Care Transformation Collaborative of RI

News & Updates | November 2022

Thank You to Our Board of Directors and Welcome New Board Members

The October CTC-RI Board of Directors annual meeting marked a change in officers and the appointment of new members who will continue the legacy of our stellar Board. CTC-RI recognizes the important work and impact made by departing Board members: G. Alan Kurose, MD, Coastal Medical; Louis Giancola, retired healthcare administrator; Claire Levesque, MD, Tufts Health Plan; Rebecca Plonsky, LICSW, Integrated Healthcare Partners; Sarah Fessler, MD, East Bay Community Action Program; and Patricia Flanagan, MD, FAAP, Hasbro Children’s Hospital, who now serves in clinical leadership at CTC-RI. Their expert direction and leadership over the past years have been invaluable.

Join us in welcoming our 2022-23 slate of Directors and our 2023 Board Officers. CTC-RI is fortunate to have such talented leadership in RI.

From left: Peter Hollmann, MD, CTC-RI President, Brown Medicine; Elizabeth Lange, MD, FAAP, CTC-RI Vice President/President Elect, Coastal Medical/Waterman Pediatrics; Noah Benedict, MHL, CTC-RI Treasurer, Primary Care Physician Corp.; John Minichiello, MBA, CTC-RI Vice Treasurer Elect, Integra Community Care Network; and Larry Warner, DrPH, CTC-RI Secretary Elect, United Way of Rhode Island.

Outgoing Board Members Reflect on Their CTC-RI Work and Share Hopes for RI Healthcare

"I hope behavioral health becomes a higher priority. Too many Rhode Islanders suffer in silence or denial, or access mental health or substance use care in emergency rooms rather than in primary care and community mental health settings. With significant marked increases in alcohol use and depressive disorders during the pandemic, we are further constrained by critical workforce shortages. My hope is that our state quickly allocates additional funding and resources so we can help those in need."

-- Rebecca Plonsky, LICSW, Integrated Healthcare Partners

“My hopes for Rhode Island’s healthcare priorities are for continued development of comprehensive patient-centered care, regardless of insurance status, for all Rhode Islanders. 

I also hope that Rhode Island can remain a leader in innovation around a healthcare system that reflects both patients’ needs and providers’ wellbeing."

-- Sarah Fessler, MD, East Bay Community Action Program

CTC-RI Clinical Director Patricia Flanagan, MD Elected to American Academy of Pediatrics Board

Patricia Flanagan MD FAAP, new Clinical Director for CTC-RI, was recently elected to the board of the American Academy of Pediatrics, representing chapters in New England, Canada, and Uniformed Services. She will serve a 4-year term beginning January 2023.

Spotlight: Gregory Steinmetz, MD, Associates in Primary Care Medicine

CTC-RI recently held a Year 2 midpoint meeting for practices participating in the NCQA Behavioral Health (BH) Distinction Readiness Collaborative. We asked Gregory Steinmetz, MD of Associates in Primary Care Medicine, to reflect on how receiving the Distinction has benefited his practice and his patients.

How has receiving the NCQA behavioral health distinction helped improve patient care?

NCQA IBH distinction has helped improve patient care at my office specifically by expanding our screenings for addiction and suicidal behavior. We now have processes in place to help the clinician make a more thorough and efficient evaluation of these conditions, and our IBH clinician helps us to access the right level of treatment. Our behavioral health treatment is more comprehensive and the processes enable us to make this care consistent among our providers.

How has receiving this distinction helped improve practice processes, such as onboarding new providers?

New providers benefit from the IBH processes because, when you have a surrounding team of MAs, providers, and IBH clinicians already following the new procedures, a new provider can easily step in and benefit from the completed screens and quickly figure out how to get help when issues are identified. 

What would you say to other practices who are considering applying for the NCQA behavioral health distinction? 

Applying for the distinction is well worth the effort! It is important to have an IBH clinician and other providers who are supportive of practice transformation. The effort is worth it in terms of better patient care, but for this to be a success, it has to be a team effort. CTC-RI clinicians are very experienced and excellent in walking a practice through the process, which is crucial to the project's success.

