Celebrating Community Health Worker progress 👏

Care Transformation Collaborative of RI

News & Updates | May 2024

Celebrating progress: One year of the Community Health Worker Roadmap journey

Since its inception a year ago, the Community Health Worker (CHW) Roadmap project has been a beacon of collaboration and progress in Rhode Island. Spearheaded by the RI Department of Health and its partners, CTC-RI has supported this initiative that has worked to elevate the role and impact of CHWs across the state.

This month in Providence, over 80 stakeholders convened to celebrate the journey and strategize the path forward. The event served as a platform for the four key components of the CHW Roadmap to showcase their achievements, confront challenges, and gather feedback crucial for future endeavors. These components are 1.) CHW Role, Agency, and Leadership, 2.) Payment and Sustainability, 3.) Person- and Place-based Coordination, and 4.) Workforce Development.

The keynote address, delivered by Seema Dixit, MPH, MS, RIDOH Deputy Director of Public Health, underscored the vital role of CHWs in the community and highlighted the progress made in integrating their role into the state's healthcare landscape, followed by an engaging panel discussion. Read more.

View the full Roadmap report here . View the Roadmap progress poster here . View the Roadmap implementation team posters here .

RIDOH's James Day discusses work and sustainability of Community Health Workers

As leaders across the state work to build a more robust Community Health Worker (CHW) workforce, we connected with James Day, CPS, Health Program Administrator, Division of Community, Health and Equity, RI Department of Health to learn more about the recent CHW strategic plan development and Roadmap release.

What is the purpose of the CHW Roadmap and how was it developed?

The Rhode Island Community Health Worker (CHW) Roadmap Project reflects the statewide CHW Strategy Team’s desire to move from discussion to action to build a sustainable and robust CHW profession. In 2023, 110 CHWs and allied partners met to create this three-year innovative strategic plan. Since late 2023, they have begun implementing milestone goals across four Roadmap implementation teams.

How does the Roadmap support CHW sustainability?

The CHW Roadmap process had uncovered four main focus areas to tackle – including “Payment and Sustainability.” An implementation team facilitated by a CHW and an allied partner is assigned to address payment and sustainability within this focused team framework, while three other Roadmap teams work to achieve other milestone goals. Additionally, all four teams work to increase visibility of the CHW profession and roles at policy and public discussion tables. By collectively raising awareness of CHWs’ needs, as well as the value and benefits to patients and communities served, members may further identify opportunities for system change to better sustain the important work of CHWs.

CHWs work in a variety of settings, including primary care. How can primary care support CHW sustainability efforts?

The benefits and return on investment for CHW services has long been established both nationally and internationally. Primary care support starts with recognizing the roles and responsibilities of CHWs and the value added for medical and community linkages. The Alliance for CHW Employers has been established to provide support for all those integrating CHWs.

Seeking support for primary care workforce legislation

CTC-RI and the Rhode Ahead Initiatives are two public/private partnerships that have been working to address the crisis in access to primary care and the lack of culturally appropriate and linguistically competent care, among other workforce issues.

The General Assembly is considering four bills to implement strategies recommended by the CTC-RI Primary Care Workforce Task Force and the Rhode Ahead, and strengthen and diversify the healthcare workforce. The bills would (1) fund a scholarship program for primary care physicians, nurse practitioners and physicians assistants ; (2) fund clinical training sites with specific primary care training criteria and curriculum; (3) increase funding for the Health Professional Loan Repayment Program to recruit and retain a range of providers; and (4) provide pathways for paraprofessionals to pursue higher education degrees and licensure, to help diversify our professional workforce.

Senate and House Finance Committees are holding hearings on the bills, and many of you have written letters of support and testified. Our work is not done! Support is needed to get these bills funded and across the finish line. Read more on ways to help.

Debra Hurwitz, MBA, BSN RN, CTC-RI Executive Director, along with CTC-RI Primary Care Work Force Task Force co-chair Jeffrey Borkan, MD, PhD and member Andrew Saal, MD MPH, testify at a House Finance Committee hearing on May 15

Applications due May 21: Rhode Island MomsPRN Quality Improvement and Training Initiative

Together with the RI Department of Health and the Executive Office of Health and Human Services, CTC-RI is offering a training and funding opportunity for up to four practices caring for pregnant/postpartum patients to support behavioral health workflows, including but not limited to screening, brief intervention, treatment, referral to care, follow-up support and linkages to community resources.

The program has two aligned and overlapping components:

10-month quality improvement initiative (June 11, 2024 - March 2025)
6-month Extension of Community Healthcare Outcomes (ECHO®) training program (September 2024 - February 2025).

Who can apply?

Any outpatient or hospital-based practices that provide prenatal and postpartum clinical care can apply, with priority given to those that:

Provide care in one of the geographic areas that are underserved and/or rural.
Provide care to patients disproportionately impacted by behavioral health.
Have an ability to meet the needs of a multicultural patient population.
Can meet behavioral health needs of patients in a timely manner.

This initiative builds on the success of past RI MomsPRN efforts, giving practices autonomy in identifying their own quality improvement project. Learn more.

