services (EOHHS/Medicaid) to cover Community Health Worker (CHW) services as a Medicaid benefit. On March 21 and 24, EOHHS staff and its fiscal agent Gainwell Technologies presented information on the proposed CHW benefit. Under the proposal, CHWs could bill for health promotion and coaching; health education and training; health system navigation, and; care planning for eligible Medicaid members. CHW services would need to be recommended for a patient by a licensed healthcare professional and providers must enroll as a CHW provider in order to be eligible to bill. Providers could back bill CHW services to July 1, 2021, with appropriate documentation. This benefit would not be covered by Medicaid managed care contracts, but rather through Medicaid directly and would be billed directly via Gainwell Technologies. EOHHS expects benefit approval from CMS in May 2022.

The CTC-RI’s March Clinical Strategy Committee Meeting provided an update on system of care PCP/Specialist Collaboration progress using the AAMC CORE (Coordinating Optimal Referral/eConsult) approach. Steven Lampert, MD, MBA, President of Lifespan, Paul Larson, MD, MBA, Chief of Primary Care with Lifespan and John Minichiello, President Integra Community Care Network ACO, presented on their progress to date with educating and engaging PCPs and specialists around enhanced referrals and econsults. Scott Shipman, MD, MPH, Director of Clinical Innovations and Director of Primary Care Initiatives, Association of American Medical Colleges provided guidance on Year 1: Implementation and Year 2: Scaling and Sustaining the Model and Measuring Impact. The Primary Care/Specialist Oversight Committee (with Co-Chairs John Minichiello and Cathleen Newman, BCBSRI) will work to improve coordination and alignment between primary care and specialists using a multi-pronged approach. Lifespan will be rolling out their referral process in May, with pediatric/adult GI and psychiatry while Integra is starting with cardiology. There was also much interest in the continued rollout of specialist waves and expansion to PCPs not on EPIC to determine if the statewide HIE, CurrentCare, could be used to assist in e-consults/enhanced referrals.

In March, the 6 Rhode to Equity Teams came together for Momentum Session facilitated by the Wellbeing and Equity in the World Team (WE Team). The bulk of the meeting was dedicated to working time for the teams to build out their action plan for year 2 of the Rhode to Equity project, with a focus on the 3rd and 4th portfolios of the Pathways to Population Health framework. Portfolio 3 is community health and wellbeing while portfolio 4 is community solutions (work that addresses underlying causes of inequity). Continue reading.
Welcome to Our New CTC-RI Staff Member!
Meet Sue Dettling, BS, PCMH CCE, Program Manager and Practice Facilitator
As a program manager, Sue is involved in numerous CTC-RI projects, including the telehealth learning collaborative, specialist/PCP collaboration project, pediatric transformation work, care delivery design learning series, and workforce development initiatives. Sue also serves as a practice facilitator/quality improvement coach for practices who participate in joint CTC-RI/RIDOH and EOHHS initiatives, including the Community Care and Equity program, Community Health Team Expansion program and the Rhode to Equity. 

Sue has provided quality improvement coaching to primary care and specialty practices for the past 12 years; 9 of those years she helped manage practice transformation work at RI Quality Institute. Sue has her BS in Health Policy and Management from Providence College, and has maintained her NQCA Certified Content Expert credential (CCE) since 2014.

“I’ve worked with CTC-RI for several years as a consultant, and I couldn’t be happier to now join this wonderful team as an employee," said Sue. "CTC-RI does an amazing job of convening key stakeholders, making possible a wide variety of innovative projects that serve to promote high-quality accessible healthcare. I’m looking forward to our upcoming projects that will use the ECHO model of learning where clinicians and staff from various sites present and learn from actual cases shared. It's another example of how CTC-RI supports best practices and learning in healthcare.”

