Care Transformation Collaborative of RI

News & Updates | July 2023

Rhode Island ranks 4th in nation on health system performance

Every year, the Commonwealth Fund’s Scorecard on State Health System Performance uses the most recent data to assess how well the health care system is working in every U.S. state. Rankings are based on 58 measures of health care access, quality, use of services, costs, health disparities, reproductive care and women’s health, and health outcomes.

This year, Rhode Island moved up to 4th in the nation (previously 6th), with exceptional performance in categories such as reproductive and women's health (2nd in nation), access and affordability (3rd in nation), prevention and treatment (3rd in nation), and racial and ethnic health equity (4th in nation). We're proud of the work that has helped us achieve these results, and look forward to our continued progress ahead! See Rhode Island's results here.

Registration is OPEN for our Oct. 5 Annual Conference!

Join us for this exciting event focused on transforming RI primary care and to better integrate health equity into our primary care settings. Register here and find more details here.

St. Joseph Health Center earns Distinction in Integrated Behavioral Health from national organization

On May 9, the team at St. Joseph Health Center, affiliate of CharterCARE, and Prospect Health System’s PCMH Specialist, Elizabeth Caruso, received word the Center had received Distinction in Integrated Behavioral Health from NCQA (National Committee for Quality Assurance). NCQA is a private, nonprofit organization dedicated to improving health care quality. 

This achievement was the culmination of more than a year’s worth of work by the St. Joseph Health Center team working in collaboration with CTC-RI. St. Joseph Health Center is located in Providence, on the campus of Roger Williams Medical Center. PCMH Distinction in Behavioral Health Integration helps practices provide comprehensive whole person care that acknowledges the behavioral health needs of the individual beyond the core requirements of NCQA PCMH Recognition. These practices have proven that they have the appropriate care team in place to manage the broad needs of patients with conditions related to behavioral health. 

As part of its Medicaid Accountable Entity (AE) initiative, Prospect Health Services RI (PHSRI) has contracted with CTC-RI to expand the number of primary care practices in their AE that offer Integrated Behavioral Health (IBH). The purposeful expansion of IBH is part of the focus Prospect’s independent physician association, PHSRI, puts on improving health management at the population level. Read more.

Best Practicing Sharing: Care + Community + Equity

Focused on sharing best practices, our June Care + Community + Equity meeting featured clinical teams from Thundermist Health Center, Clinica Esperanza Hope Clinic, and Tri-County Community Action Agency presenting their progress and successes in their self-monitoring blood pressure and cardiovascular disease programs. Practices that submitted data for the American Health Association Initiatives were also highlighted. Congratulations to the following practices: CCAP, Thundermist, Tri-County, WellOne, and Wood River.

Dr. Pablo Rodrigues highlighted the NuestraSalud, a Spanish-language resource for local communities on medical resources, health news, and a directory of Spanish-language providers. The Community Health Network (CHN) was also highlighted by Benvinda Santos, MPA and Danai Boone presented on the Community Health Network, specifically the diabetes prevention program (Ready for Health) and low-cost health programs available through the CHN.

View our June meeting's presentation and the video recording. The next CCE Best Practice Sharing meeting will be in September.

Applications open: Demographic Data Collection Pilot Project

CTC-RI, together with RIDOH/EOHHS and the CDC, are pleased to offer up to 15 primary care practices the opportunity to participate in a new Demographic Data Collection Pilot Project, and receive a stipend of up to $4,100 per practice site. Improving demographic data collection is a foundational activity for promoting health equity and addressing COVID-19 health disparities. The goal of this project is to increase capacity of primary care provider organizations to collect high-quality data and report it effectively, with a focus on populations experiencing a disproportionate burden of COVID-19 infection including medically underserved, BIPOC community members, and people living in rural communities, groups that are more effectively served in a language other than English, veterans, people who are unhoused or housing insecure, the LGBTG+ community and people living with disability. Applications are due by July 28. Learn more and apply.

Last call! Fall 2023 NCM/CC Standardized Core Curriculum GLearn Program

Now in its sixth year, the program was developed in partnership with Geisinger to meet the primary care community’s requests for more care management training in Rhode Island. The 12–15-week program supports Nurse Care Managers / Care Coordinators (NCM/CC) to apply key care management concepts in their RI primary care practices. The program will run from September to January 2024. Program participants will be able to earn up to 18.5 CEUs for their participation. This program is offered at no charge to RI NCM/CCs through generous support from UnitedHealthcare and RIDOH. Applications are due by July 24

CTC-RI to help lead national behavioral health integration initiative

As behavioral health integration (BHI) in primary care sweeps the nation, the Behavioral Health Integration Collaborative (a partnership between the American Medical Association and seven other leading physician organizations) is piloting a year-long enhanced technical assistance program for physician practices and systems across the country that is immersive, virtual, and packed with content experts.