APPLY BY MAY 21

Applications due May 22: Pharmacy Strategies to Improve Care for Patients with Diabetes

In partnership with the University of RI College of Pharmacy and RI Department of Health (RIDOH), CTC-RI is offering seven primary care practices the opportunity to apply for funding to join a two-year pharmacy quality improvement initiative.

The project aims to improve screening rates for patients with diabetes for earlier detection of diabetes-related eye and kidney disease.

Funding and quality improvement activities will support health care practices to improve their knowledge, awareness, and competency with implementing screening treatment strategies in the care of patients with diabetes and to provide earlier detection of important microvascular complications including retinopathy and nephropathy.

Thank you to UnitedHealthcare and RIDOH for funding this initiative. Learn more.

APPLY BY MAY 22

Healthy Happy Teams presents at Board of Directors meeting

At our April Board of Directors meeting, CTC-RI reviewed the recently completed project, “Healthy Happy Teams." Dr. Nelly Burdette, CTC-RI Senior Integrated Behavioral Health Program Leader and Boston Medical Center Director of Population Behavioral Health highlighted the nine participating practices, their quality improvement projects across the nine months, and the results of their team assessments. The goal of this project was to strengthen team-based care in primary care practices, by promoting high-functioning teams, communication, and clear roles for all team members. The practices who completed the project reported feeling that their team communication is more effective, and that their team roles and expectations are clearer now than before the project. This project was supported by funding from UnitedHealthcare. Click here to view the presentation materials.

Upcoming Clinical Strategy Committee meetings

Our upcoming Clinical Strategy Committee meetings (Zoom access here) are bringing together partners from the state, community, and clinical leadership to discuss important updates regarding primary care spend, RI health and business trends, behavioral health updates, and updated payment policies.

On May 17, Neil Sarkar, RI Quality Institute President and CEO, will discuss new clinical research opportunities, and Al Charbonneau, RI Business Group on Health Executive Director, will discuss the recent report on drivers of healthcare costs for Rhode Islanders. Cory King, RI Health Insurance Commissioner, will report on the primary care spend and pediatric behavioral health updates.

In June, we will hear updates on the RISE-PC (Reaching Integration and Supporting Excellence in Primary Care), alternative model of behavioral health distinction, as well as the proposed integrated behavioral health per-member-per-month model.

Join us for the June Breakfast of Champions meeting

At our June 14 Breakfast of Champions meeting, CTC-RI will be collaborating with community-based organizations, academic and clinical partners to discuss the adaptation of primary care practices to be more friendly to neurodivergent patients. Ariana DeAngelis from The Autism Project will speak about approaching neurodiverse patients across the age-span, and Francisco Cordero, MD, will discuss national and state models to support the diagnosis of autism spectrum disorder in the medical home model. In addition, Emily Feinberg, ScD, CPNP, from the Hassenfeld Institute will introduce training for community health workers (CHW’s) to implement structured behavioral observation as a second-level screening process for autism spectrum disorder.

Monthly CBO Spotlight: The Autism Project

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 The Autism Project, a Hub of Hope© that connects people—with a spectrum of needs—to the available resources and education that support independent and purposeful lives.

What ways does your organization uniquely support Rhode Islanders?

The Autism Project is a unique collaboration of self-advocates, parents, professionals, and community members that offers family support and education, professional development, navigation of resources, social skills groups, summer camp and community. We provide services to individuals with ASD who range from five to 64 years of age.

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

Partnership with primary care providers strengthens The Autism Project’s work by increasing the medical professionals understanding of how to better engage with autistic patients and their families. Improved communication with patients leads to better patient outcomes including symptom identification, accurate information sharing and compliance. This helps with understanding of a coexisting diagnosis, improved care plans and follow-through for other appointments or therapies.

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

We work with individuals with ASD throughout their life, we work with their families, and we are truly a support system. Important to note is that most of our staff have lived experience as caregivers, parents, or a neurodivergent person. We connect people to resources for physical and mental health, we work with insurance providers, case managers and healthcare professionals to support individuals on their personal goals. We also offer professional trainings for clinicians supporting neurodivergent patients to improve their skills for positive engagement with a neurodivergent patient.

Want to get in touch?

Contact: email theautismproject@lifespan.org or call 401-785-2666.

Join CTC-RI's Best Practices in Team-Based Care webinar with RIGEC on chronic pain management for older adults

Join CTC-RI for an insightful session on Best Practices in Team-Based Care, in collaboration with the RI Geriatric Education Center, focusing on chronic pain management for older adults. This webinar, titled "Multidimensional Assessment and Nonpharmacologic Treatments of Chronic Pain in Older Adults," will feature Elke Schaumberg PT, MS, SPT, PhD from Johnston & Wales University as the speaker. The session will take place on Tuesday, May 21, 8-9am. Enhance your understanding of chronic pain management strategies for older adults through three key objectives: identifying risk factors associated with chronic pain and age-related changes in neurological pain processing pathways, emphasizing the importance of conducting a comprehensive examination using the biopsychosocial framework to develop personalized pain management plans, and exploring evidence-based nonpharmacological interventions for chronic musculoskeletal pain. Register now.

