July 2015  
Care Transformation Collaborative of Rhode Island

Quarterly Advanced Collaborative Learning Session 

Friday September 11, 2015, 7:30am-9:30am
Crowne Plaza Hotel Warwick

ALL practice physician champions and practice leaders should attend.

Topics will include:
- Current direction for primary      care and what it means for you  and CTC
- Advanced learning on high risk    identification and engagement
- Additional highlights from the    Advanced Collaborative work in  the Clinical Strategy and Cost  Committee

We are at a critical inflection point in primary care and health system transformation in the state. CTC practices have the opportunity to strengthen the voice and influence of primary care in this process. Interaction and dialogue will be encouraged.


CTC would like to congratulate 

Thundermist Health Center for receiving NCQA Level 3 recognition. Thundermist Health Center is the first CTC primary care practice to receive NCQA PCMH recognition under the NCQA 2014 Standards.  

PCMH Kids Featured on RI Kids Count TV Show 
featuring Dr. Patricia Flanagan and Dr. Elizabeth Lange of PCMH Kids as they discuss RIte Care and Patient Centered Medical Homes for children. 
NCQA Corner: Learn More About the 2014 Standards
The August Practice Transformation
Committee (August 20 from 7:30 to 9:00am at RIQI) will feature a round table discussion with practices that are submitting under the NCQA 2014 standards this summer. 
Plan to attend to learn how practices are preparing for meeting the new standard requirements.
Register for the CTC Integrated Behavioral Health Webinar: "Skills Not Pills" September 17, 2015
Plan to attend and register for the third Integrated Behavioral Health Webinar: "Skills Not Pills" presented by Nelly Burdette PsyD. The webinar will be held at Healthcentric Advisors (235 Promenade St., Suite 500, 5th floor) from 7:30 - 9:00am, in place of the September Practice Transformation Committee. Practices can also participate remotely through Adobe Connect, details to follow. 

CTC would like to extend a special thanks to Tufts Health Plan who provided funding for this learning opportunity.
Webinar Learning Opportunity: Understanding Your Patients Cultural Needs
Blue Cross and Blue Shield of Rhode Island is offering CTC practices the opportunity to complete the webinar training "Understanding Your Patients' Cultural Needs." Clinical staff (physicians, nurses, mid-level providers) who complete the learning modules by October 1, 2015 will receive 3 free CME/CEU credits.

Upcoming Events 
Geriatrics-Competent Care: Caring for Individuals with Alzheimer's Disease (webinar) 
August 5, 2015 12:00PM - 1:30PM and August 12, 2015 12:00PM - 1:30PM 

The Fourth Annual Diabetes Master Series: Solving the Puzzle
August 15, 2015 7:00AM-2:30PM
Learn more and register
View Recorded CDM Lectures 
You are now able to view past CDM lectures from anywhere, as long as you have internet access and Microsoft Silverlight installed.

Watch the lecture, pass the post-test, provide feedback and receive your certificate!

Register to access the CDM library.
Practice Resources

"Accountable Care Guide For Hospice/Palliative Care" - The Carolinas Center for Hospice and End of Life Care 

CTC in the News 

"Five Questions With: Meryl Moss" - Providence Business News (July 27, 2015) 


"Standards to improve health care delivery, payment systems adopted" - Providence Business News (July 28, 2015) 

Upcoming Meetings:

August 4, 2015 7:30-9:00 AM

Data and Evaluation (Memorial Hospital Center for Primary Care)


August 11, 2015 8:00-9:30 AM

Nurse Care Manager Best Practice (RIQI)


August 17, 2015 7:00-8:30 AM South County Steering (SC Hospital)


August 20, 2015 7:30-9:00 AM Practice Transformation (RIQI)


August 20, 2015 3:00-4:30 PM Integrated Behavioral Health (RIQI)


August 21, 2015 7:30-9:00 AM Clinical Strategy and Cost Committee (Thundermist Warwick)


August 24, 2015 9:00-10:30 AM Program Evaluation Committee (RIQI)


August 25, 2015 7:30-9:00 AM

Contracting Committee (RIQI)


August 25, 2015 8:00-9:30 AM Practice Reporting (RIQI)


August 28, 2015 7:30-9:00 AM CTC Board of Directors (BVCHC)


August 28, 2015 9:30-10:30 AM Community Health Team Planning (BVCHC)


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

Nicole Mossey
CTC of Rhode Island

235 Promenade Street

Suite 500, Box 18

Providence, RI 02908

Welcome to the Care Transformation Collaborative of Rhode Island Newsletter, where CTC shares exciting updates, news, milestones, meeting information and more.
CTC Advanced Collaborative Update
CTC of Rhode Island has formed the CTC Advanced Collaborative. Initial members of the Advanced Collaborative include,15 practices who have been a part of CTC since at least 2012 and are also part of the Medicare Primary Care Clinician Program (MAPCP). The Advanced Collaborative provides health plans and CTC-RI practices an ongoing platform for innovation and translation of theory and best practices into action. These practices, their respective organizations, and key health plan representatives make up the initial membership of the new CTC Clinical Strategy and Cost Committee (CSCC). 

The CSCC is responsible to identify and test clinical and financial strategies to improve quality and reduce cost. Administrative leaders, physicians, and subject matter experts from the member practices and their associated organizations will be key active participants. CMO's and subject matter experts from the health plans will also collaborate actively in the work of the committee. Health plans will facilitate transparent sharing of performance data on clinical quality, patient experience, and cost.