Among the experts, CTC-RI's Pano Yeracaris, MD, MPH and Nelly Burdette, Psy.D will lead Module 7 - the best ways to engage and partner with patients (along with family/caregivers) in integrated care, bringing theory into the evidence-based practice by sharing how-to's such as:

  • Preparing and designing a BHI workflow
  • Identifying training opportunities for members of the primary care team
  • Trauma-informed and culturally competent care
  • Inclusivity training around LGBTQ population
  • Exploring ways to incorporate telehealth for increased access and efficiency
  • Integrating screening tools and behavioral health registry into EHRs, and more!

CTC-RI subject experts Patricia Flanagan, MD and Liz Cantor will also lead on Module 9 focused on measuring progress, focused on child/adolescent care. Stay tuned for details!

Applications open: Implementing the 4M Age-Friendly Framework for Better Care of Older Adults and People Living with Dementia

CTC-RI, in collaboration with RIDOH and UnitedHealthcare, is pleased to offer funding for up to six practices or organizations to participate in a six-month quality improvement initiative to improve care for older adults. During this initiative, participating sites will prepare to implement the 4M approach to age-friendly care and achieve Level 1 recognition through the Institute for Healthcare Improvement (IHI). Participants will also develop a process to identify caregivers of patients with dementia and provide them with education and referrals to additional support. Applications are due by August 15. Learn more and apply.

MLPB Aging and Health-Related Social Needs Learning and Action Lab Phase II Participant Recruitment

CTC-RI and MLPB invite primary care practices serving older adults to participate in a Health-Related Social Needs (HRSN) Learning-and-Action Lab series. This is a two-phased initiative designed to inform and improve clinic-based HRSN screening, referral, and problem-solving strategies impacting older adults who live in RI. Through generous funding from the Blue Cross & Blue Shield of Rhode Island, the Lab explores how the screening experience of RI-based older adults (age 55 and over) can be enhanced, and how care teams and insurers can be more responsive to patients’ goals. Phase 1 centered the perspectives of people with lived experience and non-medical professional expertise to inform Phase 2 learning, which will integrate clinical practice members with programmatic support from CTC-RI. Learn more and complete the interest form by July 21.

DULCE and ECCS Quarterly Learning Collaborative

In July, the Developmental Understanding and Legal Collaboration for Everyone (DULCE) and Early Childhood Comprehensive Systems (ECCS) learning collaborative, funded by RIDOH and UnitedHealthcare, met to deepen their understanding of the DULCE approach. The participating practices, Family Care Center and Toll Gate Pediatrics, shared progress updates on their ongoing efforts to engage families and implement the DULCE approach. Both practices have been successful in engaging 64 families thus far and established efficient workflows aimed at improving care coordination. They also continue to maintain a regular schedule of interdisciplinary team meetings to enhance communication and collaboration among staff. The family specialists at each practice continue to actively participate in well-child visits, ensuring comprehensive care for the families involved and coordination with the care team.

Additionally, two guest DULCE network medical providers joined the meeting to provide insights into DULCE implementation at their respective practices. Read more.

Recap: Improving Child Health in RI meeting

CTC-RI and PCMH Kids welcomed pediatric practices and stakeholders to the quarterly "Improving Child Health in RI" meeting this month with the purpose of providing updates on the Medicaid Pediatric Healthcare Recovery Program. Of note, 100% of the practices participating in this program are eligible to receive incentive payments based on meeting the behavioral health ECHO requirements. As of June 15, 70% of practices are meeting the July immunization / lead screening performance targets.  

In response to practices requesting more information on anxiety and young children, speakers Liz Cantor, PhD, and Sarah Hagin, PhD, delivered an overview on various aspects of anxiety in young children, including prevention, screening, assessment, and interventions. Additionally, they shared valuable resources specifically for providers and practices. (Meeting recording here and PPT here).

Register Today! Team-Based Care Meeting on sexually transmitted infection screening and best practices

CTC-RI is excited to host the STD/HIV Prevention Training Center of New England for a presentation discussing STI screening, including best practices and updated screening guidelines for common STIs, RI data on STI screening and prevalence, and discussion of how STI screening is tailored to specific populations at Women and Infants Hospital and Open Door Health. Presenters will be Philip A. Chan, M.D., M.S. and Erica Hardy, MD, MMSc. CEU credits will be available for this training. The meeting will be held on August 15 at 8am. Details and registration here.

Launching soon: Initiative to increasing access to care for children with restrictive eating disorders

With funding provided by UnitedHealthcare, CTC-RI is excited to announce a funding and training opportunity to increase pediatric integrated behavioral health (IBH) capacity in up to five RI-based practices. This project aims to increase the capacity of pediatric IBH Care Teams to support children with restrictive eating disorders by training in the gold standard for treatment – Family Based Treatment (FBT). Selected practices will participate in a 12-month ECHO® program that will include didactic training and case-based learning. This project is geared for practices with an established IBH program and IBH clinician on staff. The ECHO® program will begin in September and run through August 2024. A call for applications will be launched on July 25 and will be due on August 21.