CTC-RI hosted the 3rd quarterly learning collaborative for the Pharmacy Quality Improvement Initiative in March. Each of the 7-practice teams is working to reduce preventable hospitalizations and emergency department usage through team-based care, with a focus on a specific AIM for improving care. Kelley Doherty Sanzen, PharmD, PAHM, CDOE, who is providing practices with practice facilitation assistance, guided the discussion as practices shared best practices and progress updates (PowerPoint | Recording). The final collaborative will take place on May 26 at 7:30am. This initiative is jointly funded by UnitedHealthCare and RIDOH, offered in partnership with the University of RI College of Pharmacy.

We hope that you can join us at CTC-RI's June 10 Quarterly Breakfast of Champions, 7:30-9:00am. There will be presentations that highlight some of the important work being done in Rhode Island to improve care for people with diabetes from clinical, community/clinical, and patient perspectives. CME credits will be offered (providers, nurses and pharmacists). We are excited to welcome the following presenters:
  • Diana Mercurio, BS, RPh, CDE, CDOE, CVDOE, Rhode Island Physicians Corporation Primary Care (RIPCPC)
  • Michael Poshkus, MD and Jessica Ryan, PharmD, BCACP, Thundermist Health Center 
  • Jean Taylor, RN, BSN, CDOE, CCM, Clinical Programs Population Health, Integra Community Care Network ACO

Please register via Eventbrite to receive the link to this virtual meeting and submit questions to the panelists. CME credits will be available through AAFP for physicians, PAs, RNs, and NPs.

The RI Department of Health (RIDOH), in partnership with CTC-RI/PCMH Kids, successfully applied for a 5-year HRSA “Healthy Tomorrows” grant to improve communication and care coordination between the Family Visiting (FV) Programs and Pediatric Primary Care Practices (PCMH Kids) with a specific focus on improving well-child care.

In March, we concluded a 1-year pilot learning collaborative with 2 practices (Hasbro Pediatric Primary Care and Providence Community Health Center – Central) and 2 Family Visiting Programs (Meeting Street and Blackstone Valle Community Action Program). Over the past twelve months, teams developed and tested workflows for improving communication and coordination between FV programs and pediatric practices. Family consultants were a part of the core planning team and learning collaborative and helped inform on parental concerns and suggestions. The 1st year pilot concluded in March with a report out from Cohort 1 on lessons learned. Cohort 2 practices were invited to attend and learn from Cohort 1 practices. Year 2 practices and family visiting programs are:

Five pediatric and adult dyad practice teams completed a pilot to transfer a sample of youths from Pediatric to Adult Health Care. At the final meeting in April, the practices shared their successes, challenges, and plans for sustainability. Dr. Flanagan reviewed the feedback from youth surveys and self-assessment results. Consistently, youths agreed that the process of transitioning from pediatric to adult healthcare was a positive experience. Next steps for this initiative include launching another call for applications and working with health plans and Medicaid to discuss payment for Transfer of Care related services. Special thanks are extended to RI Department of Health and Tufts Health Plan who provided funding to support this important work and to the National Alliance to Advance Adolescent Health Care for providing invaluable content expertise.

SBIRT (Screening Brief Intervention and Referral to Treatment) and Brief Negotiated Interview (BNI) training was led by content expert Jacki Hecht, RN, MSN, Managing Director of the Center for Health Equity Research at the University of Texas at Austin School of Nursing. Sponsored by the RI Maternal Psychiatry Resource (RI MomsPRN) Program, a collaborative effort of the RIDOH, CTC-RI, and the Center for Women’s Behavioral Health at Women & Infants Hospital, practices engaged in active discussion and practiced BNI conversation. This session is approved for 1.5 AAFP prescribed credits. Staff that listen to the recording and complete the evaluation form are eligible for CME/CEU credits. (Continue reading, and access the recording and presentation here).

In April, Liz Cantor, PhD and Sarah Hagin, PhD provided Behavioral Health Technical Assistance (BH TA) Learning Sessions for pediatric practices participating in the Medicaid Pediatric Healthcare Recovery Program. Participating in the program are 44 pediatric practices (representing 60 practice sites and serving over 49,000 Medicaid-insured children 3-17 years old) to ensure that all children are up-to-date with the full array of essential, preventive healthcare services, including developmental, psychosocial, and behavioral screenings, by overcoming COVID-19 related barriers to access.

