R.I Chronic Care Sustainability Initiative
September 2014 Newsletter
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Welcome to the Rhode Island Chronic Care Sustainability Initiative Practice Newsletter, where CSI-RI shares exciting updates, news, milestones, meeting information and more with our CSI-RI practices.
Practice Spotlight: How a Nurse Care Manager Helped a Patient Reduce ER Visits

Nurse Care Managers work hard every day to increase the quality of care for their patients. Recently, in a CSI-RI practice, a Nurse Care Manager played an influential role in one patient's treatment plan resulting in a decreased number of costly emergency room visits and improvement in the patient's quality of life.


The patient, a 53 year-old male whose diagnoses included chronic obstructive pulmonary disease, chronic cor pulmonale, chronic kidney disease, non-insulin dependent diabetes mellitus, anxiety, insomnia, personality disorder and oxygen dependency, visited the emergency room 91 times from January - June 2014, costing approximately $148,000.00.  


The Nurse Care Manager and hospital team met to develop a plan to make ER visits less social for the patient and educate him to call his primary care office prior to going to the ER. This plan included weekly visits with his Primary Care Physician, weekly phone calls and visits with the Nurse Care Manager and Social Services, coordination of care with Visiting Nursing Services, prepackaged delivery of medication and a referral to Behavioral Health for counseling and psychiatric consult. The patient's Nurse Care Manager was very involved with the patient's treatment plan and even joined the patient and his mother for the first counseling visit to foster trust between him and the counselor.


Since the implementation of this treatment plan and work with the Nurse Care Manager, the patient has decreased his ER visits. In fact, from June - July 2014 the patient did not visit the emergency room. The patient is now independently managing his Behavior Health visits, has increased his activity tolerance, lost weight and is no longer oxygen dependent. Further, the patient no longer requires weekly visits with his Primary Care Physician, but continues weekly contact with his Nurse Care Manager for support. More importantly, the patient reports better quality of life. 

Update on 2014 Expansion

Consistent with our strategic plan, CSI-RI has invited primary care practices that are committed to transforming their practice to provide high-value patient-centered care to apply to become part of CSI-RI. The Selection Committee is in the process of reviewing these applications with the intent of making final recommendations to the CSI-RI Executive Committee by October 24, 2014. Applicants will be notified of the selection decision by November 7, 2014. 

CSI-RI Calls on Bureau of Labor Statistics to Adopt APHA Definition

Currently, the federal government utilizes various, inconsistent definitions of "Community Health Workers" (CHWs). To help eliminate confusion, a streamlined definition has been developed by CHWs and stakeholders throughout the public health community, endorsed by American Public Health Association. A standard definition is particularly important in this era of health reform because of the important and increasing role CHWs play and as states consider new ways to finance medical services.


CSI-RI Co-Directors Deb Hurwitz and Pano Yeracaris recently submitted a letter requesting that the Department of Labor Bureau of Labor Statistics adopt this nationally recognized definition to describe CHWs. In CSI-RI, we are planning to use CHWs within our new Community Health Teams, working with patients that have been designated as high-risk and are seen as an essential component for patient advocacy and assisting patients with navigating the health care system. 

Meaningful Use Update from RIQI

New CMS rule allows flexibility in certified EHR technology for 2014

On August 29, 2014, the Centers for Medicare & Medicaid Services issued its final rule regarding changes to the Meaningful Use stage timeline and the definition of certified electronic health record technology (CEHRT) to allow options in the use of CEHRT for a 2014 EHR reporting period. The rule was published in the Federal Register on September 4, 2014.


The rule allows eligible providers to use 2011 CEHRT, or a combination of 2011 and 2014 edition CEHRT to meet Meaningful Use. Eligible professionals (EPs) must use a 2014 edition CEHRT in 2015.


Under this final rule, Stage 2 of the Meaningful Use incentive program will be extended through 2016 and Stage 3 will begin in 2017 for certain providers.  


The effective date of the change is October 1st, 2014.  It's important to read through the rule as it appears in the Federal Register, to determine whether or not you can attest that you're "unable to fully implement 2014 edition CEHRT for an EHR reporting period in 2014 due to delays in the availability of 2014 Edition CERHT".  The Rhode Island Regional Extension Center can assist you with questions and can be reached at 888-858-4815 or at [email protected] 

Patient Spotlight: Gil Bricault

"It is one thing to have good primary care health services, it is another thing to have patients know how to use the primary care health services to their benefit," said Gil Bricault, a patient at Wood River Health Services, a patient-centered medical home in Hopkinton. Gil recently found himself utilizing the enhanced patient services offered at his practice, saving him valuable time and money.


Gil Bricault 

Gil was enjoying a relaxing day fishing alone on a lake when he cut his hand on an old knife in his tackle box. After stopping the bleeding, Gil realized he might need a tetanus shot. Knowing the emergency room can be costly and time-consuming, he decided to call Wood River Health Services.


When Gil called his practice he was transferred to a nurse who asked a few simple questions about his injury and was able to quickly access and examine his medical records. Much to Gil's surprise, there was no need for him to get a tetanus shot because the nurse saw that he had gotten one a few years prior. She advised him to clean the wound, call back if he showed any sign of infection and to enjoy the rest of his day fishing.


