Care Transformation Collaborative of RI

News & Updates | December 2022

CTC-RI Congratulates Susanne Campbell, RN, MS, PCMH CCE, NCQA Recipient for CCE Quality Award 2022-23

CTC-RI is proud to announce that Susanne Campbell, RN, MS, PCMH-CCE, CTC-RI Senior Program Administrator, has been named national 2022-23 PCMH Certified Content Expert supporting NCQA-Recognized PCMH practices.

Susanne was recognized at the NCQA annual conference for her significant contributions toward practice transformation resulting in practices achieving NCQA PCMH recognition and for her in-depth knowledge, experience, and performance with NCQA PCMH program standards, guidelines, documentation, and the recognition process. With 184 practices currently recognized as a patient-centered medical home, Rhode Island has one of the highest per capita rates of practices with NCQA recognition. The NCQA Committee also recognized what we already know about Susanne, a “positive, goal-oriented team player, coach, and advocate.” Read more.

CTC-RI Celebrates With Rhode to Equity (R2E) Teams at Biannual Conference

CTC-RI recently held its first in-person convening of the Rhode to Equity (R2E) project, bringing together 6 multi-stakeholder teams to address health inequities in their communities. About 100 people, including R2E team members, state agency staff, managed care organization staff, community health workers and other stakeholders, gathered at the Boys and Girls Club of Pawtucket. Highlights of the day included subject matter expert sessions with national and local leaders on healthy housing, food justice and housing-first models. Read more.

Keith Stokes, Director of Business

Development, City of Providence

Attendees engage in an activity lead by Valerie Tutson, Executive Director, RI Black Storytellers

November Clinical Strategy Meeting Focuses on OHIC Next Generation Affordability Standards

The November Clinical Strategy Committee (CSC) meeting focused on the Rhode Island Office of the Health Insurance Commissioner (OHIC) Next Generation Affordability Standards. Led by Cory King, OHIC Chief of Staff, the discussion included child and adolescent behavioral health spend, health equity, professional provider contract review, and recalibration of primary care Alternative Payment Model (APM) targets. Primary care spend specifications are expected to be made to align with national standards modifications that also include non-claims expense. Read more.

OHIC Updates Primary Care Aligned Measurement Set

The RI Office of the Health Insurance Commissioner (OHIC) convenes a workgroup each year to review and update the aligned measurement set used to measure primary care performance. OHIC has published the aligned measure sets (updated 9/28/22) effective for insurer-provider contractual periods starting on or after 1/1/23 for contracts subject to amendment or renewal on or after that date. Effective 8/2022, OHIC also published the Revised Measurement Specifications for Adult and Pediatric PracticesRead more

NCQA Patient-Centered Medical Home Update for 2023/24: Use of Standardized Measures

Beginning in 2024, standardized measures will be required for PCMH. A standardized measure captures data from the entire calendar year before the submission year; thus, for 2024 the reporting period will be January 1–December 31, 2023, unless stated otherwise in the measure specification. Practices are expected to use the EHR to generate the standardized measure reports for submission. 

Measures related to resource stewardship: Care Coordination and Health Care Costs (QI 02B) may not be relevant to all practices. There can also be unique challenges to obtaining a full calendar year of data (e.g., changing vendors mid-year). Exceptions to calendar year reporting will be granted on a case-by-case basis. Practices may submit a PCS ticket through My NCQA to submit a custom measure report. Learn more.

Update on Medicaid Pediatric Healthcare Recovery Program – Year 2

Be sure to register for upcoming ECHO® learning sessions

All practices participating in the Medicaid Pediatric Healthcare Recovery Program (Year 2) are encouraged to attend the February 2 Improving Child Health in RI (formerly PCMH Kids Stakeholder) meeting. New KIDSNET immunization reports will be shared with practices.

Additionally, practices are expected to attend 4 out of 6 ECHO® Learning Sessions to be eligible for the behavioral health ECHO® participation payment due in July 2023. 

As a reminder, the second payment is scheduled for early February and is contingent on meeting 3 out of 4 immunization and lead screening targets or improvement targets based on January 15 KIDSNET data. Practices can expect to receive monthly KIDSNET reports around the 18th of the 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.

Learn more about upcoming dates and topics in the ECHO® series. 

Best Practices in Team-Based Care: Improving Lead Screening

Dr. Beata Nelken led the November Best Practices in Team-Based Care meeting with best practice strategies used at Jenks Park Pediatrics to improve lead screening. These included purchasing a van to assist patients with transportation needs to their appointments, setting up an in-office lead screening workflow, and partnering with Lifespan labs. Michelle Almeida, Health Program Administrator for the Rhode Island Department of Health (RIDOH) Center for Healthy Homes and Environments, also provided an overview of RIDOH's Lead Prevention Program and the new CDC lead guidelines. Cynthia Ali shared best practice strategies used at Children’s Medical Group to improve lead screening and Janet Limoges, Provider Relations Manager at RIDOH KIDSNET, reviewed lead reports available in KIDSNET to help practices target patients with missing lead screens.

The January and February Best Practices in Team-Based Care meetings will include capstone project presentations from nurse care managers and care coordinators enrolled in the NCM Core Curriculum program. Read more.

