Care Transformation Collaborative of RI

News & Updates | November 2023

Medicaid Pediatric Healthcare Recovery Program results

Beginning in October 2022, Medicaid, in partnership with CTC-RI, offered an extended 12-month incentive program to improve Immunization and Lead Screening Results. Payments were contingent on practices meeting Immunization and Lead Screening targets or demonstrating prescribed improvement. Here are how the practices performed over the 12-month program:

Practices received practice facilitation support, which consisted of focused practice-specific discussions on Immunization and Lead Screening performance results, as well as practices’ needs around responding to behavioral health concerns. As a group, childhood immunizations (including lead screenings) improved across all categories.  

In addition, practices were paid to participate in a six-month ECHO Behavioral Health (BH) Learning Initiative. Recordings and presentations can be found here (under the Medicaid Pediatric Healthcare Recovery Program banner). 100% of the practices met the payment requirements for BH ECHO participation. This project resulted in $7.3 million funded through the American Rescue Act, paid to pediatric and family medicine practices.

Sincere thanks to Amy Katzen from EOHHS, our practice facilitators: Sue Dettling, Suzanne Herzberg, and Kim Nguyen-Leite, our CTC-RI Data Analyst Carolyn Karner, the Lead Program, and the KIDSNET Team! Thank you to the practices that participated in this program for keeping Rhode Island children healthy.

Pediatrician and PCMH Kids co-founder Dr. Elizabeth Lange weighs in on Medicaid Pediatric Healthcare Recovery Program impact

We connected with Dr. Elizabeth Lange, a pediatrician at Coastal Medical - Waterman Pediatrics and PCMH Kids co-founder on the impact of the Medicaid Pediatric Healthcare Recovery Program on the primary care industry.

How have the Pediatric Relief dollars helped support the work and impact of your practice?

Thanks to the Pediatric Relief dollars, pediatric offices had the funds to afford staff time to review the practice’s vaccine data, to contact patients with vaccines due and to protect time in the office schedule to accommodate the office visits necessary to administer these vaccines. In this program, each medical office also had a practice facilitator who helped each office access and use the vaccine data to improve their pediatric patient vaccination rates.

What unique hurdles have you experienced and worked to address through this program?

In a busy pediatric practice, especially with catch-up inherent with deferred care during the pandemic, time and staffing are a premium. The practice facilitators played a key role helping practices to access their vaccine data, to help build workflows for contacting patients and to make appointments for well child and vaccine visits. This program also highlighted the importance of accurate data. The KIDSNET database and the RIDOH staff were invaluable partners in this work. But it quickly became clear that having each patient linked in KIDSNET to the proper pediatric medical home was the key foundation to improving vaccination rates. Read more.

EOHHS' Amy Katzen weighs-in on wrap of Medicaid Pediatric Healthcare Recovery Program

As the state's Medicaid Pediatric Healthcare Recovery Program comes to a close, we asked Amy Katzen, Director of Policy and Strategy at the Executive Office of Health and Human Services (EOHHS) for insight and impact on the program.

1. What challenges did this program aim to address?

The Pediatric Healthcare Recovery Program aimed to address two major challenges: First, the impact of the pandemic on the financial stability of pediatric practices in Rhode Island. Second, the impact of the pandemic on delivery of essential preventive healthcare for children, particularly well-child visits, immunizations, and lead screenings. When families stopped scheduling most in-person visits in March 2020, this disrupted care in the immediate term and led to breaks in engagement in care – for example, people who would normally schedule subsequent visits at the conclusion of their in-person visits missed out on the opportunity to do that.

2. How has this program been successful -- for the state, practices, and families?

The program has contributed to financial stability for practices by awarding approximately $14.4 million in American Rescue Plan Act funds to participating practices across the two phases of the program, from March 2022 through October 2023. Practices also participated in technical assistance sessions to support their behavioral health work and received practice facilitation to support their efforts to increase attendance at well-child visits and performance on immunization and lead screening measures. EOHHS believes that the ongoing stability of these practices and their increased capacity to deliver these services is a major benefit to the state and to children and their families. While the federal funding that made this possible was inherently temporary, the lessons learned and enhancements to practice operations will continue to benefit the state and Rhode Island children for years to come.

3. What emerging themes, topics or lessons learned did this program spotlight that can help guide future primary care efforts?

