Care Transformation Collaborative of RI
January 2015 Newsletter
Welcome to the Care Transformation Collaborative (CTC) of Rhode Island's Newslette
, where CTC, formally the R.I. Chronic Care Sustainability Initiative, shares exciting updates, news, milestones, meeting information and more.
CSI-RI Announces Name Change to CTC
The Rhode Island Chronic Care Sustainability Initiative is proud to announce that they have changed their name to the Care Transformation Collaborative of Rhode Island (CTC). The change was made to reflect CTC's commitment to transforming the broader delivery of health care throughout the state, reaching levels beyond adult primary care. 

CTC will continue to focus around transforming primary care practices into patient-centered medical homes. CTC will continue to enhance care quality, access and management of patient care, as well as team-based comprehensive and preventative care.

To read more about CTC's name change, click here.
Nurse Care Manager Spotlight: Congratulations to Karen Sciamacco

CTC would like to congratulate Karen Sciamacco, RN, BS, CCM, CDOE, Nurse Care Manager at Associates in Primary Care Medicine in Warwick, RI, who was recently recognized as Certified Diabetes Outpatient Educator (CDOE) of the year.


"I was very honored to be recognized," said Karen, who spoke with CTC about the recognition and her work as a Nurse Care Manager. "Every day there are successes. I get up in the morning and know this is where I should be right now." Karen indeed has had many successes and she shared one example that illustrated the partnerships she creates with patients who have diabetes and their family members, and how this joint work has resulted in significant patient health care improvements.


The patient, a 44-year-old male with unique learning needs, was diagnosed with type two diabetes and had a HbA1c of 10.6. Karen and her team worked together with the patient and his mother to provide him with diabetes education, a unique care plan, and worked with his insurance to obtain a glucometer and insulin pen. During a follow up visit, the patient's HbA1c had elevated to 11.3. The patient shared that he was not testing his blood sugar and did not want to prick his finger, so Karen and her care team worked with the patient and his mother to create a plan that addressed his specific needs. Since then, the patient has shown a willingness to learn how to self-manage and accept assistance from his family members to successfully manage his chronic condition. The patient has regular visits with his primary care physician and meets with Karen every 1-2 weeks. He attends diabetes group visits held at the primary care office and has learned to make healthier food choices. Recently the patient reported a HbA1c of 6.2, a four point decrease from the year before. 


The key to success is understanding the patient and family needs and strengths. According to Karen, "Each patient has a unique set of circumstances and barriers that I work with and find solutions for." 


Each day, nurse care managers, primary care providers and other health team members' work with patients and their families to help manage their health care needs in unique and innovative ways.  This joint work, many times, drastically improves health care outcomes.  Karen is one of 18 nurse care managers in CTC who are certified diabetes outpatient educators and work every day to save lives and improve quality of life.

Practice Spotlight: Coastal Hillside Family Medicine 

Coastal Hillside Family Medicine has been working to improve their patient experience through a team approach. Coastal Hillside reviewed their protocols and processes for such items as medication refills, telephone management and billing and collections and re-tooled them based on patient, staff and provider input.  With funding from CTC's Partnering in Best Practice program, Hillside hosted a four hour workshop style retreat with staff and providers to consider how to better cultivate a patient ambassador approach in the work place and on a consistent basis recognize small and large successes. Click here to learn more

2015 New Practice Orientation

Last month, CTC hosted a new practice orientation where the 25 newly accepted practices were introduced to the CTC management team and key stakeholders, and provided an overview of the CTC developmental contract, reporting requirements, committees and available resources. The event was well attended and CTC leadership was excited to welcome and meet the new practice care team members.

Photo by Richard Asinof, ConvergenceRI

NCQA Achievements: 

New NCQA Level 3 Recognition   

CTC would like to extend congratulations to Dr Del Sesto, Denise Leonard, Susan Corner, and the entire practice staff on achieving NCQA Level 3 Recognition.  