NCQA BH Distinction Readiness Collaborative Holds Year 2 Midpoint Meeting

CTC-RI’s NCQA Behavioral Health Distinction (BH) Readiness Collaborative held its Year 2 midpoint meeting in October, giving practices the opportunity to collaborate on NCQA requirements, challenges and successes in working toward BH distinction. Bill Webb and Dr. Gregory Steinmetz of Associates in Primary Care Medicine, which achieved the NCQA BH Distinction in 2021, presented insights and tips for current participating providers. Read more.

Update: Medicaid Pediatric Healthcare Recovery Program — Year 2

Practices participating in this year’s program should have received their first payment for participation. The second payment is scheduled for early February and is contingent on meeting 3 out of 4 Immunization & Lead Screening targets or improvement targets based on January 15 KIDSNET data.

Practices can expect to receive monthly KIDSNET reports mid-month with a status of the practice’s eligibility for payment based on achievement of targets or improvement targets. Practice Facilitators are armed with resources and best practice strategies to help practices achieve their goals, so please take advantage of this support offered to you. Read more. 

CTC-RI releases 2021 Annual Report

The Care Transformation Collaborative of RI (CTC-RI) has released our 2021 Annual Report, which offers a look at how CTC-RI and PCMH Kids (a division of CTC-RI) stepped up to support primary care practices as they adjusted to caring for patients and families amid the continuing COVID-19 pandemic. 

Now that we’re all learning to live with COVID-19, CTC-RI and PCMH Kids have shifted our focus to activities that can help practices weather storms more effectively. We thank our dedicated healthcare professionals for their tireless and steadfast work, which has made a real difference in the lives of Rhode Islanders. Read our 2021 Annual Report.

CHT Expansion Program Shares Best Practices on Secondary Trauma and Burnout

The Community Health Team (CHT) Expansion project brought together South County Health and East Bay Community Action Program practice teams for a November Best Practice Sharing Meeting. The CHT Expansion program is in its third year, and the aim is to improve clinical outcomes for patients with hypertension, prediabetes or diabetes, and cardiovascular disease. This meeting was an opportunity to hear updates from the practices and to participate in a training session on Secondary Trauma and Burnout presented by Tonya Glantz from Rhode Island College’s Institute for Education in Healthcare. Read more.

October Meeting of CTC-RI Clinical Strategy Committee Meeting Focuses on Primary Care/Specialist Collaboration

CTC-RI’s Clinical Strategy Committee met in October for an engaging discussion around Primary Care/Specialist Collaboration. The meeting highlighted the ongoing work of Lifespan and Integra/Care New England to improve coordination between primary care and specialist through use of eConsults and enhanced referrals to improve access and reduce low-value referrals. Pano Yeracaris, MD, MPH presented a program overview. Speakers included:

  • Paul Larson, MD, MBA, Chief of Primary Care, Lifespan Physician Group
  • Brian Kwetkowski, DO, Integra
  • Jennifer Jarbeau, MD, Cardiology, Brigham & Women's Center
  • Alicia Berkemeyer, Executive Vice President, Chief Health Management Officer at Arkansas BCBS
  • Al Charbonneau, Executive Director, Rhode Island Business Group on Health 

Read more.

Save the Date: CTC-RI Annual Conference to Be Held October 5, 2023

CTC-RI will hold our next Annual Conference on October 5, 2023 in Warwick. The Conference will focus on identifying, developing, and using strategies to advance integrated primary care and improve patient and family outcomes. Read more

New Zoom Link for Monthly Lunchtime 'Meet and Eat' With IBH Practice Facilitators

There's a new Zoom link for CTC-RI's monthly opportunity for casual virtual conversation with our Integrated Behavioral Health (IBH) practice facilitators, Dr. Liz Cantor and Dr. Kristin David. Don't miss this chance for IBH clinicians (psychologists, therapists, social workers, and nurses) to connect with other IBH professionals to discuss best practices, challenges, successes, and more!

The Zoom event occurs every 3rd Friday of the month at noon. The next discussion is tomorrow, November 18. Register here.

