Care Transformation Collaborative of RI

News & Updates | August 2023

Annual Conference: 5 new spots for NCQA Health Equity Training!

The clock is ticking, and the excitement is building as we approach our highly anticipated Annual Conference, "Investing in Primary Care and Health Equity." With just a few weeks left, this is your exclusive opportunity to secure your spot! Don't miss the lineup of exciting presentations and best practice sharing, and your chance to engage with leading experts, explore innovative strategies, and discuss the pivotal role of primary care in achieving health equity. 

 In addition to our conference lineup, we have an exciting announcement: we have five additional spots for the NCQA Health Equity Training also offered on October 5. These spots are limited and highly sought after. NCQA's Health Equity Accreditation gives health care organizations — including health plans, managed behavioral healthcare organizations, health systems, hospitals and wellness and population health programs — an actionable framework for creating the structures and processes to begin working toward addressing health equity. This training will help prepare participants and their organizations as they consider NCQA Health Equity Accreditation. Attend the in-person session to gain in-depth knowledge from the architects of the new NCQA Health Equity Accreditation program and the developers of the new standards. 

Join us in shaping the future of healthcare by reserving your spot today and embracing the opportunity to make a lasting impact in primary care and health equity. Secure your tickets today!

OHIC PCMH reports due October 18

The Rhode Island Office of the Health Insurance Commissioner (OHIC) continues to focus on ways to promote primary care, including through patient-centered medical homes (PCMHs). As part of this initiative, OHIC requires commercial health plans to provide supplemental payments to primary care practices that meet OHIC’s three-part definition of PCMH to help finance their PCMH operations. The three-part definition includes requirements related to:


1.     a practice’s level of transformation experience;

2.     implementation of a quality improvement strategy targeted at cost management, and

3.     demonstration of meaningful performance improvement. 


For practices interested in applying for OHIC recognition, practice reports are due October 18.


Practices that are affiliated with an Accountable Care Organization/Accountable Entity (ACO/AE) do not have to submit quality measure data, as they are already held accountable for quality performance and cost of care under existing ACO/AE contracts. ACO/AEs must still submit basic information on the practice, NCQA designation, and answer the integrated behavioral health survey questions.


Documentation (practice surveys, quality benchmarks, and measure specifications) are located on the OHIC website. If you are reporting for 5+ practices, the website has Excel spreadsheet templates available that can be completed and submitted via email. Questions? Contact Acting Commissioner Cory King at

A Dive into OHIC Next Generation Affordability Standards & Prior Authorization Committee work

CTC-RI’s September Clinical Strategy meeting featured two compelling presentations focused on the OHIC Next Generation Affordability Standards and the Prior Authorization Committee work. 

Cory King, MPP, Acting Health Insurance Commissioner, provided valuable insights into the new standards, shedding light on their implications for healthcare affordability and accessibility in the state. Dr. Peter Hollman, MD, Chief Medical Officer for Brown Medicine and President of the CTC-RI Board of Directors, presented the vital work of the Prior Authorization Committee. Dr. Hollman shared updates on the committee's ongoing efforts to streamline and improve the prior authorization process, ensuring that patients receive timely and appropriate care.  

The Clinical Strategy meeting underscored the importance of collaboration, innovation, and a shared commitment to improving healthcare in RI. Watch the recording and claim CME credits here

Our August Clinical Strategy meeting featured presentations from Edward McGookin, MD, MHCDS, FAAP, President of Coastal Medical, and Monica Kucks, RN, BS, CCM, Vice President of Care Integration and Transformation, CharterCARE, with a focus on Care Design for Primary Care & Global Capitation. (Recording and CME credits).

Healthy Tomorrows Cohort 3: Quarterly Learning Collaborative meeting

Practices and Family Visiting programs participating in the third cohort of Healthy Tomorrows met in August to share their progress in building relationships and improving communication and care coordination, lessons learned and success stories. Sara Remington from the RI Department of Health (RIDOH) shared key measures on each of the family visiting programs that are participating in the program. Great results overall! Here is a look at some of their results:

  • 89-96% of enrolled children have had their most recent well-child visit.
  • 52-84% of infants under 1 yrs. old are sleeping safely--alone, on their backs, and without soft bedding nor blankets.
  • ~ 82% of enrolled children have had a 9-month, 18-month, or 24-month developmental screening.
  • Over 85% of babies receive breastmilk at 6 months of age.
  • Over 85% of enrolled children have had their most recent well-child visit.
  • 100% of primary caregivers have been screened for maternal depression within three months of enrolling in Family Visiting.
  • 100% of primary caregivers have been screened for substance use during the enrollment period.

Special thanks to Tufts Health Plan and RIDOH who are funding this important quality improvement initiative.