Congratulations to the New NCQA Content Experts   

Rhode Island can boast that it now has 14 people that have successfully achieved NCQA Patient Centered Medical Home Content Expert status.  PCMH content experts are required to complete two NCQA educational seminars, pass a comprehensive exam and commit to continuous learning and recertification to maintain the credential.  Congratulations to the following professionals who achieved this content expert status in December 2014.

  • Victoria Adewale, MSc, Brown Practice Facilitation Team
  • Joanna Brown MD, MPH Practice Transformation Director, Brown Primary Care
  • Susanne Campbell RN MS Senior Project Director CTC Management Staff
  • Kerri Costa MBA, Manager Regional Extension Center (REC), RIQI
  • Suzanne Herzberg PhD, MS, OTR/L Brown Practice Facilitator Supervisor 
Rhode Island has been Awarded $20 Million SIM Grant 
Last month, officials announced that Rhode Island had been awarded a $20 million federal grant to fund and transform Rhode Island's health care delivery system.  According to Elena Nicolla, Chief of Policy and Innovations at RI Health and Human Services, the State Innovation Model (SIM) grant "will help move Rhode Island's system of care to one that reimburses based on the outcomes patients experience and one that focuses on prevention." 

For more information about the SIM Grant click here
CTC in the News 

Practice Resources 

The Million Hearts Campaign aims to increase by 10 million, the number of people in the United States whose blood pressure is under control.  This initiative, which is co-led by CDC and CMS, recently published a guide of clinicians with action steps and resources on self-measured blood pressure monitoring.  For more information click here.

Upcoming Events 
Rhode Island Certified Diabetes Outpatient Educator's Course Application Deadline - January 30, 2015 -  CDOE Application 
AEI Preparatory Course for Asthma Educator Certification - February 5-6, 2015 - Learn More
Contemporary Diagnostic Imaging and Interventional Radiology for Primary Care 3.0 - March 4, 2015 - Learn more
Rhode Island Alzheimer's Disease Research Conference - March 5, 2015 9:00am - 6:30pm - Learn more and register

Upcoming CTC Meetings
  • Feb 3, 2015, 7:30-9:00 AM  - Data and Evaluation, Memorial Hospital CTR for PC, Pawtucket
  • Feb 5, 2015, 7:30-8:30 AM  - PCMH Kids Stakeholder, 301 Metro Ctr BLvd, Warwick
  • Feb 6, 2015, 8:30-9:30 AM - CTC Leadership Call
  • Feb 10, 2015, 8:00-9:30 AM - Nurse Care Manager Best Practice Sharing Collaborative, RIQI
  • Feb 10, 2015, 8:00-9:30 AM - Practice Facilitation Collaborative, RIQI
  • Feb 13, 2015, 9:30-10:30 AM  - Steering Committee, RIQI
  • Feb 13, 2015 -9:30-10:30 AMCommunity Health Team Planning, RIQI
  • Feb 16, 2015 -7:00-8:30 AM - South County Steering Committee, SC Hospital
  • Feb 16, 2015 7:30-8:30 AM - CTC/PCMH Kids Leadership, Hazard Bldg, Cranston 
  • Feb 19, 2015 -7:30-9:00 AM - Practice Transformation Committee, RIQI
  • Feb 19, 2015 3:30 -5:00 PM - Integrated Behavioral Health Planning Workgroup, RIQI
  • Feb 23, 2015 -9:00-10:30 AM - Program Evaluation, RIQI
  • Feb 24, 2015 -7:30-9;30 AM - Practice Reporting, RIQI
  • Feb 24, 2015 -7:30-9:00 AM - Contracting Committee, RIQI
  • Feb 24, 2015 - 1:00-3:00 PM - Practice Facilitation, RIQI
  • Feb 27, 2015 - 7:30-9:00 AM - Board of Directors, BVCHC, Pawtucket
  • Feb 27, 2015- 9:30-10:30 AM - Community Health Team Planning, BVCHC, Pawtucket, 

For meeting information or to receive a calendar invite please contact: 



CTC of Rhode Island
Rhode Island Foundation
One Union Station, Providence RI 02903