CTC-RI December 9 Breakfast of Champions to Focus on Unconscious Bias in Healthcare

CTC-RI’s December 9 Breakfast of Champions will continue the conversation on unconscious bias in healthcare. Robert T. Jones, Chief Empowerment Officer of T. Lee Associates, an international education consulting company, will lead the conversation. Additional speakers will include:

  • Crystal Fairchild, MS Chief Diversity, Equity, Inclusion, and Human Resources Officer, Thundermist Health Center
  • Nelly Burdette, PsyD, CTC-RI Sr. Integrated Behavioral Health Program Leader and Providence Community Health Centers Associate VP

The event will focus on the importance of reducing disparities, improving equity, and making space for diversity on teams. Read more and register to attend

Second Asthma Essentials ECHO® Spotlights Asthma Medications

and Action Plans

CTC-RI hosted its second Asthma Essentials ECHO® in November, bringing together 51 participants to engage in the “all teach, all learn” model. The event, facilitated by Pat Flanagan, MD, included a didactic session on the updated use of asthma medications and action plans presented by Lilllian Nieves, PharmD at Providence Community Health Centers. Sarah Fessler, MD of East Bay Community Action Program, presented a case. Read more.

Best Practices in Team-Based Care Session Focuses on Improving Hypertension Patient Care

The October Best Practices in Team-Based Care meeting included a presentation by the Women’s Medicine Collaborative on improving care for people with hypertension. The presentation included:

  • Evidence-based hypertension guideline recommendations to determine appropriate blood pressure goals based on patient-specific factors
  • An overview of a quality improvement project to reduce hypertension-related ED visits and hospitalizations by optimizing blood pressure control and instituting a self-management blood pressure program

The next Best Practices in Team-based Care will be held December 20 and will focus on Incontinence in Older Adults. Read more

Rhode Island COVID-19 Updates

Rhode Island is now reporting new COVID-19 data every Thursday. As of November 10, 2022:

  • Cases per 100,000 previous week: 114.2
  • Hospitalized previous week: 99
  • Deaths previous week: 20
  • Total deaths to date: 3,725
  • Vaccinated with two shots: 86.7%
  • Vaccinated with bivalent booster: 16.6%
Practice Resources

FRIENDS WAY to Hold Nov. 18 Conference on Diversity, Equity and Inclusive Practices in Bereavement Support

FRIENDS WAY will hold its annual professional development conference on Friday, Nov. 18, from 12:30 to 4 p.m. The virtual event, which takes place on Zoom, focuses on Diversity, Equity, and Inclusive Practices in Bereavement Support. The presenter is Dr. Tashel Bordere, Assistant Professor of Human Development and Family Science and State Extension Specialist in Youth Development at the University of Missouri-Columbia. Register here

RIDOH Office of Special Needs Invites New Members to Youth Advisory Council

The RI Dept. of Health (RIDOH) invites young people of all abilities to join its Youth Advisory Council. This diverse group offers opportunities to gain leadership skills, make new friends, and have a say in public health projects for young people in RI. The group meets virtually each month. Read more

ECHO® Series to Highlight Issues Impacting Quality of Life for Older Adults

A new ECHO® series on Issues Impacting the Quality of Life for Older Adults has launched. The next session will focus on vision concerns among older adults

Sessions are held via Zoom. These learning sessions amplify the capacity of providers to deliver best practice care to their patients. Read more

Upcoming CTC-RI Committee Meetings and Workgroups

  • November 18, 07:30-09:00AM – Clinical Strategy Committee
  • December 02, 07:30-08:45AM – Board of Directors – Combined November and December
  • December 16, 07:30-09:00AM – Clinical Strategy Committee
  • December 20, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)

Upcoming Learning Collaboratives and Professional Development

  • November 18, 12:00-01:00PM – Integrated Behavioral Health Practice Facilitator Meet & Eat
  • November 28, 12:00-01:00PM – Quarterly Healthy Tomorrows – Cohort 1 and 2
  • December 01, 07:30-08:00AM – Virtual Coffee Breaks with Drs. Flanagan & Lange
  • December 07, 07:30-09:00AM – Quarterly DULCE 
  • December 07, 08:00-09:30AM – CCE Best Practice Sharing
  • December 09, 07:30-09:00AM – Quarterly CTC-RI Breakfast of Champions
  • December 13, 07:30-09:00AM – Pharmacy QI Learning Collaborative: CGM & ABPM
  • December 14, 07:30-08:30AM – Asthma ECHO
  • December 16, 12:00-01:00PM – Integrated Behavioral Health Practice Facilitator Meet & Eat

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