RI MomsPRN Learning Collaborative: Cannabis Use in Perinatal Period

The RI Maternal Psychiatry Resource Network (RI MomsPRN) Program funded by RIDOH, in partnership with CTC-RI, hosted our final learning collaborative meeting which included a presentation by Anupriya Gogne, MD, “Cannabis Use in the Perinatal Period.” Participating practices that have completed 15 months of this quality improvement initiative reported on their progress and shared success stories. The meeting also included a highlight from DCYF about efforts to connect the individuals to a Peer Recovery Specialist and other services (find the session presentation here and the BCBSRI bias training discussed here). Linked here is a flyer which details the BCBSRI bias training opportunity mentioned during the meeting. The session recording is linked here. Thank you to the following practices for your tremendous work:

  • Full Circle Health
  • RI Women’s Health & Midwifery
  • Direct Doctors
  • Comprehensive Community Action Program (CCAP) Family Health Services of Cranston

As a reminder, any providers and health care staff seeing pregnant and postpartum people are welcome to call the RI MomsPRN teleconsultation line at (401) 430-2800 or email, M-F, 8am-4pm for real-time assistance. Behavioral health clinicians, including specialized psychiatrists, psychologists, and resource and referral specialists, from Women & Infants Hospital are available for clinical consultation regarding behavioral health diagnosis, treatment planning, and medication safety and can also provide resource and referral support to community-based treatment and support services. Please note RI MomsPRN is not a patient/public-facing line and is not a crisis line.

Pharmacy QI Learning Collaborative meeting

Six primary care practices recently completed Year 1 of a pharmacy-led, data-driven quality improvement (QI) initiative designed to improve care of patients with diabetes through implementation of Pro CGM. All primary care practices have successfully implemented this approach, and in a recent meeting looked at which patients they weren’t serving based on data risk stratification. Pharmacists reported on interventions and shared their progress, lessons learned and patient stories. Subject matter experts Rahul Vanjani, MD from Amos House, and Travis Sherman from UnitedHealthcare facilitated a discussion on housing resources based on types of housing insecurity cases that pharmacists identified in managing patients with uncontrolled diabetes. In Year 2, the practices will be focusing on spread and sustainability. Special thanks to UnitedHealthcare and Rhode Island Department of Health who are providing the funding for this important quality improvement initiative.

Breakfast of Champions: Empowering Unpaid Caregivers with ARCHANGELS

CTC-RI hosted its quarterly September Breakfast of Champions Meeting on unpaid caregivers, their role in the workforce and ARCHANGELS. This event brought together a community of dedicated individuals, including business leaders, and healthcare professionals committed to making a difference in the lives of unpaid caregivers who play an essential role in our society, providing unwavering support to their loved ones. However, the intensity of caregiving can impact all aspects of their health, particularly "double duty" caregivers and those in at-risk populations. Speakers included Alexandra Drane, Co-founder and CEO of ARCHANGELS, Rebecca Preve, Executive Director of the Association on Aging in New York, and Bernie McGuiness, Health Care Executive from BMHC. Alexandra offered valuable perspectives on caregiving and its impact, along with Rebecca and Bernie who both shared their experiences working with ARCHANGELS and the direct impact of unpaid caregiving on their workforce. Reactants highlighted partnerships and work being done in RI. The event emphasized the importance of coming together as a community to support unpaid caregivers, recognizing that this endeavor not only promotes social good, but also has a significant impact on an organizations’ employee health and bottom line. Attendees left the event inspired and equipped with knowledge to enhance their roles as primary care providers while promoting wellness for their teams. 

Practices selected to participate in "Next Building Block: Implementing 4M Age-Friendly Framework for Better Care of Older Adults and People Living with Dementia Quality Improvement Learning Collaborative"

“The Next Building Block: Implementing the 4M Age-Friendly Framework for Better Care of Older Adults and People Living with Dementia” quality improvement learning collaborative addresses the 4 M’s of Age-Friendly care which provides a framework to organize care for older adults with a focus on What Matters Most, Medication, Mobility, and Mentation. This six-month quality improvement initiative will improve care for older adults by preparing to implement the 4M approach to Age-Friendly care and achieve Level 1 recognition through the Institute for Healthcare Improvement (IHI). Participating practices will also implement a quality measure focused on identifying caregivers of people living with dementia and providing education and referral to services. Congratulations to the practices that have been selected to participate:

  • Brown Medicine
  • Charter CARE Medical Associates Lincoln
  • Drs. Brennan, Cronnin, & Associates
  • University Internal Medicine

Many thanks to our funders (Rhode Island Department of Health and UnitedHealthcare) for supporting this program.

MLPB launches Phase 2 Action Lab

MLPB kicked off Phase 2 of the Health-Related Social Needs Learning and Action Lab series this month. Fifteen Phase I participants (representing older adults and organizations serving that population) were joined by representatives from several RI primary care practices (providers, nurses, medical assistants, social workers, pharmacists and managers). The group will work together toward a goal of improving health-related social needs screening, referring, and problem-solving strategies impacting older adults living in RI.