First, primary care practices demonstrated a strong commitment to and enthusiasm for learning about care delivery strategies that would let them improve patient outcomes, both for the preventive care measures targeted in the program and for a broad array of behavioral health and general welfare issues that affect their patients. That is: there is a real appetite for resources to improve outcomes and a frankly impressive willingness to do the work, given the magnitude of practices’ pre-existing responsibilities. Second, data makes a difference: EOHHS was grateful for the steadfast support, effort, and thoughtfulness of RIDOH’s KIDSNET team, who worked closely with CTC-RI and practices to ensure data quality and make new reports that practices can use to target their outreach effectively. This is another resource that will persist into the future, beyond the life of this specific program. Finally, resources – in this case, both practice facilitation and financial support – meaningfully impact outcomes for target measures.

Thank you to our Board of Directors!

The October CTC-RI Board of Directors annual meeting was significant in that not only was it our first hybrid meeting post-Covid, but we continue to maintain the legacy of our outstanding Board. Join us in acknowledging our 2023-24 slate of Directors and recognizing the important work and impact made by departing Board member, Beata Nelken, MD. We are so fortunate to have such talented leadership in RI.

CTC-RI Board Members during October 2023 annual meeting

CTC-RI presents at the 2023 Camden Coalition annual conference

The Camden Coalition annual conference was held in Boston on November 1-3 with a focus on “Putting Care at the Center," to bring awareness to those with complex health and social needs. The event brought together organizations and systems working to further complex care services, and highlighted voices from those with lived experience. Several CTC-RI staff and members of the leadership team attended and presented a workshop, “Promoting Integrated Behavioral Health in Pediatrics: Rhode Island Efforts.” 

The session panelists included Debra Hurwitz, Executive Director; Linda Cabral, Senior Program Manager; Elizabeth Lange, MD, Waterman Pediatrics; and Swanette Salazar, CHW. The panel was moderated by Nelly Burdette, CTC-RI Senior Integrated Behavioral Health Program Leader and Director of Population Behavioral Health at Boston Medical Center. This workshop highlighted the RI policy background of pediatric behavioral health care, as well as CTC-RI’s role in building infrastructure, implementing programs, and tracking outcomes of pediatric integrated behavioral care. Highlighted projects included the Developmental Understanding and Legal Collaboration for Everyone (DULCE) project, and the Pediatric Weight Management ECHO Series. This was a great opportunity for CTC-RI to connect with other organizations across the country who are interested in implementing similar programs. View our presentation materials here.

Monthly CBO Spotlight: Amos House

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 Amos House. Since 1976, Amos House has been a staple of the Rhode Island nonprofit community, serving the homeless, unemployed, and those who are living in poverty.

What ways does your organization uniquely support Rhode Islanders?

We provide a range of social and clinical services to Rhode Islanders. We currently operate 18 programs, including the financial opportunities center, soup kitchen, residential treatment, permanent supportive housing, family shelter, vocational training programs, computer literacy, benefits enrollment, rental assistance, behavioral health services, and more. 


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

Closer collaboration with primary care providers will help to improve coordination of care for our mutual guests/patients and improve the quality of wraparound services that we're able to provide.


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

We employ a strengths-based model in caring for our guests. 

Want to get in touch?

Contact Rahul Vanjani, Medical Director at [email protected].

RI pharmacists receive 2023 Grace Diaz Blue Light Award

This month at the RI World Diabetes Day conference, seven pharmacists received the Grace Diaz Blue Light award. Their remarkable leadership has spearheaded the expansion of diabetes care within their respective teams, ultimately benefitting their patients. Initiated through CTC-RI and supported by UnitedHealthcare and the RI Department of Health, these pharmacists led their teams in a transformative project implementing professional continuous glucose

monitoring in their primary care practices. After 1 year, A1C level improvements marked a reduction from an average of 9.1% to an average of 8.0%. Their leadership extends beyond as they aim to spread these benefits to more patients and practices.

Congratulations to the honored pharmacists:


  • Bradford Pease, PharmD CDOE CVDOE at Medical Associates of RI. 
  • Kenny Correia, PharmD, BCACP CDOE, CVDOE at Anchor Medical 
  • Krystal Bevilacqua, PharmD, CDCES, CDOE, CVDOE at Coastal Medical
  • Patricia “Kish” Hoffman, PharmD, BCPS, CDOE, CVDOE at Miriam Hospital Suite C Ambulatory Clinic
  • Alex Gianfrancesco, PharmD, CDOE, CVDOE at RI Primary Care Physicians Corporation/Integra 
  • Lillian Nieves, PharmD at Providence Community Health Center

Rhode Island health centers recognized for clinical quality excellence

On November 7, the U.S. Department of Health and Human Services, through the Health Resources and Services Administration, honored community health centers that have attained excellence in overall clinical quality performance. All of Rhode Island’s health centers, who provide care to over 200,000 patients, received a Community Health Quality Recognition badge.