For Gil, this experience reconfirmed the importance of taking advantage of the services offered to him by Wood River Health Services. He is thankful that his primary care team has taken the time to talk about the services and benefits of being a patient at a PCMH. Gil's quick access to care information during extended hours is just one example of the many ways CSI-RI patient-centered medical homes, like Wood River Health Services, are supporting the unique health needs of more than 220,000 Rhode Islanders. 

In Case You Missed It: 

RI Included in PCMH Pilot Evaluation Study
Recently, a study was published in the American Journal of Managed Care that evaluated the structural capabilities associated with the PCMH model in PCMH pilots in Colorado, Ohio and Rhode Island. Further, the study evaluated changes in capabilities over two years in our RI pilot and evaluated facilitators and barriers to the adoption of capabilities. 

Sustaining Multi-Payer Medical Home Programs: 7 Recommendations for States
As multi payer medical home initiatives begin to expand across the country, Sarah Kinsler and Barbara Wirth published a great article highlighting what other states have done to make their pilot programs successful. In this article CSI-RI is highlighted for its work on participating practices and plans contracts. 

AARP Public Policy Spotlight

CSI-RI has been included in an AARP Public Policy series focusing on the evolving role of nurses in new delivery system models designed to better meet the needs of patients with chronic health conditions. This particular case study highlights the role of Nurse Care Managers in CSI-RI practices and how policy decisions have provided more support to chronically ill patients. 

Research Triangle Institute: MAPCP - PCMH - CAHPS Study

The Research Triangle Institute has published a study with the objective of determining how experiences reported by beneficiaries in MAPCP demonstration practices compare to the national average in six key domains. Rhode Island practices scored the highest out of all eight states that were part of the study in both access to care (80-85 out of 100) and communication with providers (93-95 out of 100). 


"Milbank: Aligning Payers and Practices"

Milbank Memorial Fund published a study, "Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative" by Lisa Dulsky Watkins, MD, discussing different ways primary care transformation initiatives can improve collaboration between payer, practices, and the initiative. 

Free Cultural Competency Training Program For CSI-RI Practices
Cultural competence is an extremely important aspect of practicing medicine. Thanks to Blue Cross & Blue Shield of Rhode Island who recognizes this and wants to help keep our practices as informed as possible, three computer-based programs are being offered at no cost to CSI-RI practices. This training will help meet cultural competence requirements set forth by NCQA® PCMH recognition standards as well as help providers and nurses fulfill continuing education credits.

There are modules available with both an adult and pediatric focus. The course features three patient cases and allows physicians, physician assistants, and nurse practitioners to participate in realistic clinical encounters that teach a skill set for effective cross-cultural care and communication. 

For more details, click here.
Lifespan Healthy Rewards Program - Ending Soon!
The Lifespan Healthy Rewards program for 2014 is coming to a close on Friday, October 31. Learn more about how practice staff can assist patients participating in this program earn up to $300 in incentives, and how practices can receive fees for completing patient forms, in addition to a follow-up visit fee. Learn more here.
Upcoming CSI-RI Meetings
  • October 2, 2014 - 7:30-9:00 am - PCMH-Kids Stakeholder Meeting301 Metro Center Blvd., Warwick (Committee Members only)
  • October 2, 2014 - 3:00-4:00 pm - CSI-RI Selection Committee - RIQI - (Members only)
  • October 3, 2014 - 8:30-9:30 am - CSI-RI Leadership (call in) - (Leadership Members only)
  • October  7, 2014 - 7:30-9:00 am - Data and Evaluation Committee  - Memorial Hospital - Center for Primary Care, Pawtucket 
  • October 8, 2014 - 7:00-9:00 am - CSI-RI Selection Committee - BCBS, 500 Exchange Street, Providence (Members only)
  • October 9, 2014 - 12:45-7:30pm - CSI-RI Learning Collaborative, "Primary Care: The Future is Now!" - The Radisson, 2081 Post Road, Warwick, RI (attendees must have registered by September 22) 
  • October 10, 2014 - 7:30-9:00 am - Steering Committee - RIQI
  • October 14, 2014 - 8:00-9:30 am - Nurse Care Management Best Practice Sharing Committee - RIQI
  • October 16, 2014 - 7:30-9:00 am - Practice Transformation Committee - RIQI
  • October 16, 2014 - 3:30-5:00 pm - Integrated Behavioral Health Committee - RIQI
  • October 17, 2014 - 7:00-9:00 am - CSI-RI Selection Committee - BCBS, 500 Exchange Street, Providence (Members only)
  • October 20, 2014 - 7:00-9:30 am - South County Steering Committee - South County Hospital - 3rd Floor Administrative Conference Room
  • October 24,2014 - 7:30-9:00 am - Executive Committee - Blackstone Valley Community Health Care -39 East Ave, Pawtucket, RI 
  • October 24, 2014 - 9:30-11:00 am - Community Health Team Planning - Blackstone Valley Community Health Care -39 East Ave, Pawtucket, RI
  • October 27, 2014 - 10:00-11:30 am - Program Evaluation Committee - Rhode Island Foundation - One Union Station, Providence, RI
  • October 28, 2014 - 8:00-9:30 am - Practice Reporting Committee - RIQI
CSI-Rhode Island
Rhode Island Foundation
One Union Station, Providence RI 02903