Care Transformation Collaborative of RI

News & Updates | October 2023

CTC-RI celebrates bringing people together for a successful annual conference

Our annual conference on October 5, "Investing in Primary Care & Health Equity," was a resounding success with more than 250 dedicated healthcare professionals and stakeholders in attendance. The event featured essential aspects of primary care, with 11 engaging sessions focusing on three tracks: Team-Based Care, Clinical Community Linkages, and Family-Child Health. Sessions included topics such as psychological safety, electronic consults between PCPs and specialists, strategic community-based partnerships, and behavioral health models and tools. Participants enjoyed two thought-provoking keynote sessions, the first on "Compassion as the Key to Success," delivered by Sue Kressly, MD, FAAP, and the second, titled "Medical Leadership in Changing Times" by Scott Conard, MD at Converging Health.

Another highlight of the conference was a special training session led by the National Committee for Quality Assurance (NCQA) where attendees were introduced to the new Health Equity Accreditation Standards. The training shed light on the crucial topic of health equity, underlining the importance of addressing disparities in healthcare access and outcomes. 

The conference also hosted 24 vendors, which provided participants with the opportunity to visit their tables, explore resources, and learn about organizations in the field that may serve their communities and patients. We extend our heartfelt gratitude to all the sponsors who made this event possible including Medical Legal Partnership of Boston, RI Department of Health, RI Health Center Association, URI – RI Geriatric Education Center, Healthcentric Advisors, Upstream, Equip Health, Blue Cross Blue Shield of RI, Neighborhood Health Plan of RI, Tufts Health Plan, UnitedHealthcare, American Academy of Pediatrics RI, and the RI Executive Office of Health and Human Services.

Lastly, a special thank you goes out to our dedicated planning committee members, whose tireless efforts and commitment ensured the success of this event. Their dedication to promoting healthcare excellence and health equity is truly commendable. The conference was a testament to the power of collaboration and shared knowledge, and we look forward to future opportunities to continue advancing the cause of primary care and health equity.

View more photos from the conference here. View the agenda and presentations here.

What made our conference a hit? Dr. Thomas Bledsoe, CTC-RI Board Member and primary care physician, weighs in

Following CTC-RI's largest annual conference held earlier this month, we spoke with Dr. Thomas Bledsoe about his experience and perspective.

1. Why is it helpful to bring practices together for the CTC-RI Annual Conference?

From the outset, one of the hallmarks of CTC-RI has been its collaborative nature. The twin messages of "we are more effective at promoting change when we work together" and "we all have expertise that we can share with each other" were on full display at the conference. We learned from experts, and after a strange three years, once again (re-)connected with colleagues to share our experiences and our plans for further improvements, both short and longer term!

2. Primary care workforce shortages have been top of mind for many of us. What takeaways from the Conference are important to share?

A well-functioning primary care system is good for patients and such a system requires a team both in the office and in the community. Different members of the team within and outside of the office need to learn to work together to come to agreement about goals and then to clarify roles and responsibilities. It is always primarily about the patient, but a well-functioning primary care system will only be good for recruiting primary care practitioners to Rhode Island. If you happen to get sick, in Rhode Island you will be well cared for. If you are looking to enter practice, this conference helped to demonstrate our goals of making Rhode Island a great place to practice primary care.

3. What emerging themes, topics or lessons learned did you find valuable for our practices, and why?

After a lean three and a half years of stress of COVID and anxiety about getting together, it was wonderful to see so many colleagues and reconnect. It was fun and interesting and energizing to hear about the work that continues. A small group got together to talk about reorganizing and refinancing primary care almost 20 years ago has developed into a collaborative that continues to grow and thrive, to learn and develop. We hear a lot about joy in work. Feeling like you can make a difference and then actually making a difference in the health care community have always been central to CTC-RI's mission. I saw colleagues at the conference who arrived feeling empowered and ready to share their expertise and who left feeling both educated and inspired.