The first 2 sessions, Brief Intervention Training for Pediatric Staff and Impact of COVID on children's social-emotional development, had over 77 attendees join live Zoom meetings. These sessions provided practice teams with a social-emotional development framework, information on how younger children’s achievement of developmental tasks may have been impacted by the COVID pandemic as well as tools and resources to assist families. Team member participation and engagement at these sessions have been tremendous with many practices requesting follow-up customized behavioral health technical assistance. (Continue reading, access the presentations, recordings, and evaluation forms here.)

Over the last 3 years, pediatric primary care practices have participated in a pilot program to integrate behavioral health services in primary care during which they collectively provided care for approximately 40,000 children and families (with over 50% of families insured by Medicaid). Pediatric clinical psychologist Liz Cantor, PhD worked with practices as the pediatric practice facilitator and presented information on practice screening and self-assessment results. Consistently, the practices demonstrated improvement and all implemented new screening tools and workflows, despite the impact of COVID. Practices discussed their successes, lessons learned, and plans for sustaining these efforts. Coastal Medical reported out on an upcoming Pediatric Behavioral Health Remote Patient Monitoring project that they are launching. Dr. Cantor provided highlights from the independent qualitative evaluation that the practices participated in as part of the project. This program was funded by BCBSRI through the Rhode Island Foundation Behavioral Health Fund, Tufts Health Plan and UnitedHealthcare.
Participating Practices:
  • Anchor Medical Associates - Lincoln (Pediatric)
  • Comprehensive Community Action Program
  • Coastal Medical, Inc. - Waterman Pediatrics
  • Coastal Medical, Inc. - Bald Hill Pediatrics
  • Hasbro Medicine Pediatric Primary Care Center (Pediatric)
  • Hasbro Pediatric Primary Care
  • Northern RI Pediatrics
  • Tri-County Community Action

Teams participating in the Community Health Team (CHT) Expansion Pilot came together in April to share successes and challenges so far in year 2 of their work focusing on patients with Cardiovascular Disease and Diabetes (CVD/DM). The CHT Expansion Pilot seeks to impact outcomes for participating patients by providing training in CVD/DM for Community Health Workers in CHTs in order to increase self-management education for patients. The 2 teams participating in the pilot, South County Health and East Bay Community Action Program (EBCAP), gave updates on the most recent developments in their work. EBCAP has developed a “Healthy Diet Shopping and Meal Planning Guide” and is working with Brown University students to develop a phone app where patients can access the guide. South County Health spoke about their continued work to build on their partnerships with nurse case managers who often refer participants to the program. The team is also working to enhance wellness information packets for program participants and is kicking off a collaboration with the Jonnycake Center to develop take-home meal kits. Access the presentation here.

CTC-RI is excited to announce that we are moving into an additional year of our Integrated Behavioral Health (IBH) Learning Collaborative focused on supporting practices to apply for NCQA BH Distinction. Both years of this collaborative were made possible with the generous support and funding from UnitedHealthcare. Continuing in this cohort are 5 adult PCMH practices who will be applying for NCQA BH Distinction. In addition, 6 new practices (5 pediatric and 1 adult) will be joining the learning collaborative in May, for 1 year of technical assistance and strategic guidance by CTC-RI's IBH practice facilitators. IBH Practice Facilitator Liz Cantor, PhD will work with the pediatric practices and Kristin David, PsyD will work with the adult practices. Practices will also have access to module 5 of our virtual, self-paced, practice facilitator training series focused on sustainability within integrated care, created by Nelly Burdette, PsyD, IBH Senior Director at CTC-RI. For a list of all practices in the learning collaborative, please view here. CTC-RI is working to support RI practices to achieve NCQA BH Distinction as a gold standard of IBH delivery. As outlined in the 2021 OHIC Affordability Standards, IBH practices within the State will need to achieve NCQA BH Distinction in order to continue being recognized as a Qualifying IBH Primary Care Practice.
Rhode Island COVID Updates

As of April 27, Rhode Island saw 243 new cases per 100,000 persons.

