Practice Newsletter - March 2015  
Care Transformation Collaborative of Rhode Island
Welcome to the Care Transformation Collaborative of Rhode Island Newsletter, where CTC shares exciting updates, news, milestones, meeting information and more.

NCM Reporting on High Risk Patients Activity: Recommendations for Getting Started

Select CTC practices, together with health plans, have been working for the past year to help develop a team-based system to support NCM focus on high risk patients; test and determine the feasibility of proposed high risk definitions and reporting systems; and develop stronger communication and collaborative with the health plans. In the past two months, practices that have been part of this learning collaboration have provided helpful information for other practices to consider as they seek to focus efforts on working with high risk patients.  Practices can find the most current version of the NCM specifications and the anticipated reporting template here


What actions do practices want to start taking?

  • Start creating a practice level registry for patients when they use the ER or have inpatient admission.
  • Identify how to capture patient activity (emergency room visits/inpatient admissions) within electronic health records or on an Excel spread sheet.
  • Form a team that can identify present and future work flows around how transition of care information comes into the agency; who can be assigned functions such as entering information into the electronic health record/Excel spread sheet; how information will be communicated within the practice around patient activity; and who will be assigned to follow up with patients who experience transitions of care.
  • Create work processes, policies and standards that support and use the entire team when supporting high risk patients.
  • Provide training for staff who are assigned new functions, do PDSA's  and provide feedback to improve performance.

Make sure that nurse care manager activity is captured in reportable fields

  • Identify how you plan to capture nurse care manager activity in reportable fields (telephone, home visits, office visits, web-based visits).
  • Form a team that can identify the present state of NCM documentation and what might need to be adjusted to capture and report NCM activity.

Use your resources

  • Practice reporting staff and NCM's from NCM pilot sites are available to provide guidance as you prepare to get started.
  • Practice facilitators are available to assist with understanding your present and desired work flows. Relationship managers are helpful resources for working with electronic health record vendors.
  • Deep Domain may be an option to consider if your site anticipates having difficulty with reporting from the electronic health record.  Presently, Deep Domain and Blackstone Valley Community Health Center are working together to report on nurse care manager activity with high risk patients.

Next Steps:  Anticipated time frame for reporting on NCM activity with high risk patients

  • CTC anticipates that practices (Transition, PY1, and PY2) will begin reporting NCM activity during the reporting period July 1, 2015-September 30, 2015 with the first report due October 15th 2015.
  • Health plans are working to better identify the "right" patients for the practices to focus on based on retrospective and prospective methodology. Health plans are looking to create information systems that are actionable in real time and provide practices with health plan care management resources that are available within the health plan.

Feedback from practices that have been developing systems and strategies over the course of the year indicate that it takes time to develop an effective and efficient system using a team-based approach to support patients who are at greatest risk of poor health outcomes. However, practices also report that it is important work that can improve patient care and reduce health care costs. 

Practice Spotlight: University Family Medicine - Process Mapping Information on Emergency Room and Inpatient Admission Activity

As practices start to create their own registries of high risk patients, it is helpful to consider and understand "current state" of what transition in care information is coming into the practice, who touches that information and how that information will be captured in the electronic health record. This is just what the practice team at University Family Medicine did. Working together with their practice facilitators, the team looked at the role of each team member with the goal of envisioning a future with more work place efficiency and standardization. During the team meetings, staff members shared best practices and developed standard practices to increase the use of the electronic health record in communicating information. Gina De Burgo, Practice Manager from University Family Medicine, and Practice Facilitators, Aimee Schayer and Jackie Lefebvre shared their success at the March Practice Transformation Committee. To view their presentation click here

NCQA Corner: Care Coordination, Care Transitions and Utilization Standards

The work that CTC practices are doing to look at high risk patients and nurse care manager activity will be helpful in meeting the 2014 NCQA Standards related to Standard 5: Care Coordination and Care Transitions and Standard 6: Performance Measurement and Quality Improvement. 


Standard 5 is looking at the coordination of care that patients receive from hospitals and other facilities and is expecting primary care practices to systematically coordinate transitions in care.


Standard 6 asks primary care practices to measure resource use and care coordination. The nurse care manager measurement system will be useful in helping practices report on utilization (patients who are high utilizers of the ER/IP) and report on care coordination (nurse care manager activity with high risk patients).


A summary of the 2014 NCQA Standards related to care coordination and utilization can be found here.