“Rhode Islanders should be proud of the very high quality of care that community health centers provide to anyone, regardless of a person’s insurance status or their ability to pay,” said Elena Nicolella, President and CEO of the Rhode Island Health Center Association. “These awards recognize the health centers’ hard work and achievements in improving health outcomes and reducing health disparities across our state.” Read more.

Clinical Strategy Committee: Lessons from Rhode to Equity and CHW billing

Our Clinical Strategy Committee meeting on November 17 focused on lessons from Rhode to Equity and CHW billing. We heard from RIDOH and EOHHS on the Rhode to Equity initiative, focusing on the project framework and how teams worked together to bridge clinical and community gaps. This was followed by a presentation from Roberta Goldman, PhD on the findings of a qualitative evaluation focused on the CHW Medicaid billing rollout and implementation. Speakers included:

  • Allegra Scharff, MPH, Chief of Healthcare Equity and Olmstead Coordinator, RIDOH
  • Breanna Lemieux, Accountable Entity Program Lead, EOHHS
  • Robyn Hall, Assistant Program Officer, Local Initiatives Support Corporation
  • Kinzel Thomas, MSW, LCSW, LCDP, CCHW, Vice President of Equity & Community Development, Family Service of Rhode Island
  • Lynne Driscoll, RN, BSN, CCM, Assistant VP Community Health, South County Health
  • Roberta Goldman, PhD, Brown University

December’s Clinical Strategy Committee meeting will focus on a review of the work conducted throughout the year and a discussion of the strategic plan.

Breakfast of Champions: Gender-Affirming Care

Please register for our upcoming Breakfast of Champions event on December 8 which will delve into the crucial topic of gender-affirming care with distinguished speakers: 

  • Dr. Jason Rafferty, MD, MPH, EdM is a renowned pediatrician and child psychiatrist practicing at the Gender and Sexuality Clinic and the Adolescent Healthcare Center at Hasbro Children's Hospital. With an impressive background and extensive experience, Dr. Rafferty will share insights into the importance of gender-affirming care, and the landscape of healthcare for transgender and gender-diverse individuals.

  • Dr. Amy Nunn, ScD, MS is a professor of behavioral and social sciences at the Brown University School of Public Health and executive director at Open Door Health. Dr. Nunn will explore how discrimination can act as a barrier, preventing people from accessing the healthcare they need and deserve.

CTC-RI provides recommendations to OHIC for improving prior authorization process

The CTC-RI Prior Authorization Committee submitted its final recommendations report to OHIC for consideration as it reconvenes its Administrative Simplification Committee. The report is a culmination of months of work by committee members who represent health insurance companies, pharmacists, and health care organizations from across Rhode Island. Recommendations include:

  • Reduce the prior authorization volume.
  • Improve the data collection on prior authorization.
  • Create ongoing statewide advisory committees.
  • Evaluate therapeutic substitution at the pharmacy.
  • Implement technologies that improve the process.
  • Identify and reduce processes that are “PA-like.”

The Prior Authorization Committee was convened in April 2023 at the request of OHIC to develop concrete consensus recommendations that take into account health plans/payers, providers and patients’ needs for a more effective, less burdensome and resource-intensive prior approval process, ultimately supporting evidence-based, affordable, high-quality care and reducing unnecessary/unsafe service and medication utilization.

Demographic Data Collection pilot kicks off train-the-trainer series

The first of six train-the-trainer educational webinars on demographic data collection was held in October. Christin Zollicoffer, Vice President, Chief Belonging & Equity Officer at Lifespan educated the trainers from the 15 participating practices on systemic racism, racism in medicine and threat response. The presentation provided participants with detailed historical timelines of racism in America and Rhode Island and illustrated why collecting demographic information from patients is so important to addressing health disparities. The goal of the Demographic Data Collection Pilot is to improve the accuracy and completeness of race, ethnicity, language, and other patient demographic information in primary care practices. Fifteen adult and pediatric practices from across RI were selected to participate in the project. The most recent webinar on November 12 was presented by Jen Etue and Natasha Viveiros from Providence Community Health Centers on demographic data standards. 

MLPB Phase II Action Lab: Best practices for strength-based screening, triage and response

MLPB hosted the third of its Phase II Health-Related Social Needs Learning and Action Lab series on November 9. Ariel Singer, MPH, a healthcare consultant based in Portland, Oregon presented elements of person-centered communication that can be used by individuals and organizations to create a safe and trusting environment when screening for health-related social needs. Participants broke into groups to discuss their experiences and share how they have used strengths-based, person-centered communication. 