We received amazing presentation submissions for our October 31 Annual Conference!

CTC-RI recently conducted a call for abstracts for our Annual Conference, "Investing in Primary Care & Health Equity," and the response was fantastic with 22 submissions received for 12 sessions! Submissions ranged from topics on autism, integrating community health workers into primary care settings and new technology for behavioral health. While the agenda is still being finalized, the conference promises to be an exciting event.

This in-person gathering on October 31 at the Crowne Plaza offers enriching learning opportunities across key tracks: health equity, priorities in population health, best practices in Behavioral Health (IBH), and improving child/family health. Attendees will have the opportunity to learn from local and national experts, network with colleagues, and gain invaluable insights and strategies to enhance patient outcomes by leveraging the strengths of the team, system of care, and patient voice. In addition to the engaging educational sessions, our conference will feature an exciting exhibitor hall, showcasing community-based organizations and partners. Attendees will have the opportunity to explore and meet with a diverse range of exhibitors, network, and access cutting-edge industry and local resources. Don't miss out on this exceptional opportunity to connect with colleagues, learn from experts, and discover ways to advance primary care and health equity. Secure your spot now and be part of this transformative event! Exhibitors interested in participating can contact Michelle Mooney (mmooney@ctc-ri.org) for details.

CTC-RI reports on FY2023 accomplishments

Each year, CTC-RI presents project highlights and accomplishments to our Board of Directors. Once again this year, the Accomplishments Report FY23 was aligned with our 5-year strategic plan and logic model. The narrative version of this logic model can be read here.

Next steps and projects in process include the following:

Implementing Primary Care Workforce Strategic Roadmap
Demographic Data Collection Quality Improvement Initiative
Integrated Care – e.g., IBH and CCBHC
Improving Care for Older Adults
Sexually Transmitted Infections – ECHO and Quality Improvement Learning Collaborative
Transition of Care – Payment; National Collaborative Participation
Early Childhood – e.g., Family Visiting, DULCE, MomsPRN,
TEAM-UP, AAP Wellness, and Sleep

See the full Accomplishments Report FY23 using t his link.

Asthma Collaborative Learns from PCHC Asthma Continuous Quality Improvement Pediatric Project

In April, CTC-RI hosted its asthma quality improvement (QI) initiative learning collaborative meeting focusing on strengthening partnerships with pediatric practices and elementary school nurses. The goal of this collaborative model is to improve communication among common patients/students with asthma on prescribed asthma medication to share asthma action plans, improve asthma management, and improve communication regarding school attendance.

During this meeting, Lillian Nieves, PharmD, Providence Community Health Centers Clinical Pharmacist, shared outcomes of their project, focused on improving asthma knowledge and caregiver education led by pharmacist intervention in a medically underserved population. Outcomes highlighted the need to educate patients on the spot, the importance of patient teach backs, how pharmacists can play a role in patient education, and the role of asthma action plans. Read more.

Final Demographic Data Pilot meeting and new Quality Improvement Kickoff

CTC-RI is thrilled to announce the successful conclusion of the Demographic Data Collection Pilot Baseline Needs Assessment and train-the-trainer webinar series, with our final planning meeting concluding in May. The meeting drew substantial attendance and featured Health Commissioner Cory King's informative presentation on OHIC’s Health Equity Affordability Standards, followed by BCBSRI's Tarah Provencal and Brendan Generelli, who spoke on their plans and progress with complying with the Health Equity Affordability Standard and the new CMS health equity index expectations. As this chapter draws to a close, it opens the door to our exciting new initiative for 2024 generously funded by UnitedHealthcare and Rhode Island Foundation: “Improving Demographic Data Collection in Primary Care to Address Health Disparities Quality Improvement Initiative”. At the initial learning collaborative meeting in April, 45 primary care practice team members across 15 practices, came together to review their baseline demographic data collection data looking at their race, ethnicity, and language completeness rates. We were honored to host PCHC's Jennifer Etue and Natasha Viveiros, who shared their valuable insights on collecting SOGI and REL data. Over the next eight months, participating practices will be working with practice facilitators to identify and implement best practices for improving collection of patient demographic information. We look forward to the ongoing impact our 15 practices will have in advancing toward equitable healthcare for all. Please see links for Demographic Data Collection Pilot May Planning Meeting Materials and Demographic Data Collection Quality Improvement Kickoff Learning Collaborative Materials.

Practice Resources and Information

RI Business Group on Health hosts "Food as Medicine" event and launches new Employee Health Innovation Committee

The RI Business Group on Health (RIBGH) hosted a "Food as Medicine" event at Plant City this month, featuring nationally renowned experts in the field of plant-based nutrition to prevent and reverse chronic disease. Read more here. Presentations and more information can be found here.

RI Pre-K lottery opens for the 2024-2025 school year

RI Pre-K, entering its 16th year, provides free, high-quality Pre-K education to 4-year-old children. This year, RI Pre-K is expanding to 21 communities across the state and will serve over 2,800 children. Access applications (English and Spanish) along with more details here.