As of April 27, 1,029,763 people (97.5%) are partially vaccinated in Rhode Island, 868,511 (82.2%) have completed their primary vaccine series, and 425,957 (40.3%) have received a booster dose.
In the News
RIDOH "Public Health Out Loud" Podcast 
March 18, 2022
Podcast hosts Dr. James McDonald and Dr. Philip Chan deliver accurate, light-hearted, and informative public health updates. This episode's guest expert is Dr. Tom Bledsoe, a general internist and chair of the Rhode Island Hospital Ethics Committee. Co-hosts Dr. McDonald and Dr. Chan ask him about how medical ethical issues are handled in Rhode Island. Do physicians have a different ethical responsibility from the average person? What were some of the ethical conundrums that arose during the onset of the COVID-19 pandemic? Listen now.
Practice Resources
State Makes Significant Advances Toward Health Care Affordability and Transparency
OHIC has announced the signing of a compact to accelerate the adoption of advanced value-based payment (VBP) models in Rhode Island and made available 2020 performance data against the state’s health care cost growth target. Learn more.

Free Bradley Hospital Resource: Learning About Grief and Loss
Clinicians at Bradley Hospital continue to create resources for families as part of their COVID social-emotional health support. In latest coloring book, Torrie Turtle experiences the death of a grandmother, and learns about confusing feelings, coping strategies, and ways to keep the memories alive. Email to arrange a pick up of 25 or more free copies of this coloring book in both Spanish and English.

Enrollment Open: Brown Digital Heath Innovation Certificate
The digital health field is expected to grow to $650 billion by 2026. Enroll in Brown's inaugural Digital Health Innovation Certificate to advance in this field. In just 1 synchronous hour per week, you will: Build in-demand skills (design thinking, product evaluation, commercialization, product innovation), get direct access to world-class faculty, work on a digital health innovation project of your choosing, and Earn an internationally-recognized Brown credential. Graduate certificate holders can expect to increase their salary by 13-25%. Enroll now. 

RIGEC Dementia Care: Caring 4 Caregivers
This May 17 webinar will explore the characteristics of caregivers and who they care for, discuss caregiver stresses and challenges and provide community resources and to help mitigate caregiver burden. 

RI Council on Problem Gambling: Annual Conference
This May 24 conference will provide invaluable information and resources for all statewide community agencies, schools, parents, educators, RI courts, law enforcement, attorneys and treatment providers
Job Opportunities
Community Health Worker: OBGYN Equity Outcomes
Care New England is hiring a CHW to support high risk post-partum outreach and assessment. Learn more.
Upcoming CTC-RI Committee Meetings and Workgroups
  • May 17, 08:00-09:30AM – Care Manager/Coordinator Best Practice Sharing (please see RIGEC Dementia Care Webinar in "Practice Resources" above and register to attend)
  • May 20, 07:30-09:00AM – Clinical Strategy Committee
  • May 25, 08:00-09:30AM – Practice Reporting/Practice Transformation Committee Meeting
  • May 27, 07:30-08:45AM – Board of Directors
Upcoming Learning Collaboratives and Professional Development
  • May 04, 10:30-12:00PM – Rhode to Equity Momentum Session
  • May 12, 07:30-09:00AM – Medicaid Pediatric Healthcare Recovery Program Training: Behavior Plan Basics
  • May 19, 08:00-09:00AM – NCQA BH Distinction Readiness Learning Collaborative Kickoff for New Practices
  • May 26, 07:30-09:00AM – Pharmacy Quarterly Learning Collaborative: Reducing Preventable Hospitalizations and ED Usage