Learn more about the goals of CSCC here
Practice Spotlight: The Ideal Medical Practices (IMP'S)
There are presently five Ideal Medical Practices (IMPS) participating in CTC-RI including:
  • Barrington Family Medicine (Dr. Andrea Arena and Dr. Lisa Denny)
  • North Kingstown Family Practice (Dr. Lynn Ho)
  • Primary Care of Barrington (Dr. Greg Sadovnikoff)
  • Dr. Solmaz Behtash
  • Wickford Family Medicine (Dr. John Machata)
At the July Steering Committee, Andrea Arena MD from Barrington Family Medicine, presented background information on the IMP movement within United States and the successful outcomes that have been achieved by the RI IMP's.

An IMP practice can be defined as the smallest functional work unit capable of delivering superb care in a vital and sustainable environment and noted that a IMP practice is not necessarily limited to care provided by solo physician practices. The RI IMP practices are using "How's Your Health" as a patient engagement tool and to monitor feedback from patients on their health perceptions and customer experiences. 
Rhode Island College Nurse Care Manager Graduate Certification Program 

The Nurse Care Manager Graduate Certification Program at Rhode Island College, developed with input from CTC, is the first of its kind in Rhode Island. Approved last year, the program consists of five courses (15 total credits) taught in the evenings, some using a hybrid course design that blends standard and online learning. The curriculum includes Nurse Care Management, Healthcare Systems, Professional Role Development, Epidemiology and Public Health Science courses. 


Learn more about the program here

Rhode Island Office of the Health Insurance Commission: Patient Centered Medical Home Definition

The Rhode Island Office of the Health Insurance Commission (OHIC) is in the process of developing a three part definition and evaluation process for what primary care practices will need to demonstrate to be considered a PCMH in Rhode Island and eligible for infrastructure payment.


While the PCMH definition and evaluation processes are under review, the basic tenets of the definition are likely to include:

  • Practice is participating in a formal transformation initiative (i.e., CTC-RI, PCMH-Kids or a payer-sponsored program) and/or practice has obtained NCQA Level 3 recognition. 
  • Practices demonstrate meaningful performance improvement over an annual two-year look back period.
  • Practice has implemented the following specific cost-containment strategies: 
    • develops and maintains high-risk patient registry;
    • implements care management, focusing on high-risk patients and interventions that will impact ED and inpatient utilization;
    • implements behavioral health integration strategies to improve access to behavioral health services;
    • expands access to services both during and after office hours;
    • develops referral protocols informed by cost and quality data provided by payers; and
    • develops/maintains an avoidable ED use reduction strategy.

OHIC has developed a draft outline of the evaluation criteria it is considering for successful implementation of cost-containment strategies at the practice level and is seeking input on that criterion. The Practice Self-Assessment tool can be found here.  Primary care practices are invited to comment of the criteria and feedback can be sent to: [email protected]

Save the Date for the CTC Learning Collaborative
Practices and CTC Stakeholders will want to "Save the Date" for the CTC Learning Collaborative "Primary Care Plus: Paving the Way" which will be held on 11/12/15 from 7:30am to 12:30pm at the Renaissance Hotel, Providence RI. 

The learning collaborative will feature national and regional speakers as well as local experts who will focus on key topic areas to assist primary care practices with functioning
successfully in the patient centered medical home and ACO environments. 

Keynote speakers include: Shal Nilay Ph.D from the Mayo Clinic, who will speak about the shared decision making model the Mayo Clinic has implemented and Eleni Carr from Cambridge Health Alliance, who will speak about the work CHA has done to develop care management services to assist patients with complex needs. There will also be break-out sessions with topic areas relevant for practices that treat patients across the life span. 

CTC will be applying for CME's and CEU's for both nurses and social workers and will send out registration information in the next few weeks.
CTC Practices Invited to Apply for 2015-2016 Partnering in Best Practice Funding Opportunity
The CTC Board of Directors has approved funding for the 2015-2016 Partnering in Best Practice Program for CTC practices that are in Start-up, Transition, Performance Year 1 and Performance Year 2. The intent of the Partners in Best Practice Plan Program is to provide each practice site with up to $500 to be used towards a transformation activity such as: building internal PCMH capacity, improving performance on one of the CTC Contract target areas, or receiving mentoring support from another CTC practice. 

Applications will be accepted through March 31, 2016 with final plans and completed invoices submitted by May 31, 2016. Applications and directions for applying can be found here.
Health and Human Services partners with Rhode Island Quality Institute to offer MU technical assistance for Medicaid providers
The Executive Office Of Health and Human Services has contracted with the Rhode Island Quality Institute's (RIQI) Regional Extension Center (REC) to provide technical assistance to Medicaid providers who are seeking to adopt, implement, or upgrade and meaningfully use an electronic health record under the Medicaid EHR Incentive Program. 

The REC will assist Medicaid providers seeking to adopt, implement, or upgrade an EHR, reach MU for the first time, or advance to the next year/stage of the MU program. Additionally the REC will provide educational sessions and training on issues related to MU such as performing privacy and security risk assessments, meeting MU quality measures, and preparing for MU audits.

Providers who are eligible for the Medicaid EHR Incentive program may qualify for up to $63,750 in federal incentives over the course of the program. If you are a Rhode Island Medicaid provider and would like more information, please contact the RI Regional Extension Center by phone at 888-858-4815 or email: [email protected]

The Rhode Island Regional Extension Center is a service of the Rhode Island Quality Institute (RIQI), a 501(c)(3) non-profit organization founded in 2001 and overseen by a Board of Directors comprised of senior health industry leaders from our community. RIQI is a center of collaborative innovation that advances health and healthcare transformation, whose mission is to improve the quality, safety and value of healthcare and share knowledge that advances the field of healthcare improvement.