Practice Newsletter - February 2015  
Care Transformation Collaborative of Rhode Island, Formally CSI-RI

NCQA Corner:

The changes made to the 2014 NCQA standards strengthen the "whole person" orientation within the patient centered medical home and provide better support for patients with behavioral health needs.


An outline of the NCQA standards related to behavioral health can be found here


CTC would like to extend our congratulations to Dr. Machata, M.D. from Wickford Family Medicine for achieving NCQA Level 3 recognition. 

Upcoming Events

Contemporary Diagnostic Imaging and Interventional Radiology for Primary Care 3.0

March 4, 2015 12:00-5:10pm

Learn more and register 


Rhode Island Alzheimer's Disease Research Conference

March 5, 2015 9:00am - 6:30pm 

Learn more and register  


Learner Feedback: How to Process and Respond to Challenging Evaluations

March 10, 2015 5:00-7:00pm

Learn more and register  


PANS, PANDAS. and Acute Onset Neuropsychiatric Syndrom

March 14, 2015 7:00am - 4:30pm

Learn more and register


Neurology Update, 2015

March 28, 2015 7:00am - 3:25pm 

Learn more and register 


3rd Annual New England Sports and Orthopedic Rehabilitation Summit 2015

April 11, 2015 7:00am - 4:30pm 

Learn more and register  


2nd Annual Brown Arrhythmia Symposium: State-of-the-Art Update

April 17, 2015 7:00am - 5:00pm

Learn more and register 


How to Address the Sexual Health Needs of Your Patients and Their Partners

April 30, 2015 5:15 - 7:30pm 

Learn more and register


20th Annual Rhode Island Anesthesia Conference

May 2, 2015 

Learn more 

Upcoming Meetings:

Feb 27, 2015 - 7:30-9:00 AM 

Board of Directors, BVCHC, Pawtucket


March 3, 2015 - 7:30-9:00 AM

Data and Evaluation, Memorial Hospital Center for Primary Care, Pawtucket


March 5, 2015 - 7:30-9:00 AM

PCMH Kids Stakeholder, 301 Metro Center Blvd., Warwick


March 6, 2015 - 8:00-9:00 AM 

CTC Leadership, RIQI


March 10, 2015 - 8:00-9:30 AM

Nurse Care Manager Best Practice, RIQI


March 11, 2015 - 12:30-2:30 PM

Practice Facilitation, RIQI


March 13, 2015 - 7:30-9:00 AM

CTC Steering, RIQI


March 13, 2015 - 9:30-10:30 AM 

Community Health Team Planning, RIQI


March 16, 2015 - 7:00-8:30 AM

South County Steering, South County Hospital


March 19, 2015 - 7:30-9:00 AM 

Practice Transformation, RIQI


March 19, 2015 - 2:30-3:30 PM 

Integrated Behavioral Health Subgroup, RIQI


March 19, 2015 - 3:30-4:30 PM

Integrated Behavioral Health Workgroup, RIQI


March 23, 2015 - 9:00-10:30 AM

Program Evaluation, RIQI


March 24, 2015 - 7:30-9:30 AM

Practice Reporting, 301 Metro Center Blvd., Warwick


March 25, 2015 - 12:30 - 2:30 PM

Practice Facilitation, RIQI


March 27, 2015 - 7:30-8:30 AM     Board of Directors, BVCHC, Pawtucket

March 27, 2015 - 9:30-10:30AM  Community Health Team Planning, BVCHC, Pawtucket


For meeting details or to receive a calendar invite please contact:
Cathy Sampson
CTC of Rhode Island
Rhode Island Foundation
One Union Station
Providence, RI 02903
Welcome to the Care Transformation Collaborative of Rhode Island (formally the Rhode Island Chronic Care Sustainability Initiative) Newsletter, where CTC shares exciting updates, news, milestones, meeting information and more.
2015 CTC Common Contract
Throughout the year, members of the Contract Committee meet to consider enhancements to the CTC Common Developmental Contract to improve performance results and achieve program goals. This past year, the Contract Committee placed more emphasis on practice accountability for infrastructure development to support practice transformation and achievement of the triple aim outcomes.  

Other changes include providing practices entering Transition with financial support  to develop a team based approach to support care coordination for high risk patients. The Nurse Care Manager job description has also been modified to provide more clarity on the functions of supporting for high risk patients.  