Community Health Workers - Pediatric IBH training for Community Health Workers

The CTC-RI project, Increasing Pediatric Integrated Behavioral Health (IBH) Provider Capacity with Community Health Workers (CHWs), kicked off its in-person CHW training sessions on September 13, 15 and 21. With funding provided by UnitedHealthcare, Blue Cross & Blue Shield of RI, and Tufts Health Plan/Point32Health and in collaboration with the Hassenfeld Child Health Innovation Institute at Brown University, this project aims to expand the CHW role to support integrated care in pediatric settings. We have partnered with the subject matter experts at Team UP (Transforming and Expanding Access to Mental Health Care in Urban Pediatrics) at Boston Medical Center for clinical training.

CTC-RI hosted five CHWs and several supervisors from the participating practices for the in-person trainings. The core topics included defining the role of CHWs on IBH teams, patient screening processes, core CHW skills and applications. The next phase of this project involves additional behavioral health clinician trainings, core team-based sessions for the practice staff, and monthly case consultation with the CHW team. Participating practices include:

  • Coastal Medical Bald Hill Pediatrics
  • Coastal Medical Waterman Pediatrics
  • Comprehensive Community Action Plan (CCAP)
  • Family Care Center (CNEMG)
  • Hasbro Pediatric Primary Care
  • Wood River Health Services

DULCE* Learning Collaborative welcomes three new practices and two continuation practices

We're thrilled to kick off the second year of the DULCE Learning Collaborative, which provides practices with an innovative approach that proactively addresses health related social needs, promotes the healthy development of infants and provides support to their parents/caregivers during the critical first six months of life. This year, our collaborative expands with the participation of two returning practices from cohort one: Coastal Toll Gate Pediatrics and Care New England Medical Group Family Care Center, and the addition of three new practices: Tri-County Community Action Agency, Hasbro Children's Hospital, and Blackstone Valley Community Health Center.

During our kickoff meeting, Samantha Morton, JD, a consultant for the Center for the Study of Social Policy, provided valuable insights into the DULCE model and how practices can deepen collaborative efforts in year two. It's our dedicated Family Specialists who make this program unique. Two of them, Lauren Landry from Coastal Toll Gate Pediatrics and Jalyn Alzate from CNEMG Family Care Center, shared their experiences working with the practices and partnering with families including citing the valuable outcomes of the work they have done. They exemplify the heart and soul of this initiative, working closely with families to address their specific needs and promote early childhood wellbeing.

View the presentation here. This initiative is funded by UnitedHealthcare, the RI Department of Health, Tufts Health Plan/Point32Health and Congressional Direct Spend Funds.

*DULCE: Developmental Understanding and Legal Collaboration for Everyone)

Asthma Quality Improvement Initiative wraps-up

After seven months, CTC-RI has officially concluded our Asthma Quality Improvement project with an October wrap-up meeting. Two pediatric practices, Dr. Concilio and P.R.I.M.A. Inc, participated and made great strides in improving care for patients with asthma. Their focus was on patient education of appropriate inhaler use, medication adherence and improving the usage of Asthma Action Plans (AAP). A core measure related to the QI was improved management of asthma and related reduction in urgent care, emergency, or hospital visits.

Here is a glimpse of the great work accomplished:

  • Three pediatricians at P.R.I.M.A., Inc. began the use and review of Asthma Action Plans (AAP) at all visits for patients with asthma. During the project, more than 130 AAP were distributed to patients and families.   
  • Dr. Concilio, a single provider pediatrician started and will continue to give asthma inhaler education at every visit for patients with asthma and incorporated use of colored instruction posters.
  • Both practices connected with school nurses and/or made referrals to the Home Asthma Response Program (HARP) for several high-risk patients. 
  • Both practices benefited from funding to purchase asthma-related supplies including spacers, masks, and nebulizers.

View the presentation here. We are grateful for the funding and support from Tufts Health Plan and the RIDOH Asthma Control Program that made this quality improvement initiative possible. 

Restrictive Eating ECHO Series kicks off

In September, CTC-RI, supported by UnitedHealthcare funding, launched a new ECHO program titled "Increasing Access to Care for Children and Adolescents with Restrictive Eating Disorders by Optimizing Integrated Behavioral Health Care." The participating practices are Aquidneck Pediatrics, East Greenwich Pediatrics, Atlantic Pediatrics, Bald Hill Pediatrics, Barrington Pediatric Associates, Toll Gate Pediatrics, Coastal Medical Narragansett, and Smithfield Pediatrics.