On December 7, the group will hear from guest facilitator Maureen Maigret, RN, BS, MPA who will engage the group in a discussion of "Health-Related Social Needs Priority Setting: Key Elements for Person-Center Triage and Partnership."

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, News, and Information

CMS: Request for Applications for the Guiding an Improved Dementia Experience Model now available

CMS is now accepting applications for the Guiding an Improved Dementia Experience (GUIDE) Model, which aims to support people living with dementia and their caregivers. The Request for Applications is now open. The application deadline is January 30, 2024. The model will launch on July 1, 2024, and run for eight years. The GUIDE Model will test whether providing an alternative payment methodology for participating dementia care programs to deliver a package of care management and coordination, caregiver education and support, and GUIDE Respite Services to Medicare beneficiaries with dementia and their caregivers reduces expenditures while preserving or enhancing quality of care.

RIGEC Webinar: Grief and Loss

Join CTC-RI for this month's Best Practices in Team-Based Care webinar on November 21 (8-9am) with the RI Geriatric Education Center featuring Mari Dias, Ed. D, on supporting older adults through grief and loss:

CMS GUIDE Model: Choices for Implementing Evidence-Based Dementia Care Webinar

On November 28 (1-4pm), Education Development Center will host the National Dementia Care Collaborative (NDCC) Autumn Summit, The CMS GUIDE Model: Choices for Implementing Evidence-Based Dementia Care. The NDCC Autumn Summit is a virtual event, free and open to all who are interested in attending. Advance registration is required.

December 19 Team-Based Care Meeting: Safe Sleep

Please join us for our December 19 Team-Based Care Meeting, focusing on Safe Sleep. Margo Katz, MA, Program Manager for Safe Sleep and Substance Exposed Newborns at the Rhode Island Department of Health. The presentation will provide an overview of Sudden Unexpected Infant Death (SUID), common causes and state data, and evidence-based recommendations around and how to have shared decision making conversation. Register here.

RIGEC feedback needed on interest in geriatric care topics

The Rhode Island Geriatric Education Center (RIGEC) is conducting an educational needs assessment survey and needs your input! The survey is completely anonymous and should take less than 15 minutes to complete.  Four individuals will be randomly selected to win a $75 gift card! The purpose of the survey is to determine which topics related to geriatric care are of interest to health professionals and to better understand preferred instructional formats.

Medicaid Renewals for households with kids begin in December

Due to federal mandate, Rhode Island resumed Medicaid renewals in April 2023 for the first time since before the pandemic. This means that the State has to review eligibility for everyone enrolled in Rhode Island’s Medicaid Program. Like some other states, Rhode Island chose to delay renewals for households with kids to allow more time for thoughtful outreach, engagement, and preparation. Households with kids, which includes anyone younger than 19, enrolled in Medicaid will get their renewal notice between December 2023 and April 2024, and to ask for your assistance amplifying this message to the Rhode Islanders you serve through your agency’s various programs. Learn more at

Flyer resource: What vaccines do people with diabetes need?

Access the CDC flyer resource here.

Flyer resource: Vaccines for adults and children with asthma

Access the RIDOH flyer resource here.

Flyer resource: What you need to know about fall vaccines

Access the RIDOH flyer resource here.

Upcoming CTC-RI Committee Meetings and Workgroups

  • November 21, 08:00-09:00AM – Best Practices in Team-Based Care
  • December 01, 07:30-08:45AM – Board of Directors – Combined November & December
  • December 06, 07:30-08:30AM – PCP/Specialist Monthly Oversight Meeting
  • December 06, 02:30-03:30PM – Demographic Data Monthly Committee Meeting
  • December 13, 08:00-09:00AM – Task Force for Primary Care Provider Workforce Development
  • December 14, 07:30-09:00AM – Prior Authorization Meeting
  • December 15, 07:30-09:00AM – CTC-RI Clinical Strategy Committee

Upcoming Learning Collaboratives and Professional Development

  • November 27, 12:00-01:00PM – Healthy Tomorrows Quarterly Learning Collaborative Meeting - Cohort 3
  • November 28, 07:30-09:00AM – Pharmacy QI Learning Collaborative: CGM & ABPM
  • November 29, 07:30-08:30AM – Care Coordination ECHO Series
  • December 07, 07:30-08:00AM – Virtual Coffee Breaks with Dr Pat Flanagan & Dr Beth Lange
  • December 08, 07:30-09:00AM – Breakfast of Champions
  • December 12, 09:00-10:00AM – Demographic Data Collection Pilot Train-the-Trainer Webinar
  • December 14, 07:30-09:00AM – DULCE Learning Collaborative Meeting
  • December 15, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat

Care Transformation Collaborative of RI | [email protected] |