The Health Plans sent the revised CTC Common Contract to the practices that entered the CTC Initiative in 2015. CTC practices that have entered in 2008, 2010 and 2013 will be receiving contract amendments to extend the term of the contract from April 1, 2015 to June 30, 2015. Practices that are presently in PY 2 and PY 2a will become part of the Advanced Collaborative and will receive a new contract with a term of July 1, 2015 to December 31, 2015. 

New practice expectations will also be delineated in the addendum.  A summary of the contract  changes can be found here.  
Welcome Aboard to our New CTC Practices
CTC management, together with the practice facilitators and relationship managers, are very excited to welcome our 25 new practices sites. Visits are being made to all the new practice sites and we are so impressed with the energy and talent that these practices bring to our collaborative. 

Practice facilitators and relationship managers have been assigned to each new practice site and details of those assignments can be found here

CTC has developed a revised "Scenario" document to assist practices with deliverable due dates , based on the CTC Common Contract.

All CTC practices are urged to "Save the Date" (5/5/15) for the Nurse Care Manager Orientation program, where we will offer special program for the new Nurse Care Managers and Best Practice Sharing for all Nurse Care Managers.

CTC in the News

A recent article published on the AAFP website highlighted CTC and the patient centered medical home initative in Rhode Island. The article "Public, Private Help Smooth Transition to Medical Home", dove into the tranistion process and financial implications practices face when transitioning to a patient centered medical home. The article featured comment from Debra Hurwitz. M.B.A., R.N Co-Director of CTC, Gregory Steinmetz, M.D., physician at Associates in Primary Care, and Thomas Bledsoe, M.D. Co-chair of CTC's Executive Committee. 

Integrated Behavioral Health Education and Training Program Is Off and Running! 

Eleven CTC practice sites have been selected to participate in the Integrated Behavioral Health Education and Training program, funded by Tufts Health Plan. Participating practice sites completed the Maine Foundation Needs Assessment and are in the process of setting goals using the Goal Attainment Scale. Nelly Burdette, PsyD, Direction of Integrated Behavioral Health at Providence Community Health Center will be facilitating monthly face-to-face meetings with the practice site integrating teams over the course of the next  year. Practice sites will also have the option of obtaining feedback through a clinical shadowing experience. A summary of the work that has been done to date and more information on this program can be found here

All CTC practices will have the opportunity to participate in quarterly "Lunch and Learn" sessions. Topics for the learning sessions were selected based on feedback CTC practices provided in the needs assessment survey conducted last fall.

The first webinar "Assessment and Treatment of Suicidality in Primary Care" will occur on 4/17/15.  

Medicare's Chronic Care Management Code PaymentsWhat Does This Mean for the Multi Payer Advanced Primary Care Demonstration Project (MAPCP) Practices? 

As of, January 1, 2015, Medicare has started to pay for certain non-face-to-face care management services provided for Medicare beneficiaries covered under the traditional Medicare fee-for-service program. Because the CCM service code is intended to cover services similar to what is paid for in the MAPCP program, Medicare will not pay both a demonstration model care management fee and a CCM for any individual beneficiary in the same month. CMS recently published a  Frequently Asked Questions document to assist practices participating in MAPCP to understand the billing guidelines. 
Current Care Viewer: Adding Value to Quality Reporting 

At a recent Practice Reporting meeting, advanced CTC practices reported that it's a best practice to create exception reports in their ongoing quality reporting process.  They create lists of patients who have not had their lab/test in the required time frame and then order the test for the patient. Some practices have also started checking the CurrentCare Viewer before they ordering the lab or imaging study.


"I regularly review our cardiac and diabetic patient databases. If a patient has old LDL/A1C results, then I go into CurrentCare. I am quite often able to see lab reports ordered by other providers...getting labs from CurrentCare can be faster than getting hospital records." Patty Kelly-Flis, Director of Quality, WellOne Primary Medical & Dental Care.

Best practice workflow:

  1. Run exception reports at least quarterly for those who have not had an A1C / mammogram / etc.
  2. Check the patient's record in the CurrentCare Viewer to see most recent labs or imaging reports (use the Lab Results or Diagnostic Imaging tabs to the left of the screen, or use the Summary Report)
  3. If recent information is not located in the patient's CurrentCare record, then order the tests needed.

Enrollment Continues!


We still need your help with signing up patients for CurrentCare!

If you need new forms, posters, or a pickup of completed forms,please contact Rhode Island Quality Institute at 1-888-858-4815 or [email protected]