The program will focus on three key health-related social needs priorities identified during Phase I of the project: Housing, Social Connection/Isolation, and Food Security. The group heard presentations from Phase I participants with key facts about each priority area. Next month’s meeting topic is "Moving from Theory to Practice on Anti-Racism in Healthcare" and will be facilitated by guest speaker, Dr. Baraka Floyd, Stanford University School of Medicine.

Team-Based Care meeting puts spotlight on STIs in Rhode Island

At our August Team-Based Care meeting, CTC-RI was happy to host Philip A. Chan, M.D., M.S. and Erica Hardy, MD, MMSc from the STD/HIV Prevention Training Center of New England. Dr Chan presented recent RI statistics for chlamydia, gonorrhea, and syphilis, and gave an overview of screening and treatment best practices grounded in his clinical practice at Open Door Health, a Providence-based clinic serving the LGBTQIA+ community. Dr Hardy, practicing at Women and Infants Hospital, followed with a presentation focused on screening and treatment for congenital syphilis and other common STIs in pregnant women. If you missed this training, you can access the presenter’s slides or view a recording of the meeting.

Task Force for Primary Care Provider Workforce Development addresses access crisis

The Task Force for Primary Care Provider Workforce Development met in August. Since March, a consensus of recommendations has been developed to address the looming crisis of a declining primary care workforce. Research indicates that RI will have a deficit of 100 primary care providers by 2030, while the state’s population continues to rise. Task Force recommendations focus on strategies that can make primary care practice more attractive to students in medical, nurse practitioner and physician assistant programs. The Task Force, (including all RI state colleges and universities that train physicians, nurse practitioners and physician assistants), has been gathering and reviewing data on the adequacy of clinical training sites for students in RI and exploring ideas for building a more robust training program for primary care providers that includes innovative team-based care models. Other recommendations include strengthening loan repayment and tuition reimbursement programs, equitable pay for primary care providers, reducing provider burnout, and strategies that encourage providers to spend their career in RI. The Task Force plans to release a strategic plan by the end of the year. In the interim, the group is making recommendations to our co-conveners (OHIC and Medicaid) in anticipation of the Governor’s budget and will be working to educate legislators on the value of primary care, the current access crisis, and needs for population health.

Find past CTC-RI learning session 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

EOHHS grant opportunity (up to $200,000!)

Staff recruitment and retention has been cited as a challenge across industries, especially in the direct service industry. Specifically, staff shortages in the homeless service provider and healthcare industries have been identified as a critical need. Upfront costs associated with recruiting staff and sustaining positions long-term have been cited as areas where additional resources and strategies are needed. This grant opportunity seeks to focus on workforce recruitment, retention, and sustainability through increasing organizational readiness to bill for specific Medicaid services aimed at assisting individuals who are experiencing homelessness. Deadline is November 10! Details here.

Rhode Island World Diabetes Day hosts 3 upcoming opportunities!

Join healthcare professionals and colleagues from across the state for three upcoming opportunities, including (1) nominating an individual or organization that has positively impacted diabetes in Rhode Island for the Grace Diaz Blue Light Award; (2) participating in and promoting the 2023 Rhode to Wellness Challenge (October 15-November 11); and attending the RI World Diabetes Day conference (November 14), which will include a FREE morning full of helpful, eye-opening, and inspirational presentations, discussions, and Q&A sessions. Light refreshments will be available. Learn more.

Internet for Back to School: Affordable Connectivity Program offers discounts on internet for eligible households

The federal Affordable Connectivity Program (ACP) has been helping households across the country connect to the internet and save on their monthly bill since 2021. The ACP is an important part of historic federal investment focused on universal broadband access and adoption, providing savings of $30* per month toward internet service and $75* a month on qualifying Tribal lands. Internet is no longer a luxury, but a necessity for everyone, everywhere. Healthcare providers may wish to share this information with their patients – you can simply tell them to call 877-384-2575 or visit Consumer outreach materials are available.

Upcoming CTC-RI Committee Meetings and Workgroups

  • September 22, 07:30-08:45AM – Board of Directors
  • October 04, 07:30-08:30AM – PCP/Specialist Monthly Oversight Meeting
  • October 04, 02:30-03:30PM – Demographic Data Monthly Committee Meeting
  • October 11, 08:00-09:00AM – Taskforce of Primary Care Provider Workforce
  • October 12, 07:30-09:00AM – Prior Authorization Meeting
  • October 20, 07:30-09:00AM – CTC-RI Clinical Strategy Committee - CANCELED
  • October 27, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • September 27, 07:30-08:30AM – Care Coordination ECHO Series
  • September 28, 07:30-09:00AM – DULCE Year 2 Kickoff
  • October 05, 07:00-03:30PM – Annual Conference - Investing in Primary Care & Health Equity
  • October 11, 07:30-09:00AM – Asthma QI Learning Collaborative
  • October 17, 08:00-09:00AM – Best Practices in Team-Based Care - CANCELED
  • October 19, 07:30-08:30AM – Restrictive Eating ECHO series
  • October 20, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • October 25, 07:30-08:30AM – Care Coordination ECHO Series
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