Dr. Christina Tortolani from Rhode Island College is the subject matter expert partnering with us on this project. Her first session was “Eating Disorders 101" and she will lead the majority of the monthly ECHO sessions over the next 12 months. The Integrated Behavioral Health Clinicians from the practices will receive special consultation to become familiar with Family-Based Treatment, the gold standard of treatment for eating disorders among children and adolescents. 

Best Practices in Team-Based Care focuses on social isolation and loneliness in older adults

In September, over 150 people attended CTC-RI’s Team-Based Care Meeting which was held in conjunction with the Rhode Island Geriatric Education Center’s geriatric workforce development series. The focus of the presentation was on “Social Isolation and Loneliness in Older Adults” featuring presenter Max Zubatsky, Ph.D. LMFT, Associate Professor and Program Director Medical Family Therapy Program at St. Louis University when attendees were alerted to the serious health effects. Dr. Zubatsky outlined several interventions including the “Circle of Friends,” a program originally developed by Helsinki University. If you missed the presentation, you can find the slides here or watch the recording. Thank you to Dr. Zubatsky and the Rhode Island Geriatric Education Center for this eye-opening presentation!

Team-Based Care Learning Series: Grief and Loss - Supporting Older Adults Webinar in November

Part of our Best Practices in Team-Based Care Learning Series includes attendance at the upcoming November 21 webinar (8-9am), through the RI Geriatric Education Center. Details here.

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

Reminder: Nov. 11 deadline for EOHHS grant opportunity "Staff and Agency Enhancement for Home Stabilization and Associated Medicaid Services" (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 (currently running through 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.

CTC-RI Best Practices in Team-Based Care/RI Geriatric Education Series: Grief and Loss - Supporting Older Adults

Grief often has an impact on physical health at any age, but older people are at

a much higher risk for severe health problems. This November 21 webinar will feature Mari Dias, Ed.D, the Director of GracePointe Grief Center and Certified Grief Counselor. CE credits are available. Details.

New treatment resources for teens with restrictive eating disorders!

Andrea Goldschmidt and Christina Tortolani are collaborating with Gateway Healthcare & The Providence Center to offer in-home treatment for adolescents with restrictive-type eating disorders. Eligible families have a child (12-18) with a restrictive-type eating disorder currently living at home, have at least 1 parent/caregiver willing to engage in treatment and complete surveys and interviews. Families will be compensated for their time. Spanish-speaking providers are available to assist families through all phases of the study. Please note that Rhode Island is part of PSYPACT and could be a resource for out-of-state providers who treat adolescents residing in Rhode Island. This study is funded by the National Institute of Mental Health (grant #R34-MH123589). For more information, please contact Genesis Jimenez

Boston Globe: Some health experts say there’s a ‘concerning decline’ in HPV vaccination rates since pandemic began

A September 25 Boston Globe article includes insight from PCMH Kids co-founder Dr. Beth Lange on the important work and progress made in pediatric vaccination rates.

Upcoming CTC-RI Committee Meetings and Workgroups

  • October 27, 07:30-08:45AM – Board of Directors
  • November 01, 07:30-08:30AM – PCP/Specialist Monthly Oversight Meeting
  • November 01, 02:30-03:30PM – Demographic Data Monthly Committee Meeting
  • November 08, 08:00-09:00AM – Task Force for Primary Care Provider Workforce Development
  • November 17, 07:30-09:00AM – CTC-RI Clinical Strategy Committee

Upcoming Learning Collaboratives and Professional Development

  • November 02, 07:30-08:00AM – Virtual Coffee Breaks with Dr Pat Flanagan & Dr Beth Lange
  • November 14, 07:30-09:00AM – Transition of Care / Care Coordination Kickoff Meeting
  • November 14, 09:00-10:00AM – Demographic Data Collection Pilot Train-the-Trainer Webinar
  • November 15, 07:30-08:30AM – 4M Framework Learning Collaborative Meeting
  • November 16, 07:30-08:30AM – ECHO: Increasing Access to Care for Children and Adolescents with Restrictive Eating Disorders by Optimizing Integrated Behavioral Health Care
  • November 17, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
  • November 21, 08:00-09:00AM – Best Practices in Team-Based Care
  • 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
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