December Asthma Essentials ECHO® Focuses On Environmental Triggers


CTC-RI hosted its third Asthma Essentials ECHO®, which brought together 40 participants and was facilitated by Patricia Flanagan, MD. Jim Ginda, MA, RRT, AE-C, FAARC presented the didactic session focused on “Assessing and Managing Environmental Triggers.” Marie Habershaw, School Nurse/Healthcare Coordinator for the Diocese of Providence, presented a case and led a dialogue about how school nurses and primary care offices can strengthen partnerships. 


Join us January 11 for Session 4. Daniel Fitzgerald, MPH, ICPS and Ashley Fogarty, MPH will present a didactic session focused on working with community partners. Marjorie Carges, MD will provide the case presentation. Read more.

Dec. 9 Breakfast of Champions Explores Unconscious Bias and Psychological Safety in Health Care

CTC-RI’s December learning collaborative focused on part 2 of a discussion on implicit bias, particularly on building psychological safety in diverse health care teams to promote maximum effectiveness and improve equity for patients.

Patricia Flanagan, MD moderated an impressive panel discussion. Panelists included:

  • Rob Jones, Chief Empowerment Officer of T. Lee Associates
  • Nelly Burdette, PsyD, Associate Vice President, Integrated Behavioral Health at Providence Community Health Centers
  • Crystal Fairchild, MS Chief Diversity, Equity, Inclusion, and Human Resources Officer, Thundermist Health Center 

View the recording and learn more.

CTC-RI Hosts Health Transitions of Care November Quarterly Learning Collaborative Meeting

Sixteen participants joined the November Health Transitions of Care learning collaborative to share patient and family experiences, available resources, and best practices around improving care coordination for youth transitioning from pediatric to adult care.

Stephanie Trafka, RIPIN Family Voices, kicked off the meeting speaking about family experiences and the difficulties families face throughout the transition process. Kathleen Kuiper, RIDOH, introduced the Medical Home Portal with a website demonstration and resources available for families and clinicians.

Several practices shared updates on increasing transitions of care knowledge within their system of care, while new participating practices discussed their experiences with patient transitions. Read more.

Pharmacy QI Learning Collaborative Meeting Focuses on Professional Use of Continuous Glucose Monitoring (Pro CGM) in Primary Care

Primary care practices that are part of systems of care and participate in the Pharmacy QI Learning Collaborative met in December to share their progress on identifying patients who might benefit from professional use of continuous glucose monitoring interventions. Goals and team-based workflows were presented. Leslie High of Abbott Diabetes Care provided a tutorial on Libreview and how it can be used to customize practice reports. Billing options for Pro CGM services were also discussed. Special thanks to UnitedHealthcare and the Rhode Island Department of Health (RIDOH) for providing funding for this important quality improvement initiative. Learn more and access helpful resources.

Care + Community + Equity (CCE) Program Holds Best Practice Sharing Meeting

The Care + Community + Equity (CCE) program recently held a best practice sharing meeting to hear presentations from participating practices on projects to improve pre-diabetes and diabetes care delivery. Casey Sardo of Tri-County Community Action Program and Dr. Jason Villa, Assistant Medical Director for Comprehensive Community Action Program (CCAP), presented on their progress in this CCE incentive area. Meeting attendees also heard about the Medicaid Beneficiary Enrollment Pilot (MBEP) from the Rhode Island Department of Health’s Benvinda Santos and Krystal Bevilacqua of Coastal Medical. Alayna Woodley also presented on the CODAC Behavioral Health Mobile Unit. Join us for the next CCE Best Practice Sharing meeting in March 2023. Read more.  

Rhode Island COVID-19 Updates

Rhode Island is now reporting new COVID-19 data every Thursday. As of December 15, 2022:

  • Cases per 100,000 previous week: 169
  • Hospitalized previous week: 103
  • Deaths previous week: 15
  • Total deaths to date: 3,777
  • Vaccinated with two shots: 87.2%
  • Vaccinated with booster: 21.8%
Practice Resources

RIDOH Invites New Members to Join the RI Parent and Caregiver Advisory Council

The RI Dept. of Health (RIDOH) invites parents and caregivers of young children, along with people expecting a baby, to join the RI Parent and Caregiver Advisory Council. RIDOH seeks feedback to improve programs for families and young children. The group meets virtually on the third Wednesday of each month. Read more.

RI Geriatric Education Center Offers Jan. 11 Webinar on Addressing Hearing Loss in Older Adults

The Rhode Island Geriatric Education Center will kick off the first in a series of upcoming webinars addressing issues that impact quality of life for older adults with Addressing Hearing Loss: A Common Problem for Older Adults on January 11 from noon to 1 p.m. Participants will learn about best practices for identifying and supporting older adults with hearing loss. Register for this webinar and learn more about upcoming webinars in the series. Read more.

Upcoming CTC-RI Committee Meetings and Workgroups

  • Dec. 20, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • January 17, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
  • January 20, 07:30-09:00AM – Clinical Strategy Committee 
  • January 27, 07:30-08:45AM – Board of Directors

Upcoming Learning Collaboratives and Professional Development

  • December 22, 02:00-03:00PM – Monthly Healthy Tomorrows meeting
  • January 11, 07:30-08:30AM – Asthma Essentials ECHO
  • January 11, 07:30-09:00AM – RI MomsPRN Learning Collaborative - Cohort 3
  • January 19, 07:30-08:30AM – Pediatric Weight Management ECHO
  • January 26, 07:30-08:30AM – Medicaid Recovery Program Behavioral Health ECHO - Difficult Conversations
  • January 26, 08:00-09:30AM – Community Health Teams Expansion Best Practice Sharing

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