Team-Based Care meeting addresses equitable access to contraceptive care

Thank you to Upstream USA, Wood River Health, and Providence Community Health Center for an informative June Team-Based Care meeting addressing equitable access to contraceptive care. According to Upstream, approximately 40% of pregnancies in RI are unplanned. Upstream works with primary care practices to increase access to contraception by providing technical assistance in the form of provider and staff training, patient-centered educational materials, and improvements to coding and billing and EHR systems. Presenters from Upstream outlined their innovative program and early work with RI primary care practices. Representatives from two practices currently partnering with Upstream, Wood River Health and Providence Community Health Center, spoke to their staff training and EHR updates, including pregnancy intent screening questions, and improved clinical workflows. Link to PPT here and recording here.

Clinical Strategy meeting on MassHealth Primary Care Health Reform and Social Risk Adjustment  

In June, CTC-RI’s Clinical Strategy Committee (CSC) hosted a session, MassHealth Primary Care Health Reform & Social Risk Adjustment, a collaborative effort featuring experts who shared their invaluable insights on transforming primary care and addressing social risk adjustment in the healthcare landscape.

The presentations addressed critical topics in healthcare reform, focusing on enhancing primary care services and developing strategies to mitigate social risk factors. Read more details here on the lively session, and access the recording and claim CME credits here.

Join us via Zoom on July 21 at 7:30am for our next CSC meeting focused on the primary care workforce. More details.

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.

  • Medicaid Pediatric Healthcare Recovery Program Behavioral Health ECHO® Learning Series | Suicide Risks, Prevention, and Tools | June 2023 (presentation and recording)

Practice Resources, News, and Information

Deadline TODAY: Pediatric Specialty Loan Repayment Program

Clinicians providing pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care including substance use disorder (SUD) prevention and treatment services may apply to the Pediatric Specialty Loan Repayment Program. In exchange for a three-year service requirement, eligible applicants can receive up to $100,000 in repayment for eligible educational loans. Deadline to apply is July 20 at 7:30pm.

MLPB June Update: Spotlight on Rhode Island!

This month's MLPB newsletter features Rhode Island and the recently released Rhode Island Aging and Health Related Social Needs Learning and Action Lab. This report highlights Phase 1 of a project MLPB has undertaken to improve screening, referral, and problem-solving strategies around the health-related social needs of older adults. Phase 2 learning will continue through early 2024 and will integrate Phase 1 learnings with clinical practice members from CTC-RI. Read more.

ConvergenceRI: When a strategy of convergence works

Read the recent ConvergenceRI article highlighting how our new task force on primary care delivery in RI brings together key players in a collaborative approach, offering up a patient-centered vision of care.

Free Conference: Expanding Culturally Responsive Mental Health Care: Diversity Among Hispanic/Latinx Youth and Families

Hosted in Providence August 26-27, this conference will focus on helping mental health professionals integrate culturally responsive strategies into their mental health services practices, apply an intersectional perspective of care with Latinx families in which cultural, ethnic, gender, and sexual identities are considered, and reflect on how social determinants of health may affect patients and assess individual and systemic possible solutions. Register.

CareBreaks program helps unpaid caregivers

CareBreaks is a service for Rhode Islanders that provides unpaid caregivers a short-term break from the daily responsibility of caregiving. Learn more here and access FAQs here.

Upcoming CTC-RI Committee Meetings and Workgroups

  • July 21, 07:30-09:00AM – Clinical Strategy Committee
  • July 28, 07:30-08:45AM – Board of Directors
  • August 09, 08:00-09:00AM – Taskforce of Primary Care Provider Workforce
  • August 10, 07:30-09:00AM – Prior Authorization Meeting
  • August 18, 07:30-09:00AM – Clinical Strategy Committee
  • August 25, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • July 21, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • July 26, 07:30-08:30AM – Care Coordination ECHO Series
  • August 03, 07:30-08:30AM – Virtual Coffee Break with Dr. Pat Flanagan & Dr. Beth Lange
  • August 17, 07:30-08:30AM – Pediatric Weight Management ECHO® Session
  • August 22, 07:30-09:00AM – Pharmacy QI Learning Collaborative: CGM & ABPM
  • August 23, 07:30-09:00AM – RI MomsPRN Final Learning Collaborative
  • August 15, 08:00-09:00AM – Best Practices in Team-Based Care
  • August 18, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • August 28, 12:00-01:00PM – Healthy Tomorrows Quarterly Learning Collaborative Meeting - Cohort 3
  • August 30, 07:30-09:00AM – Care Coordination ECHO®
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