CTC in the News 

Al Kurose, MD, FACP, President and CEO of Coastal Medical and member of the Institute for Healthcare Improvement Leadership Alliance shared Coastal Medical's experiences becoming an ACO in a IHI blog post

Roberta Goldman PhD, Donna Parker ScD, Joanna Brown MD, MPH, BA, Charles Eaton MD, MPH and Jeffrey Borkan MD, PhD published an article "Recommendations for a Mixed Methods Approach to Evaluating the Patient Centered Medical Home" in Annals of Family Medicine. In the article, they reported on the development of a comprehensive mixed qualitative-quantitative evaluation set for researchers, policy makers and clinical groups to consider when evaluating whether the patient centered medical home model produces desired results. 


CTC would like to extend our congratulations to South County Walk-In and Primary Care and Womens Medicine Collaborative for achieving NCQA Level 3 recognition. 

Physician Encourages Patients to Enroll in CurrentCare

Dr. Lynn Ho, a family practitioner at North Kingstown Family Practice, has enrolled over 70% of her patient panel in CurrentCare, making her the highest enrolling physician in the state.  In a recent newsletter at her practice, Dr. Ho encouraged her patients not yet enrolled to do so, citing the benefits of CurrentCare:


"....I've found CurrentCare to be an invaluable tool for your care in hunting down labs, X-rays and medications prescribed or ordered by other doctors.  I am following this newsletter with a separate email to those of you who have not signed on yet with directions on how to enroll online if interested." 


There are now more than 446,000 people enrolled in CurrentCare.  Please contact the RI Quality Institute at 888-858-4815 to learn more about:

  • How to become an enrollment partner
  • How to create an email campaign to encourage your patients to enroll
  • CurrentCare Viewer and how to utilize it in your practice
  • CurrentCare Hospital Alerts

Practice Resources 
For more information about  the patient centered medical home initiative and patient centered care check out these great resources: 

Patient Centered Medical Home Resource Center "US Experience with Doctors and Patients Sharing Clinical Notes"

Annals of Family Medicine: "Recommendations for a Mixed Methods Approach to Evaluating the Patient-Centered Medical Home"

Annals of Family Medicine: "Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge" 

Presentation by Lisa Dulsky Watkins, MD: "Transforming Primary Care Through Patient Reform"

PCMH Job Opportunity:  

Barrington Family Medicine, a small family practice located in East Bay, is seeking a Nurse Care Manager. This position offers flexible hours (7-15 hours a week). Click here to view the job description. 

If interested please contact [email protected]

Upcoming Events

Team Based Care: Working Together to Improve Patient Outcomes 

March 27, 2015 8:30-9:30 AM

Learn more and register


Neurology Update, 2015

March 28, 2015 7:00am - 3:25 PM 

Learn more and register 


3rd Annual New England Sports and Orthopedic Rehabilitation

Summit 2015

April 11, 2015 7:00am - 4:30 PM

Learn more and register  


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

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

Learn more and register 


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

April 30, 2015 5:15 - 7:30 PM

Learn more and register

Upcoming Meetings:

March 27, 2015 7:30-9:00 AM   

Board of Directors, BVCHC, 39 East Ave, Pawtucket


March 27, 2015 9:30-10:30 AM

Community Health Team Planning, BVCHC, 39 East Ave, Pawtucket

April 2, 2015 7:30-8:30 AM

PCMH Kids Stakeholder, 301 Metro Center Blvd, Warwick

April 3, 2015 8:00-9:00 AM

CTC Leadership Call 

April 7, 2015 7:30-9:00 AM

Data and Evaluation, Memorial Hospital Center for Primary Care, 111 Brewster St, Pawtucket 

April 8, 2015 12:30-2:30 PM

Practice Facilitation, RIQI

April 10, 2015 7:30-9:00 AM

Steering Committee, RIQI

April 14, 2015 8:00 -9:30 AM

NCM Best Practice Sharing Collaborative, RIQI

April 10, 2015 9:30-10:30 AM

Community Health Team Planning, RIQI 

April 14, 2015 8:00 -9:30 AM

NCM Best Practice Sharing Collaborative, RIQI

April 16, 2015 7:30-9:00 AM

Practice Transformation Committee, RIQI 

April 16, 2015 2:30-3:30 PM

Integrated Behavioral Health Subgroup, RIQI


April 16, 2015 3:30-5:00 PM

Integrated Behavioral Health, RIQI 

April 17, 2015 8:00-9:00 AM

CTC Leadership Call 

April 20, 2015 7:00-8:30 AM

South County Steering, South County Hospital 

April 22, 2015 12:30-2:30 PM

Practice Facilitation, RIQI 

April 24, 2015 7:30-9:00 AM

CTC Board of Directors, BVCHC 39 East Avenue, Pawtucket


April 24, 2015 9:30-10:30 AM

Community Health Team Planning, BVCHC 39 East Avenue, Pawtucket 

April 27, 2015 7:30-9:00 AM

Program Evaluation, RIQI 

April 28, 2015 7:30-9:00 AM

Contracting Committee, RIQI


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